Community Public Health Nursing

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FRANCES A. MAURER, MS, RN-BC
Community Health Nursing Educator and Consultant
Baltimore, Maryland
CLAUDIA M. SMITH, PhD, MPH, RN-BC

Community/Public Health Nursing Educator and Consultant
Bowie, Maryland
3251 Riverport Lane
St. Louis, Missouri 63043
COMMUNITY/PUBLIC HEALTH NURSING PRACTICE:

HEALTH FOR FAMILIES AND POPULATIONS ISBN: 978-1-4557-0762-1
Copyright © 2013, 2009, 2005, 2000, 1995 by Saunders, an imprint of Elsevier Inc.
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Unit 1: Historical—Nurse surrounded by children: Instructive Visiting Nurse Association, Richmond, Virginia; Group of children from Sri Lanka:
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Unit 2: Factory with smokestacks: Elsevier Inc. Japanese family on bridge: Photos.com.
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Unit 6: Homeless mother and child: CLG Photographics Inc.; Disaster scene with American Red Cross worker: Gene Dailey, American Red Cross
Unit 7: Children in front of fence: Monkey Business Images; Wheelchair track event: Department of Veterans Affairs
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Library of Congress Cataloging-in-Publication Data

Community/public health nursing practice : health for families and populations / [edited by] Frances A.
Maurer, Claudia M. Smith. – 5th ed.
â•…â•… p. ; cm.
â•… Includes bibliographical references and index.
â•… ISBN 978-1-4557-0762-1 (pbk. : alk. paper)
â•… I. Maurer, Frances A. II. Smith, Claudia M.
â•… [DNLM: 1. Community Health Nursing–United States. 2. Public Health Nursing–United States. WY 106]
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â•…ï»¿ v
CHAPTER ï»¿
A B OUT TH E AUTH O RS
FRANCES A. MAURER MS, RN-BC CLAUDIA M. SMITH, PhD, MPH, RN-BC

Frances A. Maurer is a community health consultant. She is Dr. Claudia M. Smith is a consultant in community/public
retired from the University of Maryland School of Nursing, health nursing. She has been a community/public health nurse
where her primary focus was baccalaureate community health and educator for over four decades. For 8â•›years she served in
nursing. Ms. Maurer received her diploma in nursing from a multi-county health resources planning agency. In 2011, she
St. Joseph's Hospital School of Nursing and her BSN from retired from the University of Maryland, School of Nursing
California State University at Long Beach. Her MS is from the where she taught both undergraduate and graduate courses
University of Maryland in Baltimore, Maryland, and her post- and served as Co-Director of the Community/Public Health
master's education has been at the University of Maryland in Nursing Masters specialty. She earned her BS in Nursing from
the field of Health Policy. the University of Maryland and her MPH with a major in Public
For more than 35â•›years, Ms. Maurer's career in nursing has Health Nursing from the University of North Carolina at Chapel
focused on community health services, both as an educator and Hill. Her PhD in Education is from the University of Maryland,
clinician. She has supervised students in a variety of clinical sit- College Park, with a major in Education Policy and Leadership.
uations and service populations, including general health ser- She has extensive national experience in curriculum evalua-
vices, prenatal care, child health, and communicable disease. tion and development in community/public health nursing and
She has had extensive experience in curriculum development. environmental health nursing. As a member of the Association
She has participated in major curriculum revisions and curricu- of Community Health Nursing Educators (ACHNE), she co-
lum evaluations. authored the Essentials of baccalaureate nursing education for entry-
She is the educator for a statewide program, funded by the level community/public health nursing (2010). With the Alliance of
Maryland Department of Health and Mental Hygiene, to facili- Nurses for Health Environments (ANHE), she is developing the
tate accurate tuberculosis control. She is also involved in several Environmental Health e-Textbook for nurses, available at http://
national studies, directed by the Centers for Disease Control envirn.org/. Dr. Smith is committed to working with low-income
and Prevention. These studies seek to help determine how best and underserved populations, especially families with young chil-
to facilitate immigrant access to tuberculosis diagnosis and dren. She co-developed the Family Needs Model for family health
treatment and to improve identification and treatment for nursing in community/public health. She has supervised numer-
multi-drug resistant tuberculosis. Her primary interests are in ous community assessments and over 65 community-focused
developing equitable access and health services for vulnerable interventions. Targeted populations include school children, older
populations and those with communicable diseases. She has adults in home health, Spanish-speaking immigrants, mater-
written on health policy and finance issues and developed cur- nal/child health populations, and teenagers. She was Director of
riculum for and served as a consultant to both local and state a Healthy Homes Project funded by the federal Department of
health departments. Housing and Urban Development (HUD). This project demon-
strated that lead dust and selected allergens can be reduced safely
in occupied homes without displacing families.
Her research interests include improving access to health pro-
motion activities and promoting safer environments, especially
in low-income communities. Through qualitative research, she
has explored the experiences of joy for low-income women with
preschool children. Despite difficult life experiences, the moth-
ers’ "hearts blossom with vulnerability and strength," especially
in their relationships with their children.
v
DEDICATION
This book is dedicated to
former community/public health nurses
and to contemporary and future
community/public health nurses, students, educators, and researchers,
who, in partnership with community members, contribute energy, insight,
and compassion directed towards a vision of
healthful families, populations, and communities.
ACKNOWLEDGMENTS
Many people have contributed to our exploration of community/public health nursing Â�practice,
including colleagues, faculty, and community members. We are especially indebted to the
Â�community/public health nursing students with whom we have worked over the years. We are
grateful for our relationships with community/public health graduates, practicing community/
public health nurses, and community/public health nursing researchers who have taught us
much. They have provided the inspiration for exploring community/public health nursing from
Â�empirical, experiential, ethical, and critical perspectives.
Without the contributors and their expertise, this book could never have been written. They
have shared their knowledge, beliefs, experiences, and visions. Our conscientious reviewers
affirmed our strengths; challenged us when we were unclear, inaccurate, parochial, or too narrow
in our focus; and made constructive suggestions.
Our families have continued to extend their support to this fifth endeavor. Fran Maurer's hus-
band, Dick, served as research assistant locating and distributing relevant materials to the edi-
tors and contributors. Her daughter, Jennifer Maurer Kliphouse, provided the fresh perspective
of a recently graduated registered nurse. Claudia Smith's husband, Tony Langbehn, and mother,
Gerry Smith, continue to encourage us and take pride in our accomplishment. All of these fam-
ily members have contributed encouragement and support of our pursuit of an excellent fifth
edition.
We thank Elsevier for transforming our manuscripts into a coherent publication, especially
Nancy O'Brien, Jennifer Shropshire, Maggie Reid, and Bridget Healy.
Thank you.
vi
â•…ï»¿ vii
CHAPTER ï»¿
C ONTR IB UTO RS
Charon Burda, MS, PMHNP-BC Christina Hughes, BSN, MS, RN, NREMT-P, Corrine Olson, MS, BSN
Assistant Professor CHEP Retired Deputy Chief, Public Health
University of Maryland School of Nursing Director, Healthcare System Preparedness Nursing
Department of Family & Community Health MedStar Health ER One Institute State of Alaska
Baltimore, Maryland Emergency Preparedness Coordinator Viroqua, Wisconsin
ChapterÂ€25: Substance Use Disorders EMS Liaison Frankston, Texas
MedStar Franklin Square Medical Center ED ChapterÂ€29: State and Local Health
Angeline Bushy, PhD, RN, FAAN, Baltimore, Maryland Â�Departments
PHCNS-BC ChapterÂ€22: Disaster Management: Caring for
Professor & Bert Fish Chair Communities in an Emergency
Anne Rentfro, PhD, RN
University of Central Florida, College of
Professor
Nursing Jennifer Maurer Kliphouse, BSN, RN, BA
College of Nursing
Orlando, Florida Wound Specialist
The University of Texas at Brownsville
ChapterÂ€32: Rural Health Frederick Regional Health System
Adjunct Faculty
Frederick, Maryland
Verna Benner Carson, PhD, PMH/CNS-BC University of Texas Health Science
TableÂ€8–3: Communicable Diseases, Community
Associate Professor Center - Houston
Health Concerns, and Treatment
Towson University Brownsville, Texas
The Nursing Process in Practice boxes
Towson, Maryland ChapterÂ€27: Children in the Community
ChapterÂ€33: Community Mental Health Helen Kohler, PhD, MSPH, RN
Visiting Professor Sally Roach, MSN, RN, APHN-BC, CNE
Robin Fleming, PhD, MN, RN, NCSN University of Eastern Africa Associate Professor
Nursing Practice and Education Baraton, Kenya University of Texas at Brownsville
Specialist Visiting Professor Brownsville, Texas
Washington State Nurses Association Moravian College ChapterÂ€28: Older Adults in the
Seattle, Washington Bethlehem, Pennsylvania Community
ChapterÂ€30: School Health ChapterÂ€5: Global Health
Linda Haddad, PhD, RN, FAAN Gina C. Rowe, DNP, MPH, APRN, BC
Cara J. Krulewitch, PhD, CNM, FACNM Assistant Professor
Associate Professor
Associate Clinical Professor University of Maryland School of Nursing
Virginia Commonwealth University
George Washington University Baltimore, Maryland
Richmond, Virginia
Washington, DC ChapterÂ€7: Epidemiology: Unraveling the
ChapterÂ€10: Relevance of Culture and
ChapterÂ€23: Violence: A Social and Family Mysteries of Disease and Health
Â�ValuesÂ€for Community/Public Health
Problem
Nursing
Tina Marrelli, MSN, MA, RN, FAAN Barbara Sattler, RN, DrPH, FAAN
Sarah Hargrave, MS, BSN, RN, CPHQ Professor
Regulatory Specialist Editor, Home Healthcare Nurse
Marrelli and Associates, Inc. School of Nursing and Health
Bartlett Regional Hospital Professions
Juneau, Alaska Healthcare Consultants
Boca Grande, Florida University of San Francisco
ChapterÂ€29: State and Local Health San Francisco, California
Â�Departments ChapterÂ€31: Home Health Care
ChapterÂ€9: Environmental Health Risks
at Home, at Work, and in the Community
Gail Ann DeLuca Havens, PhD, RN Michelle McGlynn, BSN, RN
Owner and Principal Assistant Master Technical Instructor
INSIGHT: Consultative Services in University of Texas and Brownsville Susan M. Wozenski, JD, MPH
Â�Healthcare Ethics Texas Southmost College, College of Nursing Assistant Professor and Vice Chair, Family
Bluffton, South Carolina Brownsville, Texas and Community Health
Ethics in Practice Boxes ChapterÂ€27: Children in the Community University of Maryland School
of Nursing
Gail Heiss, MSN, RN Leslie Neal-Boylan, PhD, CRRN, APRN-BC, Dual Degree Director, MPH Program
Nursing Education Specialist FNP Department of Epidemiology and Public
VA Maryland Health Care System Professor, Graduate Program Director Health
Baltimore, Maryland Southern Connecticut State University University of Maryland School
ChapterÂ€18: Health Promotion and Risk School of Nursing of Medicine
Â�Reduction in the Community New Haven, Connecticut Baltimore, Maryland
ChapterÂ€19: Screening and Referral ChapterÂ€26: Rehabilitation Clients in the ChapterÂ€6: Legal Context for Community/
ChapterÂ€20: Health Teaching Community Public Health Nursing Practice
vii
viii CONTRIBUTORS
ANCILLARY CONTRIBUTORS Jennifer Maurer Kliphouse, BSN, RN, BA Anna K. Wehling Weepie, DNP, RN, CNE
Wound Specialist Assistant Dean, Undergraduate Nursing
Joanna E. Cain, BSN, RN Frederick Regional Health System and Associate Professor
President and Founder Frederick, Maryland Allen College
Auctorial Pursuits, Inc. Care Plans Waterloo, Iowa
Austin, Texas Test Bank
NCLEX Review Questions Stephanie Powelson, MPH, EdD, RN
TEACH for RN- Case Studies Chair, Nursing Department
Discussion of Focus Questions Truman State University
Kirksville, Missouri
PowerPoint Slides
R E V I E WERS
Laurel Boyd, MA, MEd, RN Christine Crytzer Divens, MSN, RN, CPN Stephanie Powelson, MPH, EdD, RN
Assistant Professor, Nursing Clinical Nurse Specialist Chair, Nursing Department
University of West Florida Children's Hospital of Pittsburgh Truman State University
Pensacola, Florida of UPMC Kirksville, Missouri
Pittsburgh, Pennsylvania
Jo DeBruycker, MPH, RN Julie St. Clair, MSN, RN
Adjunct Professor Susan L. Fogarty, MSN, RN Instructor, Nursing Program
St. Cloud State University Associate Professor, Nursing University of Southern Indiana
Department of Nursing Science Ferris State University School of Nursing College of Nursing and Health Professions
St. Cloud, Minnesota Big Rapids, Michigan Evansville, Indiana
PR EFAC E
June 2012 marked the 100th anniversary of the term public health stroke, pulmonary diseases, and diabetes, and, at all ages, unin-
nurse, adopted by the National Organization for Public Health tentional injury. Much of the premature death and disability
Nursing, the forerunner of the National League for Nursing. is preventable through control of environmental and personal
Anniversaries and transitions offer time to reflect on the past risk factors, such as smoking and obesity. Health promotion and
and present, as well as to clarify directions and strategies for prevention have been historic aims of community/public health
the future. When the first edition of this text was published, we nursing. Today, the National Health Objectives for the year 2020
had just celebrated the 100th anniversary of modern commu- identify measurable targets for reduction in death and disability.
nity/public health nursing in the United States. The second edi- Because community/public health nurses are in the forefront of
tion anticipated the arrival of the twenty-first century, which helping families and communities identify and reduce their risk
brought both practical and symbolic implications for the future factors, the Healthy People 2020 objectives and progress toward
of community/public health nursing. As the fifth edition is pub- goal attainment are included in all appropriate chapters.
lished, we continue to confront global health issues including Reducing health disparities is a foremost national goal.
climate change, food shortages and maldistribution, refugee Health, illness, and health care are unevenly distributed among
health, exposure to environmental chemicals, and disabilities people. The relevance of population-focused nursing emerges
and deaths from conflicts and warfare. The United States health when the unmet health needs of populations are recognized.
care system is undergoing dramatic changes that will affect both For example, numbers of injured veterans, the homeless, the
consumers and providers of health care services in critical ways. chronically mentally ill, and poor children are increasing. The
Creative ways are called for to improve the health and well- poor have higher rates of illness, disability, and premature
being of our citizens and communities. death. The cost of health care and absent or inadequate health
This fifth edition explores our history and present prac- insurance coverage combine to also increase the numbers of
tice, and contemplates our future. The title: Community/ Public medically indigent, such as survivors of accidental head and spi-
Health Nursing Practice: Health for Families and Populations nal trauma. This text explores the commitments and activities
reflects the practice arena of community/public health, empha- of community/public health nursing in improving the health
sizing the application of content to nursing practice, and shows of such vulnerable families, groups, and populations. Research
the broad scope of community-based and community-focused studies discussed throughout the text illustrate the success of
practice. nursing interventions with vulnerable populations in commu-
Throughout this text, emphasis is placed on the core of "what nities and provide a basis for evidence-based practice.
a community/public health nurse needs to know" to prac- To identify the health-related strengths and problems of a
tice effectively in the context of a world, nation, society, and community, it is necessary to assess the demographic and health
health care system that are ever changing. This text is intended statistics of the community's population and to explore the
for baccalaureate nursing students taking courses related to existing community structures, functions, and resources. In this
Â�community/public health nursing, including registered nurses text, we stress the importance of developing partnerships with
returning for their baccalaureate degrees. The text is also suit- community members. We present a community assessment tool
able for entry-into-practice Clinical Nurse Leader students. with several case studies showing its application to both geopo-
Beginning practitioners in community/public health nursing litical and phenomenological communities. We discuss varied
will also find much useful information. The term community/ perspectives for planning and evaluating nursing care within
public health nursing is used in this text to remind the reader communities. Community/public health nurses recognize
that community-orientated nursing practice is broad based and that much of a person's attitude and behavior toward health is
aimed at improving the health of families, groups, and popula- learned initially in his or her own family. Family-focused health
tions. To save space in the text, the term community health nurse promotion and prevention is an important community/public
may sometimes be used in place of community/public health health nursing strategy. As was true in previous centuries, some
nurse. The term client is used to reflect individual, group, and families today experience multiple problems with unhealthy
population recipients of nursing care, while the term patient is environments, disabled or chronically ill members, develop-
used selectively to denote individuals under care in intense clin- mental issues, breakdowns in family communication, and weak
ical and hospital-based practice. support systems.
Changes in the delivery and financing of health care services The text reflects the increasing demand for community/
affect professional practice as well as individuals, families, pop- public health nursing in home health care for the ill. Hospital cost-
ulations, and communities. Therefore in this edition we explore containment measures that began in the 1980s have resulted in a
past and present efforts at health service and funding reform, decrease in the average length of stay of patients in hospitals. As
critique progress toward stated reform goals, and identify cur- was true 100â•›years ago, families today are caring for ill members
rent and future areas of concern for health care providers and at home and are requiring assistance from community health
communities. nurses. In response to client needs, newer structures of nursing
Unlike 100â•›years ago, the major causes of death in the United care delivery also have emerged, including hospice and medical
States today are not communicable diseases. Rather, the major daycare centers. A family focus and care for clients in their daily
causes today are chronic diseases, such as heart disease, cancer, settings—homes, schools, and worksites—are traditional aspects
ix
x PREFACE
of community/public health nursing. Community/public health We are pleased with student comments about the strengths
nursing acknowledges the importance of caring for the family of previous editions and have maintained these positive charac-
caregivers as well as for ill family members and of strengthening teristics in the fifth edition:
community support services. • The text is very readable.
The community/public health nurse's involvement with • The writing style maintains interest.
contemporary public health problems—substance abuse, • Tables are clear and useful.
violence, and newly emerging or persistent communicable • Explanations discuss the relevance of ideas to practice.
diseases (including HIV/AIDS, MRSA, SARS, multi-drug • Examples show practical application.
resistant tuberculosis, and West Nile Virus)—is thoroughly • Evidence-based practice examples are integrated throughout.
covered. As a response to recent events, the disaster chapter • Each chapter is self-contained, without the need to refer to
provides greater emphasis on disaster prevention and man- appendixes.
agement. Adolescent sexuality and the health risks associated This text builds on prerequisite knowledge and skills related
with sexual activity for both adolescents and their infants are to application of the nursing process, interpersonal relation-
explored. Chapters on vulnerable populations and community ships, and nurse/client communication skills. Other prerequi-
mental health examine two areas of increasing concern for sites are knowledge of human development, basic concepts of
community/public health nursing. Toxic substances in home, stress and adaptation, and nursing care with individuals. While
work, and community environments are identified as special a basic general systems language is used with family and com-
health hazards. munity theory, terms are defined for those who have not had
Changes in the age composition of our country's residents formal instruction in these concepts.
pose concerns related to the ratio of dependent persons. More
older adults and, in selected subpopulations, more children ORGANIZATION OF TEXT
make up the population. Special emphasis is given in the text to
a discussion of the support networks with which community/ The text is organized into eight units. Unit One, Role and
public health nurses work as they provide nursing care with Context of Community/Public Health Nursing Practice,
elderly people, children, and persons with disabilities. describes the ethical commitments underlying community/
public health nursing practice as well as the scope and context
LEVEL OF LEARNER of community/ public health nursing practice. We explore how
the structure and function of our complex health care system
This book is intended as a basic text for baccalaureate students and legal and economic factors influence communities and
in community/public health nursing. It is appropriate for basic community/public health nursing practice. A chapter on global
baccalaureate students, registered nurses returning for bac- health provides a broader perspective of the concepts of health
calaureate degrees, and baccalaureate graduates and entry-Â� and illness throughout the world.
into-practice Clinical Nurse Leader graduates who are new to Unit Two, Core Concepts for the Practice of Community/
community/public health employment. It assists the learner in Public Health Nursing, presents basic concepts necessary
the practical application of community/public health nursing for effective community/public health practice. An under-
content. standing of the process of epidemiology, including the
The material covered in the text has been updated to be con- impact and control of communicable diseases, is essential
sistent with the American Association of Colleges of Nursing to community/ public health nursing practice. A chapter on
2008 report The essentials of baccalaureate education for pro- environmental issues at home, at worksites, and in geopolit-
fessional nursing practice and the Association of Community ical communities identifies specific health risks. Culturally
Health Nursing Educators 2010 report Essentials of baccalau- competent nursing care depends on understanding the
reate nursing education for entry-level community/public health impact of culture and values on health and health behaviors.
nursing. Culturally competent nursing care also requires an under-
Additionally, the text can benefit registered nurses without standing of the impact that diversity in culture and values
baccalaureate degrees who are changing their practice settings among clients and health providers may have on the nurse-
because of health care system changes. For example, in some client relationships.
places, registered nurses with strong technological medical-Â� Unit Three, Family as Client, presents a broad theory base
surgical or pediatric skills are being employed in home care. related to family development, structure, functioning, and
These nurses, their supervisors, and/or in-service education health. A family assessment tool is provided, and sources for
directors can use this text to provide background information, additional tools are identified. Specific case studies demonstrate
especially in relation to the context of practice, family-focused the application of the nursing process with families. Special
care, home visiting, and scope of community resources. emphasis is given to working with families in crisis and "multi-
The text has a descriptive focus, including both historical problem" families.
changes in practice and the relative magnitude of community/ Nurses with baccalaureate degrees belong to one of a few
public health nursing problems and solutions today. The text professions whose members learn to care for people at home
also is structured to promote further inquiry related to each as a part of their educational experiences. Many nurses without
subject and to connect information with examples of practice. baccalaureate degrees who desire to transfer from hospital to
Thus, the text includes abstractions and concepts, as well as home care settings must learn on the job. Consequently a chap-
questions and examples, to promote critical thinking and appli- ter is devoted to home visiting, a continuing facet of Â�community/
cation of the information. public health nursing.
PREFACE xi
Unit Four, Community as Client, presents the commu- CHANGES TO THE FIFTH EDITION
nity and population approach that is unique to community/Â�
public health nursing. Communities may be characterized as The fifth edition updates and expands content from the fourth
Â�geopolitical or phenomenological (communities of belonging).
Â� edition, which was widely acclaimed. New content is also
Assessment tools are presented for each type of community included and listed below.
and case examples provided to illustrate the application of the
nursing process with communities. Numerous measures for Throughout the Text We Have Updated the Following:
evaluating the outcomes of community/public health nursing • Demographic statistics
programs are discussed. Additionally, process and management • Descriptive epidemiology, incidence and prevalence data
evaluations are examined. • Standards for practice and quality
Unit Five, Tools for Practice, develops three strategies for • Initiatives to improve access to health care
population-focused intervention used frequently by commu- • Current evidence-based findings and best practices
nity/ public health nurses: • References and recommended readings
• Health promotion and risk reduction • Community resources for practice
• Screening and referral
• Health teaching New Content in this Edition:
Specific tools are included that can be used to help indi- • Healthy People 2020 objectives with Healthy People 2020
viduals identify risk factors for illness and identify more boxes
healthful personal behavior. Detailed instructions are pro- • The Patient Protection and Affordable Care Act of 2010
vided for conducting health screening. Also included are (ACA) and its impact on health care delivery systems, financ-
the current recommended schedules for health screening ing of health care services, specific populations, and health
for males and females of various age groups. These specific disparities
practice skills may be applied with individuals, families, and • Shifting federal/state responsibilities in health care delivery
populations. • State and federal efforts at universal health coverage
Unit Six, Contemporary Problems in Community/Public • Trends in employer-provided health insurance
Health Nursing, focuses on contemporary problems encountered • Community health centers
in community/public health nursing practice. Demographic and • Top ten public health accomplishments during the past
epidemiological data help identify populations most at risk for decade
specified health problems. A chapter is devoted to each of the • Global health disparities
following: • International health care delivery systems
• Vulnerable populations, including people in poverty, the • Impact of war, terrorism, and national disasters on health
homeless, migrant populations, and prison populations and health care delivery
• Disaster management • Human trafficking and genital circumcision
• Family and community violence • Evidence-based home visiting programs
• Adolescent sexual activity and teenage pregnancy • New health risk appraisal tools
• Substance use disorders • Newborn screening for genetic disorders
The impact of poverty on health is explored in depth. The • Fatalities associated with weather-related disasters
health risks of vulnerable groups are explored. Societal and per- • Bioterrorism and national and state planning responses,
sonal factors contributing to health problems are identified, including role of the United States Department of Homeland
including psychological and family stress related to homeless- Security
ness, poverty, and a migrant lifestyle. • Impact of sexting, sex education, and abstinence-only pro-
The disaster chapter emphasizes the importance of preplan- grams on teen behavior
ning and outlines the roles of both public and private organi- • Addiction as a brain disorder
zations in disaster relief. Common disaster scenarios for both • Language stigma and substance use disorders
natural and manmade disasters are presented. Changes in • Community re-integration and community living arrange-
disaster preparation and management to improve commu- ments for patients in with disabilities
nity response to terrorism are outlined, and potential terrorist • Bullying
threats are identified.
Unit Seven, Support for Special Populations, discusses three Expanded Content in this Edition:
vulnerable populations: persons with disabilities, children, and • Clinical examples that are related to the chapter content and are
older adults. Prevalence of health problems, common nursing common in the practice of community/public health nurses
interventions, and the importance of community support ser- • Internet resources for both faculty and students, including
vices are discussed. additional links to Community Resources for Practice
Unit Eight, Settings for Community/Public Health Nursing • Distribution of community health nurses by worksites
Practice, describes settings for community/public health nurs- • Social determinants of health
ing practice, including state and local health departments, • Social justice
schools, home health agencies, rural communities, and commu- • Medicare Advantage and Medicare Part D – Prescription
nity mental health sites. Each chapter includes a day or a week Drug Plan
in the life of a community/public health nurse or a case study to • Cost-sharing impacts on access to health care
help students experience the reality of working in that setting. • Core public health functions
xii PREFACE
• Third-party reimbursement for nurse practitioners and clin- example of the nursing process applied with a family or commu-
ical nurse specialists nity or a case study in which the chapter concepts may be applied.
• Emerging problems with communicable diseases Learning by Experience and Reflection at the end of each
• Climate change and health chapter is designed to foster student learning through inquiry
• Chemical policies and a variety of ways of knowing. Ways of knowing include
• Immigration trends empirical knowledge and logic, interpersonal learning expe-
• Health disparities and health care disparities riences, ethics, and greater awareness of personal preferences
• Household composition in United States (aesthetics). Guidelines may promote reflection and self-Â�
• Family case management in community/public health awareness, observation, analysis, and synthesis. Each chapter
• Informatics and electronic health systems includes guidelines for learning appropriate to most students
• Evidence-based practice examples of community planning as well as suggestions for those who are interested in further
and intervention exploration and creativity.
• Evidence-based practice examples of community health pro- Community Resources for Practice appears at the end of
gram evaluations each chapter. This list of resources provides the organization
• Mobilization Action Through Partnerships and Planning names and websites.
(MAPP) Suggested Readings have been selected with the level of student
• Geographic information systems (GIS) in mind. Some readings expand on concepts and tools of practice
• Examples of epidemiological studies and their application in mentioned in the chapter. Other readings provide descriptions
public health practice of community/public health nursing programs or descriptions of
• Guidelines for screenings nurses' experiences related to their professional practice.
• Nursing interventions related to the Transtheoretical Ethics in Practice is a special feature appearing predomi-
Model—Stages of Change nantly in chapters in Units Five and Six. A situation involving a
• SMOG formula to determine readability of print materials community/public health nurse is used to identify ethical ques-
• Sample health education lesson plan tions, related ethical principles, and the actions of the specific
• Migrant and prison health problems nurse. These situations provide the opportunity for student/
• Contemporary tools for addictions screening faculty dialogue to explore one's own ethical decision-making.
• Disability prevalence by age Several of the situations demonstrate the tension between the
• Common health problems throughout the life span rights of individuals and the rights of the public at large; other
• Environmental aspects of school health situations depict competing values.
• State and local health department services and use of public
private partnerships ANCILLARY PACKAGE
• Major challenges for public health in the twenty-first century
• Trends in child, older adult, rural, and school health services A complete teaching and learning package is available on the
• National goals for the community mental health system book's dedicated Evolve website at http://evolve.elsevier.com/
Maurer/community/. This website offers materials for both
CHAPTER ORGANIZATION TO PROMOTE LEARNING Â�students and instructors.
Each chapter has the following features: Study Aids for Students
Focus Questions See previous Evolve page for more details on student resources.
Outline
Key Terms (boldfaced in the text) For Instructors
Chapter narrative TEACH for Nurses: NEW to this edition, detailed chapter Lesson
Key Ideas Plans containing references to curriculum standards such as
Learning by Experience and Reflection QSEN, BSN Essentials and Concepts; new and unique Case
References Studies; as well as Teaching Strategies and Learning Activities.
Suggested Readings PowerPoint Slides: Slides of bulleted information that high-
The majority of chapters also present one or more of the follow- light key chapter concepts to assist with classroom presentation
ing special features to aid learning: and lecture.
Case Study Teaching Strategies for Learning by Experience and Reflection:
The Nursing Process in Practice Detailed plans and suggested activities for implementing the
Community Resources for Practice Learning by Experience and Reflection exercises in the book.
Ethics in Practice Test Bank: Over 800 NCLEX-style questions, with cognitive
Focus Questions at the beginning of each chapter and Key level, topic, rationale, and text page reference provided. One
Ideas at the end help the reader focus on the material presented. question in each chapter is presented in the newer innovative
The questions encourage the reader to approach learning from item format.
the perspective of inquiry. Key Ideas summarize the important Discussion of Focus Questions: Short answers to the questions
ideas. Where appropriate, epidemiological data are presented to that introduce each chapter.
describe the magnitude of the health problems and the popula- Image Collection: Contains illustrations selected from the
tions in which they occur more frequently. textbook.
Case Studies and The Nursing Process in Practice encourage Frances A. Maurer
application of the chapter material. Most chapters provide an Claudia M. Smith
C ONTENTS IN B RI E F
UNIT 1 ROLE AND CONTEXT OF UNIT 5 TOOLS FOR PRACTICE

COMMUNITY/PUBLIC HEALTH
18 Health Promotion and Risk Reduction in the
NURSING PRACTICE Community, 466
1 Responsibilities for Care in Community/Public 19 Screening and Referral, 486
Health Nursing, 2 20 Health Teaching, 505
2 Origins and Future of Community/Public Health
Nursing, 31
UNIT 6 CONTEMPORARY PROBLEMS IN
3 The United States Health Care System, 54
4 Financing of Health Care: Context for Community/ COMMUNITY/PUBLIC HEALTH
Public Health Nursing, 86 NURSING
5 Global Health, 113
6 Legal Context for Community/Public Health 21 Vulnerable Populations, 527
Nursing Practice, 136 22 Disaster Management: Caring for Communities in
an Emergency, 552
23 Violence: A Social and Family Problem, 575
UNIT 2 CORE CONCEPTS FOR THE
â•› 24 Adolescent Sexual Activity and Teenage
PRACTICE OF COMMUNITY/ Pregnancy, 603
25 Substance Use Disorders, 631
PUBLIC HEALTH NURSING
7 Epidemiology: Unraveling the Mysteries of
Disease and Health, 161 UNIT 7 SUPPORT FOR SPECIAL
8 Communicable Diseases, 190 POPULATIONS
9 Environmental Health Risks: At Home, at Work,
and in the Community, 235 26 Rehabilitation Clients in the Community, 659
10 Relevance of Culture and Values for Community/ 27 Children in the Community, 679
Public Health Nursing, 266 28 Older Adults in the Community, 701
UNIT 3 FAMILY AS CLIENT UNIT 8 SETTINGS FOR COMMUNITY/

11 Home Visit: Opening the Doors for Family Health, 298 PUBLIC HEALTH NURSING
12 A Family Perspective in Community/Public Health PRACTICE
Nursing, 322
13 Family Case Management, 340 29 State and Local Health Departments, 726
14 Multiproblem Families, 372 30 School Health, 749
31 Home Health Care, 777
32 Rural Health, 799
UNIT 4 COMMUNITY AS CLIENT 33 Community Mental Health, 822
15 Community Assessment, 393 Index, 841
16 Community Diagnosis, Planning, and
Intervention, 427
17 Evaluation of Nursing Care with Communities, 449
xiii
C O N T ENTS
UNIT 1 ROLE AND CONTEXT OF Public and Private Sectors, 63

COMMUNITY/PUBLIC HEALTH Public Sector: Government's Authority and
Role in Health Care, 63
NURSING PRACTICE
Private-Sector Role in Health Care Delivery, 68
1 Responsibilities for Care in Community/Public Public and Private Health Care Sectors
Health Nursing, 2 BeforeÂ€1965, 71
Claudia M. Smith Public and Private Sectors, 1965 to 1992, 71
Visions and Commitments, 4 Public and Private Sectors Today, 73
Distinguishing Features of Community/Public A National Health Care System? 79
Health Nursing, 6 Challenges for the Future, 80
Theory and Community/Public 4 Financing of Health Care: Context for Community/
HealthÂ€Nursing, 7 Public Health Nursing, 86
Goals for Community/Public Frances A. Maurer
HealthÂ€Nursing, 11 Relevance of Health Care Financing
Nursing Ethics and Social Justice, 11 toÂ€Community/Public Health
The Nursing Process in NursingÂ€Practice, 87
Community/PublicÂ€Health, 13 Relative Magnitude of Health
Responsibilities of Community/Public Spending inÂ€the United States, 87
HealthÂ€Nurses, 14 Reasons for the Increase in Health CareÂ€Costs, 89
Expected Competencies Groups at Risk for Increased Costs and
of Â�Baccalaureate-Prepared Community/ FewerÂ€Services, 90
Public Health Nurses, 22 Health Care Financing Mechanisms, 90
Leadership in Community/Public Publicly Funded Programs for Health
HealthÂ€Nursing, 24 CareÂ€Services, 94
2 Origins and Future of Community/Public Health Trends in Reimbursement, 104
Nursing, 31 The Nurse's Role in Health Care Financing, 108
Claudia M. Smith 5 Global Health, 113
Roots of Community/Public Helen R. Kohler and Frances A. Maurer
HealthÂ€Nursing, 32 Health: A Global Issue, 113
Definition of Public Health, 37 Health Disparities Among Countries, 114
Nursing and Sanitary Reform, 38 International Health Organizations, 116
Population-Focused Care and Health and Disease Worldwide, 118
Subspecialties, 38 Health Care Delivery Systems, 124
Expansion into Rural America, 41 New and Emerging Health Issues, 128
Government Employment of Public Role of Nursing in International Health, 131
HealthÂ€Nurses, 42 6 Legal Context for Community/Public
Dichotomy in Public Health Nursing, 43 Health Nursing Practice, 136
Educational Preparation for Public Susan Wozenski
HealthÂ€Nurses, 44 Public Health Law, 137
Expanded Practice in Community Health Community/Public Health Nurses and
Nursing: 1965 to 1995, 44 PublicÂ€Health Law, 137
Reclaiming Public Health Nursing: Sources of Law, 138
1995 to 2010, 45 Classification of Laws and Penalties, 146
Community/Public Health Nursing: Creating Purposes and Application of Public
the Future, 45 HealthÂ€Law, 147
Continuing Issues, 50 Legal Responsibilities of Community/Public
3 The United States Health Care System, 54 Health Nurses, 148
Frances A. Maurer How to Find Out About Laws, 153
Our Traditional Health Care System, 56 Standards of Care, 154
Components of the U.S. Health Care System, 57 Quality and Risk Management, 154
Direct and Indirect Services and Providers, 63 Ethics and Law, 156
xiv
xv
CONTENTS
UNIT 2 CORE CONCEPTS FOR THE Ethnicity, 271

PRACTICE OF COMMUNITY/ Racial and Ethnic Health and Health Care
Disparities, 272
Role of Insurance in Health Disparities, 273
7 Epidemiology: Unraveling the Mysteries of Strategies for Eliminating Health Disparities, 274
Disease and Health, 161 Understanding Cultural Differences, 274
Gina C. Rowe Biological Variations, 280
Interests of Population-Based Data, 162 Culture-Bound Syndromes, 280
Types of Epidemiological Investigation, 164 Cultural Patterns of Care, 281
Understanding Aggregate-Level Data, 165 Community/Public Health Nurse's Role
Concepts Related to Prevention, Health in a Culturally Diverse Population, 284
Promotion, and Disease, 166 Culturally Appropriate Strategies for the
Health Information Systems, 168 Community/Public Health Nurse Working
Demographic Data, 170 with Diverse Communities, 289
Department of Commerce Health-Related Contemporary Issues and Trends, 290
Studies, 172
Major Causes of Death, 172 UNIT 3 FAMILY AS CLIENT
Health Profiles or Status and the Life Cycle, 178
Health Profiles or Status of Populations 11 Home Visit: Opening the Doors forÂ€Family
atÂ€High Risk, 184 Health, 298
Continuing Issues, 186 Claudia M. Smith
8 Communicable Diseases, 190 Home Visit, 300
Frances A. Maurer Nurse–Family Relationships, 301
Communicable Diseases and Control, 190 Increasing Nurse–Family Relatedness, 304
Contemporary Issues in Communicable Reducing Potential Conflicts, 309
Disease, 192 Promoting Nurse Safety, 311
Influences of Modern Lifestyle Managing Time and Equipment, 312
andÂ€Technology, 201 Postvisit Activities, 315
Issues of Population Safety Versus The Future of Evidence-Based Home-Visiting
Individual Rights, 202 Programs, 317
Role of the Nurse in Communicable 12 A Family Perspective in Community/Public
Disease Control, 202 Health Nursing, 322
Epidemiology Applied to Communicable Claudia M. Smith
Disease Control, 204 A Family Perspective, 322
Role of Boards of Health, 207 What is Family, 324
Nursing Care in the Control of Historical Frameworks, 327
Communicable Diseases, 209 How Can These Approaches be Integrated? 334
9 Environmental Health Risks: At Home, at Work, Family Perspectives in Nursing, 335
and in the Community, 235 13 Family Case Management, 340
Barbara Sattler Claudia M. Smith
Overview of Environmental Health, 236 Family Case Management, 341
Assessment of Environmental Health Family Assessment, 342
Hazards, 241 Analyzing Family Data, 346
Environmental Issues for the 21st Century, 257 Developing a Plan, 354
Community/Public Health Nursing Implementing the Plan, 355
Responsibilities, 259 Evaluation, 361
The Nurse's Responsibilities in Primary, Terminating the Nurse–Family
Secondary, and Tertiary Prevention, 260 Relationship, 363
The Future of Environmental Health Evaluation of Family Case Management
Nursing, 262 Programs, 363
10 Relevance of Culture and Values for Community/ 14 Multiproblem Families, 372
Public Health Nursing, 266 Claudia M. Smith
Linda Haddad and Claudia M. Smith Families Experiencing Crisis, 373
Cultural Pluralism in the United States, 267 Families with Chronic Problems, 373
Culture: What It Is, 268 Resilience, 377
Values, 269 Responsibilities of the Community/Public
Race, 270 Health Nurse, 377
xvi CONTENTS
UNIT 4 COMMUNITY AS CLIENT 20 Health Teaching, 505

Gail L. Heiss
15 Community Assessment, 393 Health-Teaching Process, 506
Frances A. Maurer and Claudia M. Smith Research Evidence: What Works in Client
Community Assessment: Application to Health Education? 507
Community/Public Health Nursing Nursing Assessment of Health-Related
Practice, 394 Learning Needs, 508
Community Defined, 394 Construction of Health Education
Basic Community Frameworks, 396 LessonÂ€Plans, 510
Systems-Based Framework for Community Health-Related Educational Materials, 516
Assessment, 398 Principles of Teaching, 521
Tools for Data Collection, 408
Approaches to Community Assessment, 412
Analysis, 413 UNIT 6 CONTEMPORARY PROBLEMS
16 Community Diagnosis, Planning, IN COMMUNITY/PUBLIC
and Intervention, 427 HEALTH NURSING
Frances A. Maurer and Claudia M. Smith
Population-Focused Health Planning, 428 21 Vulnerable Populations, 527
Planning for Community Change, 430 Frances A. Maurer
Steps of Program Planning, 432 Vulnerable Populations, 528
Implementation, 439 Poverty, 529
17 Evaluation of Nursing Care withÂ€ Race and Ethnicity and Their Relationship to
Communities, 449 Income and Health Status, 531
Claudia M. Smith and Frances A. Maurer The Uninsured, 533
Responsibilities in Evaluation of Nursing Care Homelessness, 534
with Communities, 449 Migrant/Seasonal Workers, 538
Steps in Evaluation, 451 The Prison Population, 539
Questions Answered by Evaluation, 451 Services Available for Vulnerable
Uniqueness in Evaluation of Nursing Care Populations, 540
with Communities, 457 Nursing Considerations for Vulnerable
Analyzing Evaluation Data, 459 Populations, 543
Modification of Nursing Care with 22 Disaster Management: Caring for Communities in
Communities, 459 an Emergency, 552
Evaluation Methods and Tools, 459 Christina Hughes and Frances A. Maurer
Definition of Disaster, 553
UNIT 5 TOOLS FOR PRACTICE Factors Affecting the Scope and Severity
ofÂ€Disasters, 554
18 Health Promotion and Risk Reduction in the Dimensions of a Disaster, 555
Community, 466 Phases of a Disaster, 556
Gail L. Heiss Disaster Management: Responsibilities of
Meaning of Health, 468 Agencies and Organizations, 557
Determinants of Health, 468 Emergency Response Network, 560
National Policy, 469 Principles of Disaster Management, 561
Health Models, 470 Reconstruction and Recovery, 563
Health-Promotion and Health-Protection New Challenges for Disaster Planning
Programs, 473 and Response, 564
Health Promotion and Nursing Nursing's Responsibilities in Disaster
Practice, 477 Management, 566
19 Screening and Referral, 486 23 Violence: A Social and Family Problem, 575
Gail L. Heiss Cara J. Krulewitch
Definition of Screening, 487 Extent of the Problem, 576
Criteria for Selecting Screening Tests: Validity National Health Priorities to Reduce
and Reliability, 488 Violence, 576
Contexts for Screening, 489 Violence in the Community: Types and
Community/Public Health Nurse's Role RiskÂ€Factors, 577
in Screening, 496 Impact of Violence on the Community, 579
Screening and the Referral Process, 499 Violence Within the Family, 579
xvii
CONTENTS
Child Abuse and Neglect, 580 Community Health Care for Children with
Intimate Partner Violence, 583 Special Needs, 693
Nursing Care in Abusive Situations: Community/Public Health Nursing
ChildÂ€Abuse or Partner Abuse, 587 Responsibilities, 694
Elder Abuse, 593 Trends in Child Health Services, 695
24 Adolescent Sexual Activity and Teenage 28 Older Adults in the Community, 701
Pregnancy, 603 Sally C. Roach
Frances A. Maurer Aging, 702
Teenage Sexual Activity, 604 Role of Older Adults in the Family
Teenage Pregnancy, 608 and theÂ€Community, 703
Comparison of Pregnancy-Related Issues Common Health Needs of Older Adults, 708
in Other Countries, 611 Impact of Poverty on Older Adults, 713
Public Costs of Adolescent Pregnancy Development and Organization ofÂ€Community
and Childbearing, 612 Resources, 714
Consequences of Early Pregnancy Trends in Health Care Services for
forÂ€Teenagers and Infants, 612 Older Adults, 716
Legal Issues and Teen Access to Reproductive Responsibilities of the Nurse Working with
Health Services, 616 Older Adults in the Community, 718
Nursing Role in Addressing Teenage
Sexual Activity and Pregnancy, 616
Primary Prevention, 617 UNIT 8 SETTINGS FOR COMMUNITY/
Secondary Prevention: The Care PUBLIC HEALTH NURSING
of Pregnant Teenagers, 620 PRACTICE
Tertiary Prevention, 624
25 Substance Use Disorders, 631 29 State and Local Health Departments, 726
Charon Burda Sarah Hargrave , Corrine Olson and Frances A. Maurer
Background of Addiction, 632 Core Functions and Essential Services
Effects of Alcohol and Drugs on the Body, 636 ofÂ€Public Health, 726
Monitoring Incidence and Prevalence, 639 Structure and Responsibilities of the State
Stigma and Language, 642 Health Agency, 728
Impact of Substance Use Disorders Structure and Responsibilities of Local Public
onÂ€Individuals and Family Members, 643 Health Agencies, 729
Addictions and Communicable Diseases, 645 Services Provided by the State Health Agency
Responsibilities of the Community/Public and the Local Health Department, 733
Health Nurse, 647 Evolution of Public Health Nursing
Community and Professional Resources, 652 in Official Agencies, 738
Funding Issues and Access to Care, 652 External Influences on Public Health Nursing, 738
Public Health Nursing Practice, 738
Future Trends and Issues in Public
UNIT 7 SUPPORT FOR SPECIAL Health and Public Health Nursing, 744
POPULATIONS 30 School Health, 749
Robin Fleming
26 Rehabilitation Clients in the Community, 659 Historical Perspectives of School Nursing, 750
Leslie Neal-Boylan Components of Coordinated School
Concept of Disability, 660 Health, 751
Concept of Rehabilitation, 660 Organization and Administration
Magnitude of Disability in the United States, 663 of School Health, 757
Legislation, 667 Responsibilities of the School Nurse, 759
Needs of Persons with Disabilities, 669 Common Health Concerns of School-Aged
Responsibilities of the Rehabilitation Nurse, 671 Children, 761
Community Reintegration Issues, 674 Future Trends and Issues in School
27 Children in the Community, 679 Health Programs, 768
Anne Rath Rentfro and Michelle McGlynn 31 Home Health Care, 777
Children in the United States, 679 Tina M. Marrelli
Families and Communities with Children, 682 Definitions, 779
Common Health Needs of Children, 685 Standards and Credentialing, 779
Children at Risk, 689 Home Health Care Today, 780
xviii CONTENTS
Responsibilities of the Home Health 33 Community Mental Health, 822

Care Nurse, 786 Verna Benner Carson
Issues in Home Care, 788 Advent of Community Mental Health Care, 822
Hospice Home Care, 794 Philosophy of Community Mental Health
32 Rural Health, 799 Care, 826
Angeline Bushy Population Served by Community Mental
Definitions, 800 Health Care, 827
Status of Health in Rural Populations, 802 Services Provided in Community Mental
Factors Influencing Rural Health, 806 Health Care, 829
Rural Lifestyle and Belief Systems, 810 Role of the Nurse in Community Mental
Rural Community/Public Health Health Care, 830
Nursing Practice, 811 The Nursing Process in Practice, 831
Building Professional-Community Continuing Issues in Community Mental
Partnerships, 815 Health Care, 836
Trends and Issues, 817 Index, 841
U N I T 1
Role and Context of Community/
Public Health Nursing Practice
1 Responsibilities for Care in Community/Public Health
Nursing
2 Origins and Future of Community/Public Health
Nursing
3 The United States Health Care System
4 Financing of Health Care: Context for Community/
Public Health Nursing
5 Global Health
6 Legal Context for Community Health Nursing Practice
1
CHAPTER
1
Responsibilities for Care in
Community/Public Health Nursing
Claudia M. Smith
FOCUS QUESTIONS
What is the nature of community/public health nursing practice? What is meant by the terms population-focused care and
What values underlie community/public health nursing? aggregate-focused care?
How is empowerment important in community/public health What are the responsibilities of community/public health
nursing? nurses?
What health-related goals are of concern to community/public What competencies are expected of beginning community/
health nurses? public health nurses?
Who are the clients of community/public health nurses? How are community/public health nurse generalists and
What are the basic concepts and assumptions of general specialists similar and different?
systems theory?
CHAPTER OUTLINE
Visions and Commitments Surveillance, Monitoring, and Evaluation
Distinguishing Features of Community/Public Health Policy Enforcement and Development
Nursing Environmental Management
Healthful Communities Case Management, Coordination of Care, and Delegation
Empowerment for Health Promotion Partnership/Collaboration
Theory and Community/Public Health Nursing Consultation
General Systems Theory Social, Political, and Economic Activities
Nursing Theory Empowerment for Creativity
Public Health Theory Self-Care and Development
Goals for Community/Public Health Nursing Expected Competencies of Baccalaureate-Prepared
Nursing Ethics and Social Justice Community/Public Health Nurses
Ethical Priorities Direct Care with Individuals
Distributive Justice Direct Care with Families
Social Justice Direct Care with Groups
The Nursing Process in Community/Public Health Direct Care with Aggregates/ Populations
Responsibilities of Community/Public Health Nurses Leadership in Community/Public Health Nursing
Direct Care of Clients with Illness, Infirmity, Suffering, and Professional Certification
Disability Quality Assurance
Referral and Advocacy Community/Public Health Nursing Research and
Teaching Evidence-Based Practice
KEY TERMS
Aggregate General systems theory Public health nursing
Commitments Group Risk
Community-based nursing Population Social justice
Community health nursing Population-focused Visions
Community/public health nurse Professional certification
Distributive justice Public health nurse
2
CHAPTER 1â•… Responsibilities for Care in Community/Public Health Nursing 3
Imagine that you are knocking on the door of a residential trailer, BOXÂ€1-1â•…â•‡SELECTED DEFINITIONS
seeking the mother of an infant who has been hospitalized because OFÂ€COMMUNITY/PUBLIC
of low birth weight. You are interested in helping the mother HEALTH NURSING
Â�prepare her home before the hospital discharge of the infant.
Or imagine that you are conducting a nursing clinic in a high- American Nurses Association
rise residence for older adults. People have come to obtain blood Community health nursing is a synthesis of nursing practice and
pressure screening, to inquire whether Â�tiredness is a side effect of Â�public health practice applied to promoting and preserving the health
their antihypertensive medications, or to validate whether their of Â�populations. The practice is general and comprehensive. It is not
recent food choices have reduced their sodium intake. Or picture Â�limited to a particular age group or diagnosis, and it is continuing,
yourself sitting at an office desk. You are Â�telephoning a physical not episodic. The dominant responsibility is to the population as a
therapist to discuss the progress of a school-aged child who has whole; nursing directed to individuals, families, or groups contrib-
mobility problems secondary to cerebral palsy. utes to the health of the total population. … The focus of community
Now, imagine yourself at a school parent–teacher associa- health Â�nursing is on the prevention of illness and the promotion and
Â�maintenance of health.
tion (PTA) meeting as a member of a panel discussion on the
prevention of human immunodeficiency virus (HIV) trans- American Public Health Association
mission. Think about developing a blood pressure screening Public health nursing is the practice of promoting and protecting
and dietary education program for a group of predominantly the health of populations using knowledge from nursing, social, and
African American, male employees of a publishing company. public health sciences. … Public health nursing practice includes
Picture yourself reviewing the statistics for patterns of death in assessment and identification of subpopulations that are at high risk
your community and contemplating with others the value of a for injury, Â�disease, threat of disease, or poor recovery and focusing
hospice program. resources so that services are available and accessible. … [Public
Who would you be to participate in all these activities, with health nurses work] with and through relevant community leaders,
people of all ages and all levels of health, in such a variety of set- interest groups, employers, families, and individuals, and through
tings—homes, clinics, schools, workplaces, and community meet- involvement in Â�relevant social and political actions.
ings? It is likely you would be a community health nurse, and you
would have specific knowledge and skills in public health nursing. Quad Council of Public Health Nursing Organizations
Note that we have used the terms community health Â�nursing Public health nursing is population-focused, community-oriented
Â�nursing practice. The goal of public health nursing is the prevention of
and public health nursing. In the literature, and in Â�practice,
disease and disability for all people through the creation of conditions
there is often a lack of clarity in the use of these terms. Also,
in which people can be healthy.
the use of these terms changes with time (see ChapterÂ€2).
Both the American Nurses Association (ANA, 1980) and the Data from American Nurses Association. (1980). A conceptual model
Public Health Nurses Section of the American Public Health of community health nursing (pp. 2, 11). Washington, DC: Author;
Association (APHA, 1980, 1996) agree that the type of involve- American Public Health Association, Public Health Nursing Section.
(1996). The definition and role of public health nursing: A statement
ment previously described is a synthesis of nursing practice and of APHA Public Health Nursing Section (pp. 1, 4). Washington, DC:
public health practice. What the ANA called community health Author; and Quad Council of Public Health Nursing Organizations.
nursing, the APHA called public health nursing (BoxÂ€1-1). (1999). Scope and standards of public health nursing practice.
In 1984, the Division of Nursing, Bureau of Health Professions Washington, DC: American Nurses Association.
of the Health Resources and Services Administration of the U.S.
Department of Health and Human Services (USDHHS), spon-
sored a national consensus conference. Participants were invited Following the logic of the consensus statements, a registered
from the APHA, the ANA, the Association of State and Territorial nurse who works in a noninstitutional setting and has either
Directors of Nursing, and the National League for Nursing. The received a diploma or completed an associate-degree nursing
purpose was to clarify the educational preparation needed for education program can be called a community health nurse and
public health nursing and to discuss the future of public health practices community-based nursing because he or she works
nursing. It was agreed that “the term ‘community health nurse’ outside of hospitals and nursing homes. However, this nurse
is … an umbrella term used for all nurses who work in a com- would not have had any formal education in public health
munity, including those who have formal Â�preparation in pub- Â�nursing. Such a nurse may provide care directed at individuals
lic health nursing (BoxÂ€1-2 and FigureÂ€1-1). In essence, public or families, rather than populations (ANA, 2007).
health nursing requires specific educational preparation, and Public health nurses provide population-focused care.
community health nursing denotes a setting for the practice of Assessment, planning, and evaluation occur at the population
nursing” (USDHHS, 1985, p. 4) (emphasis added). The consen- level. However, implementation of health care programs and
sus conference further agreed that educational preparation for services may occur at the level of individuals, families, groups,
beginning practitioners in public health nursing should include communities, and systems (ANA, 2007; Minnesota Department
the following: (1) epidemiology, Â�statistics, and research; (2) ori- of Health, 2001; Quad Council of Public Health Nursing
entation to health care systems; (3) identification of high-risk Organizations, 2004). The ultimate question is: Have the health
populations; (4) application of public health concepts to the and well-being of the population(s) improved?
care of groups of culturally diverse persons; (5) interventions Large numbers of registered nurses are employed in home
with high-risk populations; and (6) orientation to regulations health care agencies to provide home care for clients who are
affecting public health nursing practice (USDHHS, 1985). This ill. This text can assist those without formal preparation in
educational preparation is assumed to be complementary to a public health nursing to expand their thinking and practice to
basic education in nursing. Â�incorporate knowledge and skills from public health nursing.
4 CHAPTER 1â•… Responsibilities for Care in Community/Public Health Nursing
BOXÂ€1-2â•…â•‡WHERE ARE COMMUNITY For those currently enrolled in a baccalaureate nursing

HEALTH NURSES EMPLOYED? Â�
education program, this text can assist in integrating Â�public
health practice with nursing practice as part of the formal
1. More than 355,000 registered nurses are employed in community Â�educational preparation for community/public health nursing.
health in the United States (see FigureÂ€1-1), who constitute 14% of The terms community/public health nurse and public
all employed registered nurses. health nurse are used in this text to denote a nurse who has
2. Between 1980 and 2000, the numbers of nurses employed in received formal public health nursing preparation. Community/
Â�community health nursing settings increased by 155% compared public health nursing is population-focused, community-ori-
with an increase of 55% in nurses working in hospitals. ented nursing. Population focused means that care is aimed at
3. Between 2004 and 2008, the numbers of nurses in community improving the health of one or more populations. To save space
health settings remained stable, with fewer working for state and in the narrative of this text, the term community health nurse is
local health departments as a result of government budget cuts. sometimes used instead of community/public health nurse.
4. The largest percentage (47%) of community health nurses work in home
health and hospice agencies to provide nursing care to Â�individuals with
illnesses, injuries, and disabilities and to their families. VISIONS AND COMMITMENTS
5. Almost one in five community health nurses is employed by a local
or state health department or community health or rural health When describing an object, we often discuss what it looks like,
Â�center. These nurses provide primary care services, promote health, what its component parts are, how it works, and how it relates
and prevent illnesses, injury, and premature death. to other things. Although knowledge of structure and function
6. Other community health nurses work with populations associated is important, in interpersonal activities, the exact form is not as
with a specific age group or type of organization: youth in public important as the purpose of the exchange. And the quality of
and parochial schools, students in colleges and universities, indi- our specific, purposeful relationships derives from our visions
viduals in correctional facilities, and adults at work sites. of what might be as well as our commitments to work toward
7. It is not the place of employment that determines whether a nurse these visions.
is a community/public health nurse, however. Instead, community/ Visions are broad statements describing what we desire
public health nurses are distinguished by their education and by the something to be like. They derive from the ability of human
community/population focus of their practice. beings to imagine what does not currently exist. Commitments
Data from U.S. Department of Health and Human Services. (2006).
are agreements we make with ourselves that pledge our energies
The registered nurse population: Findings from the March 2004 for or toward realizing our visions.
National Sample Survey of Registered Nurses. Washington, DC: As a synthesis of nursing and public health practice, commu-
Health Resources and Services Administration, Bureau of Health nity/public health nursing accepts the historical commitments
Professions, Division of Nursing; and USDHHS. (2010). The registered of both. By definition and practice, our caring for clients who
nurse population: Findings from the 2008 National Sample Survey of are ill is part of the essence of nursing. Likewise, we bring from
Registered Nurses. Washington DC: Health Resources and Services
nursing our commitment to help the client take responsibility
Administration, Bureau of Health Professions, Division of Nursing.
for his or her well-being and wholeness through our genuine
interest and caring. We add, from public health practice, our
role as health teacher to provide individuals and groups the
Community mental health opportunity to see their own responsibility in moving toward
and substance abuse
(10,700) health and wholeness.
Correctional
(nonhospital) Community/public health nurses are concerned with the devel-
(14,200) Home health opment of human beings, families, groups, and Â�communities.
Hospice (128,200) Nursing provides us our commitment to assist individuals
(37,500) Â�developmentally, especially at the time of birth and death. Public
health expands our commitment beyond Â�individuals to consider
Occupational the development and healthy Â�functioning of families, groups,
health
(18,800)
and communities.
Public health practice makes its unique contribution to
Â�community/public health nursing by adding to our commit-
ments. These commitments include the following:
School health
1. Ensuring an equitable distribution of health care
(84,400) 2. Ensuring a basic standard of living that supports the health
and well-being of all persons
3. Ensuring a healthful physical environment
These commitments require our involvement with the Â�public
State and local health departments and private, political and economic environments.
and community and rural health centers BoxesÂ€1-3 and 1-4 list the commitments of nursing and public
(61,300)
health, respectively, that are grounded in their Â�historical devel-
FIGUREÂ€1-1â•‡Estimated community health nurses by work opments. These commitments are the foundations on which
sites—2008 (total community health nurses = 355,100). (Data
from U.S. Department of Health and Human Services. [2010]. The regis-
specific professional practices, projects, goals, and Â�activities can
tered nurse population: Findings from the 2008 National Sample Survey be created.
of Registered Nurses. Washington, DC: Health Resources and Services Because our culture is biased toward “doing” (being active,
Administration, Bureau of Health Professions, Division of Nursing.) being busy, and producing), we often are not conscious of
BOXÂ€1-3â•…â•‡COMMITMENTS OF NURSING that we draw on to empower our professional practice and bring
vitality to our relationships with individuals, families, and groups.
1. Patterning an environment of safety and asepsis that promotes Expressing our visions and commitments to others provides
health and protects clients them an opportunity to become partners in working for what
2. Promoting health for individuals by caring for them when they are might be. By having partners, we gain support not only for our
not able to do so themselves because of age, illness, disability, or visions but also for specific projects.
dysfunction
3. Promoting health for individuals and support for families related to
developmental stages (pregnancy, labor and delivery, and care of Janel, the mother in a young family consisting of a mother,
newborns; care of dependent family members; care of dependent a father, and a 2-year-old son with cerebral palsy, called
elderly; care of the dying) the health department during her second pregnancy. She
4. Promoting wellness and integration during illness, disability, requested that a nurse assist her in having a healthy sec-
and dying ond child. No one could guarantee that vision, but Janel's
5. Treating clients equitably without bias related to age, race, gender, Â�willingness to seek a partner in the commitment provided
socioeconomic class, religion, sexual preferences, or culture an Â�opportunity for a nurse–client relationship that would
6. Calling forth the client's commitment to his or her own well-being increase the likelihood of a healthy newborn. The nurse,
and wholeness Shari, and Janel developed specific projects related to, among
other things, financial access to prenatal care, nutrition,
Â�prenatal monitoring, and anxiety management.
BOXÂ€1-4â•…â•‡COMMITMENTS OF PUBLIC
HEALTH
Community/public health nurses often have visions about
1. Patterning of an environment that promotes health health that others do not know are possible. Nurses can educate
2. Promotion of health for families and populations
and speak about visions of health and specific commitments that
3. Assurance of equitable, just distribution of health care to all
can increase the likelihood of particular health possibilities.
4. Creation of a just economic environment to support health and Â�vitality
of individuals, families, groups, populations, and communities
5. Prevention of physical and mental illnesses as a support to the Amos and Joice, a married couple in their sixties, were
wholeness and vitality of individuals, families, groups, populations, Â�committed to remaining self-sufficient. Both had diabetes,
and communities and Joice had had a stroke that resulted in right hemipare-
6. Provision of the greatest good for the greatest number—thinking sis and expressive aphasia. When Joice had to retire from
collectively on behalf of human beings her job, their income declined dramatically. Amos worked
7. Education of others to be aware of their own responsibility to move two jobs and was rarely home to be a companion to his
toward health, wholeness, and vitality
wife. The couple fought about money, and because Joice's
verbal Â�
Â� communication was very slow and unclear, for
the first time in their marriage, they resorted to express-
our visions of what might be. We study, exercise, go out with
ing frustration and anger by hitting each other. Initially,
friends, cook, clean, play with children, invest money, and shop.
the family did not ask Cassandra, the community/public
We can get bogged down in “doing” the activities and projects
health nursing student, for assistance. On one visit, recog-
appropriate to our commitments. For example, if you are com-
nizing that the wife was angry, Cassandra began to explore
mitted to having relationships with friends, recall a time when
the family stressors. The student's vision that “families can
a meeting with friends felt like a duty and obligation. You were
solve problems through communication” made it possible
going through the motions of being together, but you were
for her to discuss the problem with the spouses and solicit
not Â�genuinely relating to your friends. At that moment, you
their commitment to explore alternatives with her. The
were not creating
Â� the relationship from your commitment;
couple eventually agreed to turn to their extended family,
you probably felt burdened rather than enlivened.
social service agencies, and a bank for additional sources of
Likewise, it is possible to get bogged down professionally
revenue. In this situation, it was the nurse who Â�initiated the
by doing the “right” things that public health nurses are sup-
discussion of her vision and enlisted the family Â�members'
posed to do, but not feeling satisfied. We are disappointed that
commitment to exploring possibilities.
results do not show up quickly or that suffering persists. We
create too many professional projects and feel spread too thin.
We burn out. We have discussed two examples of expressing a vision as a
Working on activities directed toward the commitments basis for creating commitments in nurse–client relationships
underlying community/public health nursing does not guaran- and in relationships between the nurse and other service pro-
tee that we will achieve our visions. But not working toward our viders. It is helpful for each nurse to express his or her visions
visions and giving up on our commitments guarantees that we and commitments to peers and supervisors. As nurses, we need
are part of the problem rather than part of the solution in our colleagues to encourage us, work with us, and coach us. Work
communities. Not working toward our visions also results in groups whose members can identify some visions common
dissatisfaction and disconnectedness. to their individual practices and can agree on some common
Remaining in touch with the reasons we are doing some- Â�commitments have a vital source of energy. When we know
thing empowers us. Our vision of healthy, whole, vital individu- what we are for, we can assertively invite others to participate
als, Â�families, and communities, as well as our related commitments, with us. When others are working with us, more possibilities are
can provide a renewing source of energy. And it is hope and energy created for synergistic effects.
DISTINGUISHING FEATURES OF COMMUNITY/ Community/public health nurses seek to empower Â�individuals,

PUBLIC HEALTH NURSING families, groups, community organizations, and other health and
human service professionals to participate in creating
Â� health-
Community/public health nurses are expected to use the ful communities. The prevailing theory about how Â�healthful
nursing process in their relationships with individuals, communities develop has been that individuals and social
Â�
Â�families, groups, populations, and communities (ANA, 2007). groups clarify their identities first and then protect their own
Community/public health nursing is the care provided by rights while also considering the rights of others. More recent
educated nurses in a particular place and time and directed studies on the moral development of women in the United
toward promoting, restoring, and preserving the health of the States suggest that women first participate in a network of
total population or community. Families are recognized as an Â�relationships of caring for others and then consider their own
important social group in which values and knowledge are rights (Gilligan, 1982).
learned and health-related behaviors are practiced. The ideal for a healthful community is a balance of
Â�individuality and unity. Community/public health nurses seek
Healthful Communities to promote healthful communities in which there is individual
What aspects of this definition are different from definitions of freedom and responsible caring for others. It is impossible for an
nursing in general? The explicit naming of families, groups, and individual to consider only his or her desires without infringing
populations as clients is a major focus. Community-based health on the freedom of others. For collective well-being to exist, we
nurses care for individuals and families. Community/public must also be concerned about caring accountability. We must
health nurses also may care for individuals and families; Â�however, “ask about justice, about … each person having space in which
they are cared for in the context of a vision of a healthful com- to grow and dream and learn and work” (Brueggemann, 1982,
munity. Beliefs underlying community/public health nursing p. 50). We must ask about the conditions that promote health.
Â�summarized from ChapterÂ€2 are presented in BoxÂ€1-5. Community/
public health nursing is nursing for social betterment. Empowerment for Health Promotion
Because community/public health nurses often work with
persons who are not ill, emphasis is placed on promoting and
preserving health in addition to assisting people to respond
to illnesses. Although not all illnesses can be prevented and
death cannot be eliminated, community health nurses seek
to empower human beings to live in ways that strengthen
resilience; decrease preventable diseases, disability, and
Â�
Â�premature death; and relieve experiences of illness, vulnerabil-
ity, and suffering.
Empowerment is the process of assisting others to uncover
their own inherent abilities, strengths, vigor, wholeness, and
spirit. Empowerment depends on the presence of hope. Power
is not actually provided by the community/public health nurse.
Empowerment is a process by which possibilities and opportu-
nities for the expression of an individual's being and abilities are
ommunity health nursing focuses on the health of a group,
C revealed. Nurses can assist in this process by fostering hope and
community, or population.
by removing barriers to expression.
Community/public health nurses use the information
BOXÂ€1-5â•…â•‡BELIEFS UNDERLYING
and skills from their education and experiences in medi-
COMMUNITY/PUBLIC HEALTH
cal–surgical, parent–child, and behavioral or mental health
NURSING Â�nursing to assist individuals, families, and groups in Â�creating
• Human beings have rights and responsibilities. Â�opportunities to make choices that promote health and whole-
• Promoting and maintaining family independence is healthful. ness. In community/public
Â� health nursing, nurses rarely
• Environments have an impact on human health. make the choices for Â�others. Instead, as a means of Â�expanding
• Nurses can make a difference and promote change toward health opportunities for others, community/public
Â� Â� health nurses
for individuals, families, and communities. provide Â� information about interpersonal relationships and
• Vulnerable and at-risk populations/groups/families need special alternative ways of doing things. This is especially true when
attention, especially the aged, infants, those with disabilities and community/public health nurses instruct others in how to care
illnesses, and poor persons. for those with illnesses or how generally to support the growth
• Poverty and oppression are social barriers to achievement of health and development of other members of families or groups. For
and human potential. example, a husband might be shown how to safely transfer his
• Interpersonal relationships are essential to caring for others. wife from the bed to a chair, or a young father might be taught
• Hygiene, self-care, and prevention are as important as care of theÂ€sick. how to praise his son and set limits without resorting to threats
• Community/public health nurses can be leaders and innovators in
and frequent punishment.
developing programs of nursing care and programs for adequate
Being related to people can invite a person to risk being
standards of living.
connected and to trust in the face of his or her fears. This is
• Community/public health nursing care should be available to all,
not just to the poor. particularly true for those who have experienced intense or pat-
terned isolation, abuse, despair, or oppression. A nurse is said
to be “present” with a client when the nurse is both physically COMMUNITY

near and psychologically “being with” the person (Gilje, 1993).
Group
Various ways a community/public health nurse can be “present”
are revealed in the case study at the end of this chapter.
Person
Culturally competent care is essential in both public health
Person
and nursing practice (ACHNE, 2010; ANA, 2007; Campinha- Person
Bacote etÂ€al., 1996; USDHHS, 1997). Community/public health
Family Person
nurses must recognize the diverse backgrounds and preferences Person
of the individuals, families, populations, and communities
Person
with whom they work. Cultural influences on health problems,
Organization
health promotion and disease prevention activities, and other
health resources should be assessed. In addition, cultural differ- Person
ences must be considered when developing and adapting nurs-

ing interventions. Person
THEORY AND COMMUNITY/PUBLIC Person
HEALTHÂ€NURSING Person
Nursing practice is based on the concepts of human beings,

health and illness, problem-solving and creative processes, and
the human–environment relationship (Alligood & Marriner-
Tomey, 2010; Hanchett, 1988). Our environment includes
Â�physical, social, cultural, spiritual, economic, and political facets.
FIGUREÂ€1-2â•‡ Social systems.
Our knowledge of these concepts evolves from several routes,
including personal experience, logic, a sense of right and wrong
(ethics), empiric science, aesthetic preferences, and an under-
standing of what it means to be human (Alligood & Marriner- Compared with inpatient settings, the environments in
Tomey, 2010). Concepts are labels or names that we give to our Â�
community/public health nursing practice are more variable
perceptions of living beings, objects, or events. Theories are a set and less controllable (Kenyon etÂ€al., 1990). General Â�systems
of concepts, definitions, and hypotheses that help us describe, theory provides an umbrella for assessing and analyzing the
explain, or predict the interrelationships among concepts Â�various clients and their relationships with dynamic environ-
(Alligood & Marriner-Tomey, 2010). ments. In this text, family and community assessments are
Although Florence Nightingale began the formal develop- approached from a general systems framework.
ment of nursing theory, most theory development in nurs- Each open system has the same basic structures (Smith &
ing has occurred since the 1960s (Choi, 1989). Alligood & Rankin, 1972) (FigureÂ€1-3, A). FigureÂ€1-3, B, is an example
Marriner-Tomey (2010) describe the work of numerous nurs- of application of the open system model to a specific organi-
ing theorists. (Obviously, we cannot discuss all of them here.) zation. The boundary separates the system from its environ-
In community/public health nursing, general systems theory ment and regulates the flow of energy, matter, and information
Â�provides a way to link many of the concepts related to Â�nursing. between the system and its environment. The environment is
The nursing theories of Johnson (1989), King (1981), Neuman Â�everything outside the boundary of the system. The skin acts
and Fawcett (2002), and Roy (Roy & Andrews, 1999) rely, as a Â�physical boundary for human beings. A person's preference
in part, on general systems theory. Perspectives on client–Â� for Â�relatedness is a more abstract boundary that helps deter-
environment Â�relationships from these theories are discussed mine the Â�pattern of interpersonal relationships. Family bound-
later in this chapter. aries might be determined by law and culture, such as a rule that
a family consists of blood relatives. A family can have more open
General Systems Theory boundaries and define itself by including persons not related
An open system is a set of interacting elements that must by blood. Groups, organizations, and some Â�communities have
exchange energy, matter, or information with the external envi- membership criteria that assist in defining their Â�boundaries.
ronment to exist (Katz & Kahn, 1966; von Bertalanffy, 1968). Other community boundaries might be geographic and
Open systems include individuals as well as social systems such Â�political, such as city limits.
as families, groups, organizations, and communities with whom Outcomes are the created products, energy, and Â�information
the community/public health nurse must work (FigureÂ€1-2). that emerge from the system into the environment. Health
Systems theory is especially useful in exploring the numerous behaviors and health status are examples of outcomes. External
and complex client–environment interchanges. For example, influences are the matter, energy, and information that come
a community/public health nurse might provide postpartum from the environment into the system. External influences
home visits to a woman and her newborn, simultaneously can be resources for or stressors to the system. Each system
focusing on the adjustment of the entire family to the birth. The uses the external influences together with internal resources to
same nurse might also teach teen parenting classes in a high achieve its purposes and goals. Feedback is information chan-
school and monitor the birth rates in the community, identi- neled back into the system from its environment that describes
fying those populations at statistical risk of having low-birth- the Â�condition of the system. When a nurse tells a mother that
weight infants. her child's blood pressure is higher than the desired range,
ENVIRONMENT:
(includes suprasystem)
UNDARY
BO
INTERNAL
EXTERNAL structures
and OUTCOMES:
INFLUENCES:
processes
Internal feedback
A EXTERNAL FEEDBACK:
ENVIRONMENT:
Spiritual –Elderly revered Political –Legislators responsive to requests of elderly
Physical –Air pollution Economic –High unemployment; many youth have left city
Social –High street crime Cultural –Eastern European descent
SUPRASYSTEM: City Department of Aging
D
EXTERNAL INFLUENCES: BOUN ARY: M OUTCOMES:
em
Money from Dept. of be Health status of residents
Structures
Aging for Eating (i.e., mortality rate,
rs
Resident council
Together Program incidence of falls, use
hi
Physical safety
p c
of health resources,
Legislation and rules features
risk factors such as
governing residence
Processes rite hypertension,
ria–55 ye
Information regarding Communication functional levels)
health Emotional climate Craft products sold in city
Decision-making
Resources such as Lobbying efforts for seniors
availability of primary
a r
health care provided INTERNAL FEEDBACK: Quality of life

s a
Satisfaction with residence

nd
Extended family support

o
ve
r o
r d
isabled
EXTERNAL FEEDBACK:
Information that rate of falls is higher than in
B other similar residences
FIGUREÂ€1-3â•‡ A, Model of an open system. B, Residence for older adults viewed as an open system.
the nurse is providing health information as feedback to the the health care subsystem, the educational subsystem, and the
mother. Feedback provides an opportunity to modify system Â�economic subsystem.
functioning. The mother can then decide when and where to Systems might relate as separate entities that interact, or
seek Â�medical evaluation. they might create a variety of partnerships and confederations.
Each system is composed of parts called subsystems. Systems might be hierarchical. The suprasystem is the next larger
Subsystems have their own goals and functions and exist system in a hierarchy. For example, the suprasystem of a county
in Â�relationship with other subsystems. In a human being, is the state; the suprasystem of a parochial school might be the
the gastrointestinal system is an example of a subsystem. In church or the diocese that sponsors the school.
social systems, the subsystems might be structural or func- The assumptions that relate to all open systems (von
tional. Structural subsystems relate to organization. Examples Bertalanffy, 1968) are similar to those underlying holism in
of structural subsystems are a mother–child dyad in a fam- nursing (Allen, 1991) and the ecological model of health in
ily or the nursing department in a local health Â�department. public health (Institute of Medicine, 2003):
Functional subsystems are more abstract and relate to 1. A system is greater than the sum of its parts. One Â�cannot
Â�specific purposes. For example, the subsystems of organiza- understand a system by studying its parts in isolation.
tions have been Â�conceptualized as production, maintenance, For example, we cannot make inferences about the health
Â�integration, and adaptation (Katz & Kahn, 1966). Subsystems Â�status of a family unless we inquire about the health status
of a Â�community are often named by their function, such as of each member. However, knowing the health history and
Â�
present status of individual members does not tell us how Self-Care
the family addresses its health concerns. Knowing the parts Self-care is “the production of actions directed to self or to
is Â�necessary, but not sufficient, to describe the health of the the environment in order to regulate one's functioning in the
family system. Â�interests of one's life, integrated functioning, and well-being”
2. The primary focus of systems theory is the relationship of (Orem, 1985, p. 31). Self-care depends on knowledge, resources,
the parts, not the parts per se. Life is dynamic. When and action (Erickson etÂ€al., 1983). The concept of self-care
nurses assess a family or community at a specific time, theÂ� is consistent with the community/public nursing focus on
assessment is more like a photograph than a movie. empowerment of persons and groups to promote health and to
Exploring how the Â�system has changed, how the individual care for themselves.
members affect each other, and how the system interacts Although each person is responsible for his or her own
with the environment helps the assessment to become health habits, the family and community have responsibilities to
more like a movie. Â�support self-care (USDHHS, 1995). The family is the Â�immediate
3. A change in one part of a system affects the whole system. source of support and health information. The Â�community
Change is a part of life. It might be accompanied by suffer- has responsibilities to provide safe food, water, air, and waste
ing because of either the type of change (an accident) or disposal; enforce safety standards; and create and support
Â�
the quantity of the change (too many changes exceed the opportunities for individual self-care (USDHHS, 1995). When
resources). At other times, change brings relief and strength- the focus is on self-care, the family and community are viewed
ened resources. primarily as suprasystems to individuals.
4. Elements of one system can also be parts of another system.
For example, a college student also belongs to a family, social Client–Environment Relationships
groups, and perhaps a religious organization. Nursing theories acknowledge that humans live within an envi-
5. Exchanges between a system and its environments tend to ronment (Alligood & Marriner-Tomey, 2010). Nurses are Â�caring
be circular or cyclical. Interaction exists between the system professionals within clients' environments and Â�influence clients
and its environment. For example, in a community with a through direct physical care, provision of information, inter-
high percentage of hazardous occupations, a high Â�accident personal presence, and environmental management. Nursing
rate might increase the rates of disability and unemploy- theories that build on general systems theory tend to place
ment within families. Because the unemployed pay less more emphasis on the environment than do other nursing
income tax, less money is available to develop services for Â�theories (Hanchett, 1988). The continuously changing environ-
those with Â�disabilities within a community that has a high ment requires that the client expend energy to survive, perform
disability rate. Such a community has fewer resources, and activities of daily living, grow, develop, and maintain harmony
therefore, new businesses might find it a less attractive or balance. Clients must adapt within a dynamic environment
Â�location. Although a single cause-and-effect relationship (TableÂ€1-1). (Also see ChapterÂ€9 on environment.)
cannot Â�usually be Â�established, health problems are inter-
connected with social concerns. In the community just Public Health Theory
described, accident rates might be related to unemployment Public health theory is concerned with the health of human
and economics. populations. Public health is a practice discipline that applies
6. Human beings and social systems seek to survive and to avoid knowledge from the physical, biological, and social sciences
disorganization and randomness (or entropy). As social sys- to promote health and to prevent disease, injury, disability,
tems develop, they tend to become more complex, with spe- and premature death. Epidemiology is the study of health in
cialized structures and functions. Organizations often change human populations and is explored in more detail in ChapterÂ€7.
their goals rather than disband when they have achieved Population, prevention, risk, and social justice are among
their original goals. A multitude of health care professions, the concepts from public health theory that are Â�important
services, programs, and equipment have developed within to Â�community health nursing. The first three concepts are
the U.S. health care system. Community/public health Â�discussed here, and justice is discussed later in this chapter.
nurses must recognize this complexity when helping others
access health care and when proposing changes. Populations and Risk
7. Systems operate with equifinality, meaning that the same end Population has two meanings: people residing in an area, and a
point can be reached from a variety of starting points and group or set of persons under statistical study. The word group
through various paths. There is not one right way. Culture is used here to mean a set or collection of persons, not a system
influences child-rearing practices among families, for of individuals who engage in face-to-face interactions, which is
Â�example, and local communities organize their health care the definition of group used in the discussion of systems Â�theory.
Â�services differently. The fact that there are many definitions for population and
group leads to lack of clarity and fosters debate and dialogue.
Nursing Theory Both definitions of population are used in public health and
Nursing theories are based on a range of perspectives about community health nursing. The initial goal of public health
the nature of human beings, health, nursing, and the environ- was to prevent or control communicable diseases that were
ment. Most nursing theories have been developed with individ- the major causes of death within human populations (i.e., the
ual Â�clients in mind (Hanchett, 1988). However, many concepts Â�people living in specific geographic or political areas). Today,
from the different nursing theories are applicable to Â�nursing that for example, a director of nursing in a city health department
addresses families and communities. The concepts of Â�self-care is concerned with the health of the population within the city
and environment are introduced here. limits. When used in this way, population means all the people
TABLEÂ€1-1â•…â•‡PERSPECTIVES community/public health nurses apply the problem-solving

ON CLIENT–ENVIRONMENT process. For example, aggregates can be identified by virtue
of setting (those enrolled in a well-baby clinic), Â�demographic
RELATIONSHIPS IN SELECTED
characteristic (women), or health status (smokers or those with
NURSING THEORIES
hypertension) (APHA, 1980, 1996). It is the community/Â�public
RELATIONSHIP OF CLIENT health nurse who identifies the aggregate by naming one or
THEORIST ANDÂ€ENVIRONMENT more common characteristics.
Dorothy Johnson Clients attempt to adjust to environmental
factors. Strong inputs from the environment
might cause imbalance and require excess
energy to the point of threatening the
existence of the client. Stable environments
help clients conserve energy and function
successfully.
Sister Callista Roy Clients attempt to adjust to immediate
environmental excesses or absences within
a background of other stimuli. Successful
adaptation allows survival, growth,
and improved ability to respond to the
environment.
Imogene King Clients interact purposefully with other people
and the environment. Health is the continuous
process of using resources to function in daily Children in a sports league are one example of a group because
life and to grow and develop. they have one or more characteristics in Â�common as well as a
Betty Neuman Clients continuously interact with people and face-to-face relationship.
other environmental forces and seek to defend
themselves against threats. Health is balance The terminology for statistical groups and aggregates is
and harmony within the whole person. Â�
confusing. Although there are subtle differences, the terms
Â�at-risk population, specified population, and population group
Data from Alligood, M., & Marriner-Tomey, A. (2010). Nursing theorists are used to mean aggregate. The APHA (1980, 1996) uses the
and their work (7th ed.). St. Louis: Mosby.
term at-risk population in place of the term aggregate. In its
description of community health nursing, the ANA (1980) uses
in the area or community. The noun public is often used as a the term specified population. Others use population group to
Â�synonym for this definition of population. mean a population that shares similar characteristics but has
Because not everyone has the same health status, the Â�second limited face-to-face interaction (Porter, 1987). It is important
definition of population—a set of persons under Â� statistical to remember that regardless of which of these terms is used,
study—is especially important in public health practice. Using such a Â� population is not a system. The individuals within
this definition, a population is a set of persons having a Â�common these Â�populations are not classified because of interaction or
personal or environmental characteristic. The common char- Â�common goals. It is the community/public health nurse who
acteristic might be anything thought to relate to health, such conceptually classifies, collects, or aggregates the individuals
as age, race, gender, social class, medical diagnosis, level of into such a population. The individuals within such a popu-
Â�disability, exposure to a toxin, or participation in a health-seek- lation often might not even know one another. The nurse has
ing behavior such as smoking cessation. It is the researcher or identified the population to focus intervention efforts toward
health care practitioner who identifies the characteristic and health Â�promotion and prevention.
set of Â�persons that make up this population. In epidemiology,
numerous sets of persons are studied clinically and statisti- Prevention
cally to identify the causes, methods of treatment, and means Prevention is a complex concept that also evolved from an
of Â�prevention of diseases, accidents, disabilities, and premature attempt to control diseases among the public. Epidemiology
deaths. In community/public health nursing, epidemiologi- is the science that helps describe the natural history of specific
cal information is used to identify populations at higher risk diseases, their causes, and their treatments. The natural history
for specific preventable health conditions. Risk is a statistical of a disease includes a presymptomatic period, a symptomatic
Â�concept based on probability. Community/public health nurs- period, and a resolution (death, disability, complications, or
ing is concerned with human risk of disease, disability, and recovery) (Friedman, 2003). The broad concept of prevention
premature death. Therefore, community/public health nurses has three levels: primary, secondary, and tertiary. The goal of pri-
work with persons within the population to reduce their risk mary prevention is the promotion of health and the Â�prevention
for developing such a health condition. of the occurrence of diseases. Activities of primary prevention
Aggregate is a synonym for the second definition of include environmental protection (such as maintaining asep-
Â�population. Aggregates are people who do not have the related- sis and providing clean water) and personal protection (such
ness Â�necessary to constitute an interpersonal group (system) but as providing immunizations and establishing smoke-free areas).
who have one or more characteristics in common, such as preg- The goal of secondary prevention is the detection (screening)
nant teenagers (Schultz, 1987). Williams (1977) focused atten- and treatment of a disease as early as possible during its natural
tion on the aggregate as an additional type of client with whom history. For example, Papanicolaou (Pap) smear testing allows
cervical cancer to be detected earlier in the disease process so BOXÂ€1-6â•…â•‡MAJOR GOALS FOR
that cure is more likely. Tertiary prevention is geared toward COMMUNITY/PUBLIC HEALTH
preventing disability, complications, and death from diseases.
NURSING
Tertiary prevention includes rehabilitation.
All levels of prevention can be accomplished through work • Care of the ill, disabled, and suffering in nonhospital settings
with individuals, families, and groups. Prevention can also be • Support of development and well-being throughout the life cycle
accomplished by targeting changes in the behaviors of specified • Promotion of human relatedness and mutual caring
populations, changes in social functioning of communities (law, • Promotion of self-responsibility regarding health and well-being
social mores), and changes in the physical environment (waste • Promotion of relative safety in the environment while conserving
disposal). The well-being and health of the entire population resources
within the community is the ultimate goal of public health. • Reduction of health disparities among populations
From Smith, C. M. (1985). Unpublished data. Baltimore: University of
GOALS FOR COMMUNITY/PUBLIC Maryland School of Nursing.
HEALTHÂ€NURSING
Care is always in the here and now, responsive to the needs of NURSING ETHICS AND SOCIAL JUSTICE
specific persons, in a specific place, at a specific time. It is always
personal and intimate. Even when community/public health The goals of community health nursing reflect the values and
nurses work with other professionals and community groups, beliefs of both nursing and public health. Each profession has
they express care through recognition of the uniqueness of each an ideology, or set of values, concepts, ideas, and beliefs, that
of the others. defines its responsibilities and actions (Hamilton & Keyser,
There are several major goals for community health Â�nursing 1992). Ideologies are linked closely with ethics—the study of,
(BoxÂ€1-6). TableÂ€1-2 identifies examples of health outcomes and thinking about, what one ought to do (i.e., right conduct).
for each of the goals for each category of client. All nurses Public health and nursing are based on the same ethical prin-
address these goals, but most do so with individuals, hospi- ciples: respecting autonomy, doing good, avoiding harm, and
talized Â�individuals and their families or friends, and small treating people fairly (Fry, 1983; Wallace, 2008) (TableÂ€1-3).
groups. In Â�addition to formulating these goals with individu- These principles are sometimes in conflict. Issues related to
als, Â�community/Â�public health nurses do the same with Â�families, application of these principles are discussed in case examples
groups, aggregates, populations, and organizations/systems in Ethics in Practice boxes (see ChaptersÂ€8, 9, 21, 23, 24, 25, 26,
within the community. 27, and 28).
TABLEÂ€1-2â•…â•‡EXAMPLES OF HEALTH OUTCOMES RELATED TO GOALS OF COMMUNITY/

PROMOTION
SUPPORT OF SUPPORT OF PROMOTION OF OF HEALTHFUL
CARE OF THE ILL DEVELOPMENT RELATEDNESS SELF-RESPONSIBILITY ENVIRONMENT
Individual Individual learns Teenage mother adjusts Adult joins group for Adult child of alcoholic Homeless person seeks
self-management of to newborn care socialization seeks counseling shelter
diabetes mellitus
Family Family cares for member Extended family decides Family with disabled Family identifies Older adult couple
with terminal cancer how best to care for child seeks out other preferences of members improves safety in the
aging grandparents such families home
Group Children with physical Junior high school Several women in a Women at a mother and Mothers Against Drunk
disabilities are cared students explore residence start a children's center take on Driving advocates
for in school responsibility sharing group responsibilities in the laws against driving
regarding sexual center while intoxicated
activity
Aggregate/ Barriers are identified Work site program * Work site program for Curriculum is developed
Population in a number of clients regarding counseling for health risk for schools regarding
regarding failure to preretirement planning reduction is initiated burn prevention
return for tests of cure is established
after antibiotics
Community Hospice program is Regulations for safe A network of case Crisis hotline is established Waste recycling program
initiated in a city daycare are passed as management is is established
country ordinance established for
discharged clients with
psychiatric disorders
*By definition, aggregates are individuals or families with common characteristics who are identified as such by the community health nurse or
other professional. If such clients become known to one another and develop a sense of belonging or support, the aggregate would become a
group or community.
TABLEÂ€1-3â•…â•‡ BASIC ETHICAL PRINCIPLES IN HEALTH PROFESSIONS

PRINCIPLE DEFINITION EXAMPLE
Altruism Concern for the welfare of others Being present
Beneficence Doing good Providing immunizations
Nonmaleficence Avoiding harm Not abandoning client
Respect for autonomy Honoring self-determination (i.e., right to make Allowing client to refuse treatment, informed
one's own decisions; respecting privacy) consent; maintaining confidentiality
Veracity Truth-telling Communicating authentically and not lying
Fidelity Keeping promises Arriving on time for home visit
Justice Treating people fairly Providing nursing services to all, regardless of
ability to pay
Data from American Association of Colleges of Nursing. (1986). Essentials of college and university education for professional nursing, Washington,
DC: The Association; and Beauchamp, T., & Childress, J. (2008). Principles of biomedical ethics (6th ed.). New York: Oxford University Press.
Ethical Priorities ethic and a society-focused ethic (Fry, 1983; Hamilton &
Historically, the ANA Code for Nurses (ANA, 1985, p. 2) stated Keyser, 1992). Community/public health nurses consider both
that the most important ethical principle of nursing practice is ethical perspectives.
“respect for the inherent dignity and worth … of human exis- How does a nurse respect the autonomy of individuals while
tence and the individuality of all persons” (BoxÂ€1-7). However, securing health for many? There is no single “right” answer.
because public health is concerned with the well-being of the The question needs to be asked often and answered anew as
entire population, the foremost ethical principle of public circumstances change. At times, the community/public health
health practice is doing good for the greatest number of persons nurse's decision will be to protect the autonomy of an indi-
with the least amount of harm. Consequently, in community vidual while working for environmental changes that seek to
health nursing, there is a tension between an individual-focused protect many. For example, a community/public health nurse
honors a Â�teenager's autonomy and does not force him or her
to avoid smoking cigarettes. However, the nurse can lobby for
higher cigarette taxes that decrease consumption, for enforce-
BOXÂ€1-7â•…â•‡CODE OF ETHICS FOR NURSES
ment of laws prohibiting cigarette sales to minors, and for
1. The nurse, in all professional relationships, practices with compas- substance-free Â�
Â� recreation centers. Both nursing and public
sion and respect for the inherent dignity, worth, and uniqueness of health ideologies value education and environmental modifiÂ�
every individual, unrestricted by considerations of social or Â�economic cations over coercion.
status, personal attributes, or the nature of health problems. The ANA (2008, p. 149) acknowledges that there are “situa-
2. The nurse's primary commitment is to the client, whether an tions in which the right to individual self-determination may be
Â�individual, family, group, or community. outweighed or limited by the rights, health, and welfare of oth-
3. The nurse promotes, advocates for, and strives to protect the ers, particularly in relation to public health considerations.” For
health, safety, and rights of the client. example, in an airplane disaster, one individual already close to
4. The nurse is responsible and accountable for individual Â�nursing death might be allowed to die to save several others. Individual
practice and determines the appropriate delegation of tasks
Â� autonomy might also be curtailed by involuntary confinement
Â�consistent with the nurse's obligation to provide optimal client care.
if a person is threatening to commit suicide or to abuse or kill
5. The nurse owes the same duties to self as to others, including
another, or if the person has a drug-resistant form of tubercu-
the responsibility to preserve integrity and safety, to maintain
losis. Community quarantine may be necessary to prevent the
Â�competence, and to continue personal and professional growth.
6. The nurse participates in establishing, maintaining, and improv- spread of an outbreak of avian flu.
ing health care environments and conditions of employment
Distributive Justice
Â�conducive to the provision of quality health care and consistent
with the Â�values of the profession through individual and collective A more difficult issue emerges when we consider the number of
actions. individuals with competing interests and needs. “Quality health
7. The nurse participates in the advancement of the profession care is a human right for all” (ANA, 2008). If so, what kind, and
through contributions to practice, education, administration, and how much? Nursing is working to “ensure the availability and
knowledge development. accessibility of high-quality health services to all persons whose
8. The nurse collaborates with other health professionals and the health needs are unmet” (ANA, 1985, p. 16).
Â�public in promoting community, national, and international efforts How are health care, nursing, and other social services
to meet health needs. to be distributed within the population? How are healthful
9. The profession of nursing, as represented by associations and environments to be created and hazards reduced? Justice is
their members, is responsible for articulating nursing values, for an ethical concept concerned with treating human beings
Â�maintaining the integrity of the profession and its practice, and for fairly. Nurses are to provide competent, personalized care,
shaping social policy. regardless of an individual client's financial, social, or per-
From Fowler, M. (Ed.). (2008). Guide to the Code of Ethics for nurses: sonal characteristics (ANA, 2007). Distributive justice is
Interpretation and application. Silver Spring, MD: American Nurses the ethical concept Â� concerned with the fair provision of
Association. Â�opportunities, goods, and services to populations of people.
Because the nursing code of ethics focuses primarily on the do we determine who has a reasonable chance of benefiting?
care of individuals, community health nurses also need other In our democratic society, there are competing interests, and
perspectives of justice in helping to provide ethical care to the process is ongoing. Potentially, all community Â�members,
populations (Fry, 1985). Â�government leaders, nurses, and other health care profession-
There are two perspectives for determining justice when als contribute to priority setting. Community/public health
working with populations: egalitarian (equal) and utilitarian Â�nursing practice and research contribute information to help
(Fry, 1985). In an egalitarian system of justice, each person has answer these questions. An ethic that includes social justice also
equal access to equal health services. Providing every person in helps focus priorities.
a country with access to basic health services is an example of There is a constant tension between facilitating the Â�freedom
egalitarian justice. In a utilitarian system of justice, resources of individuals and nurturing a community in which people
are distributed so as to provide the greatest good for the great- feel connected enough to care for one another. One of our
est number with the least amount of harm. When resources challenges as community/public health nurses is to Â�
Â� foster
are limited, the utilitarian perspective is helpful. At times, indi- Â�communities in which people experience their interconnec-
viduals might be harmed under the utilitarian perspective. The tion and treat one another justly. In the remainder of this
airplane disaster mentioned earlier is an example of utilitarian Â�chapter, the specific responsibilities and competencies that
decision making. With utilitarian justice, it is important to try assist Â�community/public health nurses in working for social
to determine the benefits and risks of an action (Wallace, 2008). betterment are explored.
A health care system does not meet the criterion for justice
if health care services are provided only to those who can THE NURSING PROCESS IN COMMUNITY/
pay. In such a system, health care is provided unequally (only PUBLICÂ€HEALTH
to those who can afford it), and the good of the entire popula-
tion is not considered. Public Health Nursing: Scope and Standards of Practice (ANA,
2007) was developed in concert with the steps of the nursing
Â�
Social Justice process and indicates that community/public health nurses
Our public health ethic goes further. Not only is health care are to apply the entire nursing process to promote the “health
considered a right, but “a basic standard of living necessary for of the public” (p. 88). To improve the health of one or more
health” is also a right (Winslow, 1984). Furthermore, a health- populations, baccalaureate-prepared community/public health
ful environment and protection from environmental hazards nurses often implement programs with individuals, Â�families,
are prerequisites for health (Kotchian, 1995). Because environ- and groups to promote health and wellness (BoxÂ€1-8).
mental risks are greater for some individuals, groups, families, Masters-prepared Â�
Â� community/public health nurses “develop
and populations, environmental issues have been framed as and Â�evaluate programs and policy designed to prevent Â�disease
social justice issues (Lum, 1995). If hazardous waste is dumped and promote health for populations at risk” (ANA, 2007,
Â�primarily in low-income communities, justice is not achieved. pp.Â€88–89). These standards describe both a competent level of
Social justice is explicitly defined in the most recent edition nursing care provided to clients (see BoxÂ€1-8) and a Â�competent
of Public Health Nursing: Scope and Standards of Practice: level of behavior within the profession (discussed later in the
chapter under Quality Assurance). Therefore, standards of clin-
[Social justice is] the principle that all persons are Â�entitled ical Â�community/public health nursing practice help define the
to have their basic human needs met, regardless of Â�differences scope and quality of community/public health nursing care;
in economic status, class, gender, race, ethnicity, Â�citizenship, they also help to distinguish community/public health nursing
religion, age, sexual orientation, disability or health. This from other nursing specialties. One of the particular Â�features
includes the eradication of poverty and illiteracy, the of the Â�specialty is that community/public health nurses are
Â�establishment of sound environmental policy, and equality Â�concerned with the health of communities.
of opportunity for healthy personal and social development. How do community/public health nurses work with
(ANA, 2007, p. 43) communities? Community/public health nurses use demo-
Â�
As discussed in the history of public health nursing in graphic and epidemiological data to identify health problems
ChapterÂ€2, public health nursing is rooted in social justice. of Â�families, groups, and populations; community/public health
However, social justice has not been consistently described in nurses incorporate knowledge of community structure, organi-
recent national nursing documents (Bekemeier & Butterfield, zation, and resources in developing solutions to meet the needs
2005). Fahrenwald and colleagues (2007, p. 190) advocate for of families, groups, and populations (Quad Council, 1999).
public health nursing faculty to assist “students to understand From this point of view, the community might be seen as part
and participate in social justice actions that aim to amend … the of the environment or suprasystem of the families, groups, and
social conditions that influence health and the delivery of health populations.
care.” Other public health nursing scholars Â�recommend that The ANA (1980) makes a distinction between direct and
social justice “from a population vantage point” be Â�recognized as indirect care in community health nursing. Direct Â�community/
the central concept in public health nursing (Schim etÂ€al., 2007). public health nursing care is the application of the nursing
Â�
Creating a just society and a just health care system in a con- process to individuals, families, and groups and involves
text of limited resources is a major challenge in the twenty-first face-to-face relationships. Direct care includes management
century. Questions that are being asked to determine health care and coordination of care. For example, a community/Â�public
priorities for populations are, for example, the following: Who health nurse who performs a developmental assessment of an
decides what is good? What are the benefits and risks? How do infant, teaches the mother about age-appropriate play, and
we weigh the short-term and long-term benefits and risks? How administers immunizations is engaged in direct care. Indirect
BOXÂ€1-8â•…â•‡STANDARDS OF CARE All professional nurses are expected to collaborate with their
OFÂ€PUBLIC HEALTH NURSING peers to improve nursing care and to collaborate with others to
develop new health resources and “ensure safe, legal, and ethical
PRACTICE
health care practices” (AACN, 1986, p. 18). Therefore, we might
Standard 1: Assessment ask: How is community/public health nursing distinct from other
The public health nurse collects comprehensive data pertinent to the specialties? One distinction is that community/public health
health status of populations. nursing has a broader perspective and is concerned with the
health of the entire community and all of the aggregates within
Standard 2: Population Diagnosis and Priorities it. A second difference is that the direct care in community health
The public health nurse analyzes the assessment data to determine
is targeted toward individuals, families, groups, and aggregates
the population diagnoses and priorities.
based on those at risk (Quad Council, 1999). Care is not provided
Standard 3: Outcomes Identification just to those who seek it. It is the responsibility of community/
The public health nurse identifies expected outcomes for a plan that is public health nurses to identify those who might benefit from
based on population diagnoses and priorities. health promotion and health prevention, as well as those with ill-
nesses and disabilities who are not receiving care (ANA, 2007).
Standard 4: Planning
The public health nurse develops a plan that reflects best practices RESPONSIBILITIES OF COMMUNITY/PUBLIC
by identifying strategies, action plans, and alternatives to attain
expected outcomes.
HEALTH NURSES
Community/public health nurses have a basic set of responsiÂ�
Standard 5: Implementation
bilities regardless of where they work. The traditional
The public health nurse implements the identified plan by partnering
Â�historical responsibilities of community/public health nurses
with others.
(see ChapterÂ€2) are summarized in BoxÂ€1-9. At present, the
Standard 5A: Coordination Minnesota model for public health nursing practice, known
The public health nurse coordinates programs, services, and other as the interventions wheel or the Minnesota wheel, describes
activities to implement the identified plan. 17 Â�public health interventions that may be focused on (or
targeted to) Â�several levels of practice: individuals/families,
Standard 5B: Health Education and Health communities, and systems
Â� that impact population health
Promotion (Minnesota Department of Health, 2001). Although these
The public health nurse employs multiple strategies to promote health, interventions are also used by other public health disciplines,
prevent disease, and ensure a safe environment for populations. the constellation of interventions and the levels of practice
Standard 5C: Consultation
“represent public health nursing as a specialty practice of
The public health nurse provides consultation to various community nursing” (Minnesota Department of Health, 2001, p. 1). The
groups and officials to facilitate the implementation of programs and Public Health Nursing Section of the Minnesota Department
services. of Health developed this practice-based model and with a
grant from the federal Division of Nursing identified support-
Standard 5D: Regulatory Activities ing evidence from the literature, research, and expert opinion
The public health nurse identifies, interprets, and implements public (Keller etÂ€al., 2004a, 2004b). The interventions wheel is pre-
health laws, regulations, and policies. sented in FigureÂ€1-4. TableÂ€1-4 includes Â�definitions of each
of the interventions. This model is being used to strengthen
Standard 6: Evaluation public health nursing Â�practice, Â�education, and management
The public health nurse evaluates the health status of the population.
From American Nurses Association. (2007). Public health nursing: Scope
and standards of practice. Silver Spring, MD: Author. Public Health Nursing: BOXÂ€1-9â•…â•‡RESPONSIBILITIES
Scope and Standards of Practice is currently out of print. Please refer to
the newly revised edition that is scheduled to be released in early 2013.
OFÂ€COMMUNITY/PUBLIC
HEALTH NURSES
community/public health nursing does not involve interper- 1. Providing care to the ill and disabled in their homes, including
sonal relationships with all persons who benefit from care. teaching of caregivers
Priorities are determined after assessing the health status of the 2. Maintaining healthful environments
entire population and aggregates, the existing resources, the 3. Teaching about health promotion and prevention of disease and
environment, and the social mechanisms for solving problems injury
(American Association of Colleges of Nursing [AACN], 1986). 4. Identifying those with inadequate standards of living and untreated
Goals include Â�promotion of self-help and appropriate use of illnesses and disabilities and referring them for services
health resources by Â�community members, development of new 5. Preventing and reporting neglect and abuse
Â�services, and provision of effective, adequate direct nursing 6. Advocating for adequate standards of living and health care services
7. Collaborating to develop appropriate, adequate, acceptable health
care services (ANA, 1980). Indirect care also includes the use of
care services
political, social, and economic means to ensure a basic standard
8. Caring for oneself and participating in professional development
of living for community members. A nurse who writes a grant activities
Â�proposal for providing primary health care to a rural p
Â� opulation 9. Ensuring quality nursing care and engaging in nursing research
is engaged in indirect community/public health nursing care.
Di
icy
Pol ment &
Surveillance He sease
a
l o p n t Inv lth Ev &
e est
e
Dev forcem iga ent
tion
l En
Population-Based
cia ting
O
o e
ut
S k
ar
re
ac
M
h
Population-Based
cy
Scr
oca
Cas
een
e
Adv
Fi n
din
ing
g
Population-Based
Community
Organizing
Referral &
Follow-up
Individual-Focused
ent
Co lding
Bui
Ma Case
em
alit
nag
ion
Community-Focused
C
ol
la ed
bo g at ns
ra Systems-Focused le tio
tio
n De unc
F
Con lth
sult
atio Hea ing
n c h
Counseling Tea
FIGUREÂ€1-4â•‡Minnesota Public Health Interventions Wheel (March, 2001). (From Minnesota

Department of Health, Division of Community Health Services, Public Health Nursing Section. [2001]. Public
health interventions: Applications for public health nursing practice. St. Paul: Author.)
(Keller etÂ€al., 2004a, 2004b). (More information about this home (see ChapterÂ€31), and the decreased length of hospital
model can be found at the end of this chapter under the stays resulting from efforts to reduce hospital costs.
Community Resources for Practice). Care of individuals in the home today builds on care that
Several responsibilities stand out as being of great importance nurses have learned to provide in institutional settings. Whatever
for baccalaureate-prepared community/public health nurses: theoretic framework is used for viewing the needs and health
(1) identification of unmet needs; (2) advocacy and referral to problems of individuals, with creativity, it can be transferred to
ensure access to health and social services; (3) teaching, especially the home setting. Generally, a family's access to 24-hour home
for health promotion and prevention; (4) screening and case nursing care for sick family members depends on the family's
finding; (5) environmental management; (6) collaboration and ability to pay for such services. Most insurance policies limit
coordination; and (7) political action to advocate for adequate payment for nursing care for persons with illnesses in their
standards of living and health care services and resources. In the homes to the intermittent performance of specific treatment
following discussion of nursing responsibilities in community/ procedures and to the nurse's instructing a family member or
public health, direct care of the clients who are ill is discussed other caregiver in 24-hour care.
first because it is the responsibility with which nurses are most As is discussed in Unit Three, a distinguishing feature of
Â�familiar. (See ChapterÂ€19 for an in-depth discussion of screening community/public health nursing is that care is provided from a
and case finding and ChapterÂ€13 for family care management.) family-focused model, which is broader than, and qualitatively
different from, an individual-focused model. The community
Direct Care of Clients with Illness, Infirmity, Suffering, health nurse is concerned not only with the health of the iden-
and Disability tified client but also with the health of other family members,
“Doing for” those who cannot do for themselves because of ill- especially the caregiver, and the family as a unit.
ness, infirmity, suffering, or disability is the historical basis of Populations also can experience illness and suffering as a
nursing. Hospitals and nursing homes have been the places result of natural or human-caused disasters such as Hurricane
where most nursing care has been provided in the United Katrina in New Orleans. ChapterÂ€22 discusses emergency
States during the twentieth century. However, home care of Â�preparedness and nursing during disasters.
persons with illnesses by nurses preceded hospital care. Since
the mid-1960s, care for clients with illnesses in their homes has Referral and Advocacy
reemerged as a significant mode of care. Reasons for this include Community/public health nurses often encounter individuals
the aging of the population, the relatively high Â�prevalence of who have significant concerns, untreated diseases, or unmet
chronic Â�diseases, reimbursement for skilled nursing care in the needs related to a basic standard of living (food, clothing,
TABLEÂ€1-4â•…â•‡ PUBLIC HEALTH INTERVENTIONS WITH DEFINITIONS

PUBLIC HEALTH INTERVENTION DEFINITION
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 Systematically gathers and analyzes data regarding threats to the health of populations,
investigation 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.
Screening Identifies individuals with unrecognized health risk factors or asymptomatic disease conditions
in populations.
Case-finding Locates individuals and families with identified risk factors and connects them with resources.
Referral and follow-up Assist individuals, families, groups, organizations, and/or communities to identify and access
necessary resources 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.
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 that best meets 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, E., Lee, J., Cohen, J. [1995]. Collaboration: A concept analysis, Journal of
Advanced Nursing, 21, 103–109.)
Coalition building Promotes and develops alliances among organization 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 buildings for health.
New Brunswick, NJ: Rutgers University Press, p. 30.)
Advocacy Pleads someone's cause or acts 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 maker's 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.
From Minnesota Department of Health, Division of Community Health Services, Public Health Nursing Section (2001); and Minnesota Department
of Health, Division of Community Health Services, Public Health Nursing Section. (2001). Public health interventions: Applications for public health
nursing practice. St. Paul: Author. Retrieved December 19, 2011, from http://www.health.state.mn.us/divs/cfh/ophp/resources/docs/phinterventions_
manual2001.pdf
Â�
shelter, transportation) or who have experienced oppression Referral is the process of directing someone to another
such as neglect or abuse. The community/public health nurse source of assistance. The community health nurse is expected to
is not expected to independently solve all existing problems. make assessments with clients, discuss the possible significance
When problems cannot be managed solely by the nurse and of such findings, explore the meaning of the experience with the
client, the community/public health nurse assists the client in client, and refer the client to appropriate resources. This process
seeking appropriate resources. is discussed in more depth in ChapterÂ€19.
To facilitate a match between the client's need and the the ill at their homes, especially in relation to nutrition, Â�comfort,
Â�
available resources, the community health nurse must be aware and maintaining a healthful, clean home. For practical reasons,
of the channels for accessing that help. Assessing the presence it is mandatory that family members or other caregivers both
and quality of other health and social resources is a skill that provide nursing care and follow the medical treatment plan for
Â�community/public health nurses learn. There are some resources the sick person. Community health nurses have provided this
such as welfare departments, faith communities, and schools teaching and continue to do so today, especially in home health
that exist in all geopolitical areas. There are other resources care. For example, individuals newly diagnosed with hyperten-
such as drug detoxification units that may not be found within sion and their families or significant others are taught about
easy traveling distance or may have waiting lists. A community/ taking multiple medications, modifying dietary intake, and
public health nurse should not be surprised if it takes up to 6 employing relaxation techniques.
months to feel knowledgeable about the resources in a specific
community. Keeping abreast of the changes in the resources, Preventing Illness and Injury
their services, and contact persons is an ongoing activity. All life involves risk of disease, injury, and premature death.
Unless a service requires that a referral be initiated by a However, individuals have choices that affect their risks. Nurses'
health professional, clients are usually encouraged to initiate knowledge of these risks depends on the prevailing evidence
the contact. At times, clients will be reluctant to pursue a refer- about the natural history of diseases, epidemiology, modalities
ral because they are afraid or do not know how to make requests for early detection and treatment, methods of protection and
for themselves. Others might be unable to pursue the referral prevention, and determinants of human behavior. Community/
because of limits in functioning or inadequacy of means (such public health nurses apply this information in education for
as lack of fluency in English or not having a telephone). In such prevention of disease, injury, and premature death.
instances, community/public health nurses attempt to empower For example, we know that smoking is a risky behavior
the client to overcome barriers and Â�initiate referral contacts. that has been related to cancer, heart disease, and lung disease
Community/public health nurses have the option of advocat- and that alcohol consumption by a pregnant woman harms
ing for the client. Advocacy is the action of speaking or writing her fetus. Treatment of childhood asthma reduces the num-
on behalf of someone else and using persuasion in support of ber of days missed from school. Use of bicycle helmets and
another. This requires the skill of assertive communication and automobile seat belts reduce head injuries. Safer sex practices
the knowledge of communication channels within and among and Â�sexual abstinence reduce the likelihood of transmission of
organizations. Especially in large, bureaucratically administered HIV. A basic truth about the teaching–learning process is that
programs, special channels for complaints and appeals exist if information alone is not Â�sufficient to change human behavior.
services have been denied. As health care consumers, clients have Telling someone what to do or how to do it will not result in
general legal rights that can be inquired about through a state modified behavior unless the Â�person can relate the behavior
attorney general's office. In addition, administrators of health care to his or her values and goals and believes that the behav-
programs can provide information about client rights related to ior change will contribute to the Â�achievement of aspirations.
specific programs (such as Medicare insurance for older adults). Consequently, the clarification of values is a primary strategy
In some circumstances, families, groups, or popula- in identifying and changing people's health-related attitudes
tions do not have access to a health service or a social service. (see ChapterÂ€10).
Community/public health nurses can advocate for a population
by networking with others for the development of such services. Promoting Wellness and Transcendence of Suffering
For example, a community/public health nurse might work A primary responsibility of community/public health nurses
with other professionals, religious leaders, welfare-rights advo- is teaching to promote health (see ChapterÂ€18). Each of us has
cates, and homeless persons to develop a primary health care a perception of what is necessary to promote health, which
site for the homeless. Advocacy is linked with being a leader in depends, in part, on our definition of health (Benner & Wrubel,
collaborating with others. 1989). If health is viewed as the ability to fulfill our social roles,
we will be interested in learning about what will support us in
Teaching performing activities of daily living, communicating, thinking,
Teaching is the process of imparting cognitive knowledge, skills, problem solving, and relating to others. If we define health as
and values. Nurses have information and skills that make them a commodity, we will be interested in learning what will repair
Â�specialists in caring for the ill; preventing diseases, illnesses, disabil- or replace our deficiencies, and what will cure or “fix” us. If we
ities, suffering, and premature death; and promoting well-being. define health as the ability to adapt, we will be interested in
“Self-determination, independence, and choice in decision Â�making learning about stress-reduction techniques, the resources avail-
in health matters” is of “highest regard” to nurses (ANA, 1980, able for support, and the methods of environmental control.
p. 18). Because community/public health nurses work with people If we view health as well-being, we will be interested in learn-
in various stages of wellness, community health nurses have Â�special ing to create meaning and a sense of belonging in our lives and
opportunities to foster human development and capabilities to accept that total control and autonomy are not possible. For
through client education. The teaching process is discussed in more example, a family with a child who has severe developmental
depth in ChapterÂ€20. Anticipatory guidance is education that occurs delays might focus on providing loving care for each family
before the client is expected to need to act on the information. member, even though they cannot predict exactly what the child
might be able to learn to do as he or she develops.
Following Nursing and Medical Plans Nurses working in acute care settings with the critically ill
Community/public health nurses have always imparted infor- and dying have opportunities to promote well-being by help-
mation and demonstrated to family members how to care for ing the clients and their family members to find meaning and
interpersonal connectedness. Community/public health nurses of health care and other community resources. Community/Â�
also have opportunities to address well-being with those dying public health nurses often analyze data collected by others and
at home or in hospices. Steeves and Kahn (1987, p. 116) discuss can participate in data collection, especially as it relates to the
ways to reduce suffering by establishing conditions for “expe- need for and client responses to nursing care. Monitoring the
riences of meaning.” Meaning cannot be imparted through health of communities is an interdisciplinary process.
providing information or skills; rather, through discussions, Both objective and subjective information are collected dur-
meaning might be discovered as a possibility by the client. When ing monitoring. Because nursing is concerned with human
the nurse attends carefully to the verbal and nonverbal messages experiences and responses (ANA, 2010), it is insufficient for
of the client and family members, the nurse might help them community health nurses to monitor objective information
discover what will provide meaning within the experience of such as physiological outcomes, patterns of death and illness,
suffering and death (Callanan & Kelley, 1993). See ChapterÂ€31 health-related behavior, and the presence and quality of com-
for more about hospice care. munity resources. Subjective meaning and life experiences also
In community/public health nursing, there are circum- must be explored. What do clients think about their health sta-
stances besides illness and a client's impending death that evoke tus? What are their foremost health concerns? Interviews, con-
the need for finding meaning. The death of a loved one, divorce, versations, and surveys are some of the ways community health
abuse by a family member, unemployment, neglect, loss of one's nurses learn how clients view their own health needs.
home by fire or foreclosure, and acts of prejudice are examples.
Policy Enforcement and Development
Surveillance, Monitoring, and Evaluation Because our culture values individual autonomy highly, and
Community health nurses monitor the health of individuals, because nursing and public health both value human growth
families, populations, and communities. Monitoring is the veri- and self-actualization, most health-related interventions do
fication of the state or condition of health, and evaluation is the not involve coercion. However, there are instances in which
determination of the significance or value of this information. the rights of the majority take precedence over the rights of
Assessment also denotes determination of the state of health Â�individuals. To protect the health of the family or community,
and involves the collection and analysis of data; reassessment individual autonomy might be limited. Most states have laws
might occur at a later time. A distinction between monitoring that protect nurses from liability for reporting neglect, abuse,
and reassessment is that monitoring implies either a continuous and threats of bodily harm by clients to themselves or others.
process or short intervals between episodes of data collection Many states also provide forced treatment to, or curtail the
and evaluation. behavior of, individuals who have specified communicable dis-
Monitoring the health of individuals in their homes and in eases such as tuberculosis and who refuse to protect others from
clinics differs from monitoring patients in hospitals. In inpa- exposure. In these circumstances, community health nurses
tient settings, many individual patients are monitored continu- develop their skill in balancing persuasion with enforcement,
ously because of the acuteness and instability of their diseases and empowerment with coercion (Zerwekh, 1992b).
and illnesses. When people with illnesses are cared for in their Community/public health nurses employed by local or state
homes, the family is taught what to monitor and what is sig- health departments have special responsibilities as agents of gov-
nificant to report to the nurse or other health care professional. ernment to enforce selected public health laws (see ChapterÂ€6).
The nurse, in collaboration with the physician and other health For example, if a source of food poisoning has been attributed
care professionals, determines the frequency of monitoring by to an infected food handler, it will likely be the community
health care professionals. health nurse who explains to the restaurant employee why stool
In clinics, protocols are often used to schedule the next cultures (with negative results for specific microorganisms) are
appointment. For example, individuals receiving antibiotics are required before he or she can return to work.
often scheduled to return after 10 days for evaluation of treatment Social and public policy development are also a responsibil-
Â�effectiveness; women are rescheduled annually for Pap testing. ity of community/public health nurses to promote social justice
When providing family-centered care, the Â�community/Â�public (ANA, 2010). For example, in 2012, to reduce human expo-
health nurse determines the frequency of monitoring based on sure to toxic substances, nurses worked to update federal policy
the health status of the family, the preferences of the family, and regarding control of toxic substances.
agency policy. When determining the frequency of contact with
families, the nurse must always consider any life-threatening sit- Environmental Management
uation and the family's perception of priorities. Environmental management means (1) the control of those things
Monitoring the health of groups, aggregates, and communi- in the immediate surroundings to protect human beings from
ties involves collecting and evaluating information about popu- disease and injury, or (2) the promotion of a place Â�conducive
lations. Monitoring the health of populations and communities to healing and well-being. Environmental management also
is called surveillance (Minnesota Department of Health, 2001). includes the conservation of resources and limitation of pollu-
Demographic and epidemiological data are used to determine tion in the environment (see ChapterÂ€9). Providing asepsis and
age distributions, mortality, morbidity, and risky behavior of safety are basic ethical and legal responsibilities of all nurses in
populations (see ChapterÂ€7). Surveillance is an ongoing pro- managing the physical aspects of the environment. The ANA
cess to detect trends in health status and determinants of health Code of Ethics (Fowler, 2008) also calls for nurses to relate to
(Meagher-Stewart, etÂ€al., 2009). Disease and other health event clients in ways that promote their dignity and respect their reli-
investigation involves identification of cases and determina- gious, cultural, and political preferences. Nurses are expected
tion of control measures. Unit Two discusses data important to foster interpersonal and social environments that recognize
for determining the availability, accessibility, and acceptability Â�cultural differences and promote the dignity of all persons.
Institutional Environments use of environmental resources for humans, the need to focus
Some community/public health nurses are employed by local on the conservation, regeneration, and sustainability of natural
or state governments to inspect daycare centers (for children resources, where possible, has been recognized.
and adults), nursing homes, and residential care settings as part Health care professionals are recognizing that the social
of quality control of the environment (see ChapterÂ€29). School environment is especially important when considering such
nurses, employed by health departments or school boards, also concerns as teen pregnancy, poverty, homicide, suicide, and
seek to promote healthful environments, especially to prevent substance abuse. Community/public health nurses are explor-
communicable diseases, injuries, substance abuse, and violence ing ways to strengthen human connectedness, promote a basic
(see ChapterÂ€30). standard of living, and reduce dependence on violence as a
means of conflict resolution.
Home Environments
Community/public health nurses who make home visits Case Management, Coordination of Care, and
and those who work in clinics have special responsibility for Delegation
assisting families to provide safe home environments. The Coordination is bringing together the parts or agents of a plan
kinds of injuries that can occur depend, in part, on the ages or process into a common whole. Community/public health
of the family members, characteristics of housing structures, nurses work within complex community networks of resources
limitations in the activities of daily living, family members' to coordinate care for clients in a variety of ways. Community/
knowledge about prevention, and presence of specific hazards. public health nurses coordinate or manage care through case
Falls, burns, poisoning, and gunshot wounds are prevalent management, caseload management, site management, and
injuries in U.S. homes. coordination of teams.
Clean, orderly physical environments and safe, adequate Case management refers to the development and coordina-
food, water, and waste disposal are to be provided in hospitals tion of a plan of care for a selected client, usually an individ-
and other institutions. In homes, families have this immediate ual or family. In community/public health nursing, it includes
responsibility. Some families might need information on what both coordination of care and service provision (Minnesota
constitutes safe preparation and storage of food. For Â�example, Department of Health, 2001). This is similar to the concept of
parents might not realize that their infants can be made ill primary nursing in the hospital. Case management depends
by microorganisms growing in improperly stored formula. on the nurse's ability to accurately assess client needs and
Community/public health nurses can provide informa- community resources. The community/public health nurse
tion about proper formula preparation and storage. At other works with the client and the other disciplines and resources
times, families might not have sufficient food because of involved to create and manage a coherent plan of care that
chronic poverty or an emergency. Community/public health neither overwhelms the client nor results in the overlooking
nurses assist the family in obtaining the necessary resources in of some needs; in addition, the plan of care is cost effective
such circumstances. and Â�efficient (see ChapterÂ€13). The goals of case manage-
To promote development and well-being, community/pub- ment include promoting client self-care, facilitating access to
lic health nurses instruct family members in such tasks as pro- resources, and creating new services (Bower, 1992). Within
viding stimulation for infants, communicating with bed-bound managed care organizations, cost containment is also a goal of
family members, and exploring the meaning of health and case management (see ChapterÂ€4).
Â�well-being with those who experience pain or isolation. Caseload management refers to the coordination of care for a
number of clients for whom the community/public health nurse
Occupational Environments is accountable. Caseload management involves the community/
ChapterÂ€9 describes occupational health nursing as a subspe- public health nurse's self-management, time management, and
cialty of community health nursing. As part of their Â�practice, resource management for numerous clients during a speci-
occupational health nurses seek to limit hazards in the Â�workplace fied period. Community/public health nurses often schedule
and to promote safer working habits. their own workdays and determine who will receive home vis-
its, who will be scheduled for clinic appointments, when phone
Community Environments calls and meetings will take place, and how much time will be
The environmental responsibilities of community/public health devoted to each activity. Travel time must also be Â�considered.
nurses do not stop at the physical boundaries of homes or insti- Community/public health nurses need to make certain that
tutions. Through observations in communities and discussions they have Â�sufficient supplies such as forms for documentation,
with clients and others, community/public health nurses are health teaching materials, and biologics for immunization.
in special positions to observe hazards and the environmen- Site management refers to the coordination of nursing effort
tal concerns of community members (Afzal, 2007; Lum, 1995). at a specific geographical place such as a clinic, school, or office
Community/public health nurses can collaborate with others for community/public health nurses, where nursing care is
such as sanitarians, environmental scientists, and environmen- planned and provided. Although community/public health
tal advocacy groups (see ChapterÂ€9). nursing supervisors usually manage nursing administrative
The view of the environment primarily as a suprasystem to offices, community/public health nurses might be responsible
be controlled and used for human consumption is evolving to for the equipment, cleanliness, and efficiency of clinic sites and
an ecological view that the survival of humans as a global com- nursing areas in schools.
munity is inextricably linked with the environment. There is Community/public health nurses are often the Â�coordinators
more focus on living not in, but in relationship with, the envi- of direct care teams. Management of nursing teams is the
ronment (Kotchian, 1995). Rather than focusing solely on the Â�coordination of care provided by nurses, nursing assistants,
licensed practical nurses (LPNs) (called licensed vocational Community health nurses also help create professional–
nurses in some states), nurse practitioners, homemakers, and community partnerships to assist communities in planning to
parent aides. This is identical to the concept of team nursing improve their health (ANA, 2007; Bushy, 1995). The goal is
in inpatient settings except that the community/public health to strengthen a community's competence to interact, develop
nurse is not always immediately available to the nursing team solutions to community problems, and promote health.
member. Management often occurs via telephone calls, meet-
ings, and intermittent on-site supervisory visits. Community/ Consultation
public health nurses might delegate to nonbaccalaureate Consultation means the seeking of advice, especially from an
Â�registered nurses, LPNs, nursing assistants, and others such as expert or professional. Community/public health nurses are
Â�homemakers, parent aides, and community workers. experts in community health nursing by virtue of education
Coordination of personnel in multiple disciplines can occur and experience. Community health nurses also are experts on
within a single organization. For example, within a health the health status and needs of families, population groups,
department immunization clinic, there might be nurses, sec- aggregates, and the community with which they work. This is
retaries or receptionists, social workers, and dietitians. The especially true in regard to the needs for nursing care services.
community/public health nurse might be the designated coor- Community/public health nurses have special knowledge of the
dinator of services. At other times, the community/public health meaning of health for the people they serve.
nurse might emerge as coordinator because he or she is the one Legally, community/public health nurses can be called as
who initiates the interdisciplinary communications across two expert witnesses to testify in courts about the quality of care ren-
or more organizations. The latter often occurs because the com- dered by other community health nurses. Some state nurses'
munity/public health nurse has frequent contact with the Â�client associations establish criteria for expert witnesses and maintain
and has developed a meaningful relationship with the client. lists of qualified nurses (see ChapterÂ€6).
Coordination occurs through phone calls, meetings, and shar- Community/public health nurses seek expert opinions from
ing of written client records. As coordinator, the nurse needs to nurses, other professionals, agency representatives, key leaders
ensure that written records of discussions and decisions are kept or informants, and clients themselves. For example, if a parent
and shared with team members, consistent with confidentiality is giving his or her child a chemical home remedy, the nurse
laws and policies. might consult with a registered pharmacist about the clinical
compounds and their actions, and perhaps with a community
Partnership/Collaboration elder regarding the cultural meaning of the remedy.
Collaboration means working together and denotes that the
participants have relatively equal influence. Collaboration can Social, Political, and Economic Activities
occur informally or formally. It takes place among nursing peers, The ANA (2010, p. 89) asserts that all of nursing derives from
Â�community members, and interdisciplinary professional teams. a social contract that permits autonomy within the profession
Peer sharing occurs when nurses share with each other their as long as nurses act “responsibly, always mindful of the public
experiences, both successful and disappointing ones, in provid- trust.” Community/public health nurses were the first nurses to
ing care. It is an educational process and a means for giving and focus on identifying the health needs of populations, promoting
receiving support. adequate standards of living, and facilitating and encouraging
Networking means the establishment and maintenance of people to care for themselves.
relationships with other professionals and community lead- Public health practice seeks to collectively “assure condi-
ers for the purpose of solving common problems, creating new tions in which people can be healthy” (Institute of Medicine,
projects or programs, identifying experts for future consulta- 1988, p. 7). The three core public health functions of government
tion, maintaining mutual support, or enlisting others to work in fulfilling that mission are (1) assessment of the community,
toward common goals. (2) assurance that services are provided, and (3) health policy
Community/public health nurses can be team members of development. Community health nurses are in key positions to
multidisciplinary teams that plan and provide direct care. The contribute to these functions (ACHNE 2010; ANA, 2007). See
care is organized, but not through one coordinator. Rather, ChapterÂ€29 for more detail.
each team member is seen as having something to contribute Community/public health nurses, by virtue of their spe-
that is of equivalent value, and the whole team is held account- cial commitment to the health of communities, are called on
able for results. In practice, influence varies among the mem- to be involved in the social power structures in the health care
bers, but influence is not dependent on a designated leader system and in the larger community. What would be a more
or coordinator. healthful balance of individual choices and social responsibil-
Membership in community planning groups is essential for ity in our culture? How can nurses model and advocate for a
collaborating with interagency and community-wide planning more humane society? Community/public health nurses might
groups. Such groups exist to assess the health status and needs work for change within existing systems and work to change the
of the entire community or populations, to target recipients of Â�systems themselves. Social action is the influencing of decisions
direct care, to develop additional health care services, and to in a community.
evaluate the quality of existing care. Individuals who are seen
as influential in their respective fields are usually included as Change within Existing Power Structures
members. They are expected to contribute their perspectives to Change is a continuous process. There is room for change
collaborative planning. Community/public health nurses have within the existing organizations and governmental struc-
relevant contributions because they know about nursing, and tures. Assessment of unmet health needs followed by the
they can advocate for client needs as well. creation of nursing services through social planning is one
example (see Unit Four). Identification of population groups health for a community should include equity, empowerment,
at special risk and development of outreach, screening, and and cooperation (Maglacas, 1988). Although these values are
educational programs for them is another example. Nurses inherent in care and responsibility, they are not dominant values
exert influence to promote change. in our culture. Dominant values within the American culture
Coalition building involves community/public health nurses' include preferences for quick fixes, action, production and tech-
development of linkages or alliances among organizations or nology, material goods, control of natural resources, individual
those persons with similar interests. Change is targeted primar- autonomy, and hierarchical power structures. What would it
ily at health care and other systems (Minnesota Department of take to transform our current structures of power to allow the
Health, 2001). emergence of values that are currently subordinate? How can
Such changes can be encouraged through political and speaking about our values, and what we are for, transform the
Â�economic strategies. Political action depends on the use of current structure into a more balanced and caring community?
power to influence decisions. Governments make many public Specific answers to these questions are still being created.
health decisions. Community/public health nurses can support Many nurses are speaking for more human Â�connectedness
the election of those sympathetic to community needs. and caring in our communities (Aroskar, 1987; Benner &
Nurses can influence policy development, that is, the devel- Wrubel, 1989; Cumbie, Hagedorn, & Wagner, 2006; Leininger,
opment of legislation and administrative rules and regulations. 1984; Maglacas, 1988; Moccia, 1988; Watson, 1988). National
Policy development places health issues, plans of action, and and state interests in health care reform provide opportuni-
provision of resources on decision makers' agendas (Minnesota ties for nurses to advocate for equitable health care for all and
Department of Health, 2001). This can be done by Â�testifying to apprise policy makers of the contributions of community/Â�
at hearings, participating on task forces, supplying written public health nurses.
testimony, and personally visiting legislators. Lawsuits can
Â�
The process of “enabling people to increase control over and
be initiated as an attempt to influence judicial decisions. For
to improve their health” represents a mediating strategy
Â�
example, the APHA and the ANA worked together to Â�challenge
between people and the environments in which they live,
the first President Bush's executive order that temporarily
synthesizing personal choice and social responsibility to
Â�prohibited health care professionals from discussing abortion
Â�create a healthier future. (Maglacas, 1988, p. 68)
in clinics that received federal funding.
Political action also includes attempts to influence decisions
made by nongovernmental groups. For example, a commu- Nursing's role was always to extract from the bureaucracy its
nity/public health nurse employed by the health department hidden humanity and use it to “civilize the system,” to bring
might assist the local mental health association in obtaining caring into interpersonal relations. (Jessie Scott, quoted in
grant money from a private foundation to establish a substance Moccia, 1988, p. 31)
abuse hotline. A contextual question for each community health nurse
Economic action depends on the use of money to influ- might be: How does my practice further a more caring or
ence social decisions. Money is contributed to political action socially just community?
Â�committees (PACs) to support those candidates for political In summary, all nursing is concerned with public and non-
office who espouse specific values and health programs. For governmental decisions that shape health care services and
example, the ANA PAC contributes money to the campaigns of delivery systems and affect access to care. Community/public
those supportive of the nursing profession. Financial decisions health nurses have special concerns related to adequate stan-
also can affect business policy. For instance, some profession- dards of living, appropriate and adequate health care and social
als Â�boycotted imaging equipment made by a major company services for the underserved and at-risk populations, environ-
because it also made nuclear bombs; the boycott was ended mental management and preservation, and empowerment of
when the company sold its defense business. community members.
Becoming Part of Power Structures. Obtaining membership
in decision-making groups is another way to increase Â�influence. Empowerment for Creativity
Having nurses in political office and as members of planning
Â� Empowerment depends on the presence of hope or an expec-
bodies increases the influence of the nursing profession. tation that “what is not” could actually be. Empowerment
Community/public health nurses can recognize power imbal- is blocked by “magical thinking,” in which a desire or wish
ances and injustices that oppress individuals and groups. Nurses itself is held as the solution to a problem. Rather, empow-
can empower disenfranchised people such as the poor, cultural erment involves the creation of a vision of what is desired
minorities, and persons with disabilities, to become members of and the development of a plan to work toward that vision.
influential groups or to form their own organizations. The planner should take into consideration the reality of
During the past 25 years, nurses have become better Â�educated the circumstances.
in the areas of business and economics so that they can partici- Empowerment consists of more than solving problems or
pate as full partners in the business of health care. Equality in fixing what does not work. For example, a man with paraplegia
a flawed health care system has its value, but also has its Â�limits who is living in the community has hope that he can become
(Reverby, 1987). Although business participation increases more mobile and envisions himself as a participant in sports.
nurses' power within existing structures, it is Â�important that A plan is created, depending on what sports he is interested in,
nursing also seeks to make the health care system more eÂ� quitable and involves the creation of equipment adapted to his physical
and caring for clients. capabilities and limitations. There is no ready-made means to
Changing Power Structures. According to a former chief of achieve his vision, and he might not be able to achieve exactly
nursing of the World Health Organization, the values Â�underlying what he envisioned. Yet, were it not for the original vision, even
the current degree of exercising and participating in sports As humans, we are social beings. To care for others, we must
would not have come about. be cared for (Wallinder, 1997). To be cared for, we must be in
At the community level, community organizing helps com- relationships with others who are able and willing to give to
munity groups identify common problems or goals and use us, and we must be willing to receive (Karl, 1992). Nurses often
strengths to mobilize resources to plan and implement strate- are so committed to caring for others that a conscious effort
gies for goal achievement (Minnesota Department of Health, must be made to include sufficient “being cared for.” In our
2001). Communities take control of their lives and resources own lives, we must address the issues that also confront families
through collective action. See ChapterÂ€16. and Â�communities. Given your specific circumstances, what is a
Empowerment allows creation of new ways of being and workable balance between your own individuality and “being
doing and provides for transformation—that is, going beyond in Â�community”? You can ask yourself what balance you want to
the next obvious step to radical shifts. Fritz (1989) discusses how establish between the professional and personal aspects of your
individuals can move from reaction and response to the circum- life. There is no right way to work toward knowing ourselves
stances of life to creativity. Chinn (2008) describes a process by and developing our empiric, experiential, and moral knowledge.
which caring communities can be created in groups. Duncan Carper (1978) proposed four patterns of knowing: (1)
(1996) includes political action and community development empiric or factual knowledge; (2) knowledge that emerges from
as strategies for empowering communities (see Unit Four). The experiential acquaintance with others; (3) self-knowledge; and
possibility of a culture more balanced between autonomy and (4) ethical knowledge, which involves moral judgments. There
relatedness exists for the future. are other schemes for thinking about knowing.
Changing the structures of power and the dominant cul- TableÂ€1-5 describes some ways in which nurses can develop
ture of our society depends on empowerment of ourselves and different patterns of knowing to promote professional develop-
others to envision an equitable, cooperative society in which ment. TableÂ€1-6 provides specific examples of knowledge that
individuals have the opportunity to develop their uniqueness, emerge from different ways of knowing.
regardless of age, race, gender, culture, sexual orientation, or
Nursing, therefore, depends on the scientific knowledge
economics and “to be” in a caring community. Does this sound
of human behavior in health and in illness, the aesthetic
like a magical wish? It might be—or it can be a vision of com-
Â�perception of significant human experiences, a personal
munity toward which to strive.
understanding of the unique individuality of the self, and
Self-Care and Development the capacity to make choices within concrete situations
involving particular moral judgments. (Carper, 1978, p. 22)
Professional development is a lifelong process. To continue to
give accurate information to others, we must stay informed. To
continue to stay in touch with our own concerns and commit- EXPECTED COMPETENCIES
ments, we need caring professional partners and persons who OF Â�BACCALAUREATE-PREPARED COMMUNITY/
will listen to and coach us when we have forgotten our calling. PUBLIC HEALTH NURSES
To continue to competently perform therapeutic treatments,
we must have opportunities to learn from other nurses Generalists in community/public health nursing are those pre-
and practice new skills. To assist others in finding mean- pared at the baccalaureate level (ACHNE, 2010; ANA, 2007;
ing in life's circumstances, we must continue to face our own APHA, 1996; Quad Council, 2004, 2012). Such commu-
Â�imperfections, vulnerabilities, and mortality and to re-create nity/public health nurses are expected to be able to apply the
Â�meaning for our lives. entire Â�nursing process with individuals, families, and groups
TABLEÂ€1-5â•…â•‡WAYS OF DEVELOPING PATTERNS OF KNOWING

FACTUAL EXPERIENTIAL ETHICAL SELF-KNOWLEDGE
Reading Joining peer sharing groups and Studying human rights Participating in counseling
interest groups regarding professional
experiences
Studying logic and analysis Studying codes of ethics Clarifying values
Continuing education Exploring values underlying Participating in spiritual study
goalsÂ€and actions and worship
Extending formal education Studying art, music, dance Studying philosophy Clarifying commitments
Participating in quantitative Perceiving own experiences Studying ethical frameworks Accepting uncertainty
research Participating in qualitative research
Participating in study groups Exploring meaning with clients Participating on ethics panels
Observing and describing Seeking cross-cultural experiences, Continuing education/formal
traveling education regarding ethics
Becoming aware of own creativity Exploring own ethical decisions
Envisioning personal desires
Continuing education regarding
creativity
Categories of knowing adapted from Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-23.
TABLEÂ€1-6â•…â•‡WAYS OF KNOWING RELATED is especially important when resources and environments are
TO THE EXAMPLE OF INFANT severely Â�compromised, as occurs in some household settings.
New baccalaureate-prepared community/public health nurses
FEEDING
are expected to independently and proficiently use numerous
KNOWLEDGE ROUTE* EXAMPLE skills and to adapt them to client needs. Such skills include those
Experiential related to medication use, treatment, management of the envi-
Personal and interpersonal You have cared for a newborn and ronment, asepsis, documentation, and provision of assistance
experience experienced your own alertness with activities of daily living (AACN, 1986).
and anxiety when the infant cried. The AACN expects recent baccalaureate graduates to seek
You have felt satisfaction when the supervision (validation of performance) when exercising the
infant quieted during feeding. following skills (AACN, 1986, pp. 20-23):
Factual 1. Administering developmental, functional, and psychosocial
Logic You use knowledge of nutrition and screening tools
physiology to assist the infant in 2. Using consultation skills
rooting and in sucking formula or 3. Monitoring psychological crises and using crisis Â�intervention
breast milk. skills
Empiric science You ask whether there are different 4. Analyzing results of evaluation tools, such as surveys of Â�client
types of cries. You systematically satisfaction with nursing care
observe infant crying patterns and
5. Resolving conflict
read research reports.
6. Using change strategies as coordinators of care and as
Ethical
Ethics You wonder whether crying is good/
Â�members of the profession
helpful or bad/unhealthy for the
Direct Care with Families
infant.
Self Novice community health nurses with baccalaureate degrees are
Aesthetic preferences You prefer a quiet environment, expected to apply the nursing process with limited supervision
without infant crying. while adapting care to the “preferences and needs” of families
Understanding of what it You recognize that every culture has a (AACN, 1986). Goals of family care include providing support
means to be human way of caring for human infants and during the death of a family member, fostering “family growth
that specific details might differ. during developmental transitions,” and promoting “family
integrity and autonomy” (AACN, 1986, pp. 11-12).
*Knowledge routes adapted from Carper, B.A. (1978). Fundamental
patterns of knowing in nursing. Advances in Nursing Science, 1(1),
By conducting interviews and taking family histories, commuÂ�
13–23; and Alligood, M., & Marriner-Tomey, A. (2010). Nursing theorists nity health nurses should collect and analyze the following
and their work (7th ed.). St. Louis: Mosby. information about the family system (AACN, 1986, p. 9):
• Family development
• Structure and function
to Â�promote health and wellness. The individuals, families, and • Communication patterns
groups targeted for direct community/public health nursing • Decision making
care are to be selected on the basis of the results of population- • Family dynamics and behavior
focused and community-wide analysis. Baccalaureate-prepared • Family dysfunction
nurses are expected to assist advanced practice community/pub- Historically, family assessment is the competency that com-
lic health nurses with master's degrees, interdisciplinary teams, munity health nursing educators in baccalaureate programs
and community members in conducting community-wide have ranked the most important (Blank & McElmurry, 1986;
data collection, analyses, and priority setting. It is the Â�generalist Quad Council, 2012).
community/public health nurses who often implement the
Â� The predominant intervention strategies used with families
interventions that emerge from such community planning. are primary care, health teaching (including anticipatory guid-
Through direct delivery of care, coordination, health educa- ance), referral, and collaboration in and coordination of care
tion and promotion, consultation, and regulatory activities (AACN, 1986). In their survey of all baccalaureate Â�programs
(ANA, 2007), the nurses ensure that health care is available and accredited by the National League for Nursing, Blank and
Â�accessible (Quad Council, 1999). Generalist community health McElmurry (1986) determined that educators emphasized
nurses also Â�participate in collecting data used for Â�evaluation of these competencies regardless of geographical location and size
Â�nursing care. or type of curriculum. Ability to perform these intervention
strategies is consistent with the responsibilities of community/
Direct Care with Individuals public health nurses in family case management and caseload
In the direct care of individuals in nonhospital settings, new management. Family care is explored further in Unit Three.
baccalaureate graduates are expected to apply the nursing
process with limited supervision—that is, they have already Direct Care with Groups
learned to provide such care and need to validate their judg- Application of the nursing process with groups is also
ments and interventions with a nursing supervisor (AACN, expected of baccalaureate-prepared community health
1986). Most employers of newly graduated community/pub- nurses; limited supervision is to be made available (AACN,
lic health nurses will provide a more experienced nurse who is 1986). Here, group means a system of individuals who engage
available to Â�validate adaptations to nonhospital settings. This in Â�face-to-face Â�interaction. Required nursing skills include the
abilities to assess group dynamics and group dysfunction, to community/public health nurses are expected to be able to
facilitate group process, to teach groups, and to solve coor- Â�collaborate with others to assess the entire Â�
population and
dination problems (AACN, 1986). Some emphasis on group multiple aggregates in a geopolitical community. Unit Four
Â�
leadership is Â�provided in most baccalaureate community/ Â�provides more in-depth discussion of working with Â�communities
public health Â�nursing Â�curricula, although it is not emphasized and aggregates.
to the degree that it is stressed by professional organizations'
definitions of community/public health nursing (Blank & LEADERSHIP IN COMMUNITY/PUBLIC
McElmurry, 1986). HEALTHÂ€NURSING
Direct Care with Aggregates/ Populations Leaders in community health nursing have demonstrated a
Since the early 1970s, as more community/public health nurses common set of concerns, skills, and actions (BoxÂ€1-10). Leaders
have become employed in agencies that serve a specific popula- are sensitive to the needs of others, are able to respond, and are
tion rather than in agencies with a broad public health mandate, willing to work toward their visions of what might be. All com-
direct care of aggregates has become a more prevalent form of munity/public health nurses have opportunities to be leaders
delivering community health nursing care. It is the responsibil- for healthful communities. Specialists in community/public
ity of nurses in such settings to assess the entire caseload or health nursing provide orientation, staff development, con-
clinic enrollment for common health needs, to target those who sultation, and professional leadership to nurse generalists. The
have not received services but who are eligible, and to plan ANA and the APHA reserve the term nurse specialist for those
interventions accordingly (ANA, 2007; APHA, 1996). who have graduate degrees in specific areas of nursing. Nurse
specialists have both specialized and expanded knowledge and
skills (ANA, 2010). Generalists are licensed professional nurses
Eileen, a nurse employed in a home health agency, recognized
with a baccalaureate degree in nursing.
that many of the older adults she visited had limited social-
Community/public health nursing specialists usually have
ization and recreation. She joined with a social worker and
a master's degree in community health nursing/public health
neighborhood groups to develop a more systematic survey of
nursing from a school of nursing or a master's degree in Â�public
older adults. Eventually, a senior center was established in the
health (MPH) from a school of public health. Community/
urban neighborhood, and the baccalaureate-prepared nurse
public health nurse specialists are capable of performing
was appointed to the board of directors, where she contin-
and might perform the functions of a community/public
ued to assess the health-related needs of the Â�center Â�members.
health nursing generalist and are competent to provide care
Besides assessing the unmet affiliation needs of older adults
to Â�families and groups. However, community/public health
and determining that inadequate resources existed, she
nursing specialists usually focus their practices on commu-
Â�collaborated to develop services such as health screening.
nities, the entire population, or multiple aggregates. Such
Eileen did not stop at serving older adults enrolled in the
specialists are proficient in assessing the health of an entire
home health agency or the senior center. She knew that many
community or population and in planning, implementing,
older adults are at risk of social isolation and participated
and evaluating population-focused health programs (ANA,
with others in publicizing the senior center and finding older
2007). Community/public health nursing specialists struc-
adults who could benefit from attendance at the center.
ture systems of data collection and evaluation. They target
intervention strategies toward the health care delivery Â�system,
Eileen was reaching out to those who were eligible for institutions, and organizations (Helvie, 1998; Kalb etÂ€al.,
Â�
the program but were not using it. Such outreach is another 2006), including development of health and social policy,
distinguishing feature of community/public health (ANA,
Â� development and evaluation of health programs, and research
2007). In business language, this practice might be called and theory development (ANA, 2007).
Â�capturing market share; however, the primary motivation of
Â�outreach is not Â�revenue but provision of health care to the BOXÂ€1-10â•…â•‡LEADERSHIP
Â�previously underserved. CHARACTERISTICS
Population-focused care and aggregate-focused care are INÂ€COMMUNITY/PUBLIC
essential concepts that constitute the basis of baccalaureate-pre- HEALTH NURSING
pared community/public health nursing education (Minnesota
Department of Health, 2001). Community assessment is one 1. Ability to recognize and be present to human suffering
of the basic competencies expected of baccalaureate-prepared 2. Ability to create a vision of improvement in the health and well-
community health nurses (AACN, 2008; ACHNE 2010; ANA, being of people
2007; Blank & McElmurry, 1986). Community/public health 3. Commitment to action
nurses are to collect and analyze information such as the 4. Ability to identify specific health problems and sources of suffering
Â�following (AACN, 1986, p. 10): within a specific time and place
• Epidemiological data 5. Openness to possibilities to alleviate and prevent suffering and
• Risk factors ability to develop a plan
6. Ability to communicate with other people to enlist support and
• Resources
enroll partners
• Environmental factors
7. Ability to create opportunities for people to help themselves
• Social organization 8. Commitment to advocacy to affect social policy
Such nurses are expected to apply the nursing process with 9. Patience and persistence
aggregates with limited supervision. Baccalaureate-prepared
All community/public health nurses can contribute to improv- • Provision of leadership in nursing and public health
ing the quality of community/public health nursing practice by • Advocacy to protect the health, safety, and rights of
meeting qualifications for professional certification, participating the population
in quality-assurance programs, and Â�generating and disseminating These standards help guide community/public health nurs-
new knowledge through nursing research (ANA, 2007). ing practice and “describe competency in the professional role”
(ANA, 2007, p. 13). For instance, public health nurses in the Los
Professional Certification Angeles County Department of Health Services used the public
The ANA has a program of certification for community/pub- health nursing standards to develop their Public Health Nursing
lic health nurses managed through the American Nurses Practice Manual (Sakamoto & Avila, 2004). This manual serves
Credentialing Center (ANCC). Professional certification is a as a tool to standardize practice and monitor the performances
process that validates an individual registered nurse's qualifi- of baccalaureate-prepared public health nurses.
cations, nursing practice, and knowledge in a defined area of
Â�nursing (ANA, 2011) and acknowledges that the nurse's educa- Community/Public Health Nursing Research
tion, experiences, and knowledge meet standards determined by andÂ€Evidence-Based Practice
the profession. Certification is voluntary. Community/public health nurse generalists actively Â�participate
Prior to 2005, nurse generalists (those with a Bachelor of in research activities appropriate to their education and posi-
Science degree in Nursing) could become certified as commuÂ� tion. These activities may include, but are not limited to,
nity/public health nurses and use the credentials RN-BC identifying questions for investigation; participating in data
(Â�registered nurse, board certified). However, as of 2005, the Â�collection; “participating in agency-based, organization-based or
ANCC no longer accepts new applications for this certification. Â�population-focused research” under the supervision of nurse or
Nurse generalists who were previously certified by the ANCC as other researchers; implementing research Â�protocols; and apply-
community/public health nurses, school nurses, college health ing research findings to practice (ANA, 2007, p.Â€36). Community-
nurses, or home health nurses can continue to be recertified. based participatory research actively involves communities,
Nurses with a master's degree or a more advanced degree in Â�populations, organizations, and others in the process.
nursing with a specialization in community/public health nurs- Evidence-based practice is an approach to practice in which
ing and baccalaureate-prepared nurses who also have a master's “the public health nurse is aware of the evidence in support of
degree in public health with a specialization in nursing are eli- one's clinical practice, and the strength of that evidence” (ANA,
gible to take an advanced examination. These nurse specialists 2007, p. 42). Generalists are to use “the best available evidence,
can become certified as an advanced public health nurse–board including research findings, to guide practice, policy and ser-
certified and use the credential APHN-BC. vice delivery decisions” (ANA, 2007, p. 36). Using this evidence
Certification expires in 5 years and can be renewed. The in practice strengthens both nursing practice and the commu-
nurse needs at least 1000 hours of practice during the Â�previous nity's health. This text documents multiple sources describ-
5 years and documentation of professional development or ing evidence-based community/public health nursing practice.
Â�reexamination to become recertified (ANA, 2011). Integrated throughout this text are contemporary citations of
best practices and nursing or public health research.
Quality Assurance Community/public health nurse specialists collaborate or
Community/public health nurses have a responsibility to main- consult with researchers with doctoral degrees to engage in all
tain and improve the quality and effectiveness of community phases of the research process (ANA, 2007). Community/pub-
health nursing practice. Community health nurses are expected lic health nursing specialists ensure that research findings are
to fulfill requirements for relicensure and participate in disseminated and assist nurse generalists in interpreting and
Â�self-evaluation, continuing education, and peer review. In peer applying the research findings in their nursing practices.
review, nurses “appraise the quality of nursing care in a given Nurses at the National Institute of Nursing Research (NINR)
situation in accordance with established standards of practice” collaborate with other nurses to identify a national agenda for
(ANA, 1980, p. 18). nursing research. The agenda focuses on both nursing care
Standards of professional performance for community/public delivery and specific nursing interventions. Many of the priori-
health nurses call for nurses to engage in the following activities ties in the national agenda are relevant to community/public
(ANA, 2007): health nurses. During the 1990s, nurse researchers studied ways
• Systematic evaluation of nursing practice for populations to to improve the health of the underserved as well as of those
enhance quality and effectiveness with HIV infection and acquired immunodeficiency syndrome
• Maintenance of up-to-date knowledge and competency in (AIDS), cognitive impairment, and chronic illness. In 2006, the
nursing and public health practice NINR emphasized areas of research in which nursing had a base
• Evaluation of own nursing practice of previous funding and showed promise for additional con-
• Establishment and maintenance of partnerships with commu- tributions. These research emphasis areas include the following
nity members, health professionals, and others (NINR, 2006):
• Contribution to the professional development of students • Promoting health and preventing disease, including chang-
and colleagues ing lifestyle behaviors for better health
• Application of ethical standards for health care delivery and • Managing the effects of chronic illness to improve health and
for advocacy for health and social policy quality of life
• Integration of research findings for evidence-based practice • Identifying effective strategies to reduce health disparities
• Use of resources safely, effectively, and efficiently to ensure • Harnessing advanced technologies to serve human needs
“maximum possible health benefit to the population” • Enhancing end-of-life experience for clients and families
Specific topics related to community/public health nursing was expanded because nurses demonstrated that quality care
include research in family caregiving, culturally sensitive inter- could be provided for some clients in the home at a lower cost
ventions to modify health disparities, prevention of cardiac and than in the hospital (Brooten etÂ€al., 1986).
other chronic conditions, creative ways to use the Internet and One example of cost savings involves maternal and infant
telehealth for client education, and evaluation of cost-effective health promotion. A prenatal and infancy home visitation
nursing interventions. Federal funding for nursing research is Â�program not only led to healthier infants, fewer injuries, less
not limited to these topics. abuse, and improved maternal social outcomes but also resulted
Nursing research also helps describe the scope of practice in a net savings in government expenditures such as cash
and to strengthen nursing theory. Often, nurses take much Â�assistance and food stamps (Olds etÂ€al., 1993).
of their practice for granted and do not describe Â�explicitly A second example of cost savings relates to Â�tuberculosis
what they are doing and how they are relating to clients. control. When community health nurses visit clients with
Â�
Studies ofÂ€the practices of community/public health nurses can Â�tuberculosis to directly administer antibiotics at the Â�clients'
uncover the details of nursing practice (Monsen, et al., 2010; homes, work sites, or shelters, it is less expensive than
Zerwekh, 1991, 1992a, 1992b). Community/public health hospitalization. This practice has been named directly
Â�
nursing practice can be improved only when nurses are clear observed therapy (DOT). Furthermore, under this program,
about their practice and how interventions explicitly relate to the Â�percentage of clients who complete a course of Â�antibiotic
human health and client satisfaction (Deal, 1994; Kalb etÂ€al., Â�therapy is increased, emergence of drug-resistant
Â� strains of
2006; Reutter etÂ€al., 1998). tuberculosis is thereby prevented, and mortality is reduced
Much research is needed to explore what encourages health- (Lewis & Chaisson, 1993). Health Â�outcomes are better when
promoting and risk-reducing behavior. Even when interven- nurses are involved in the administration of medications than
tions are based on existing scientific knowledge, attempts at when clients self-administer medications obtained from clinics
assisting others such as intravenous drug users in modifying or private physicians.
their behavior have not been very successful. Community/public In summary, nurses are concerned with people's experiences
health nurses need to study what works with specific aggregates and responses as they seek to restore or promote health (ANA,
and to learn more about targeting care to different populations 2008). Community/public health nursing research needs to con-
(Reutter etÂ€al., 1998). Evaluation of environmentally oriented sider the degree to which clients become healthier Â�(epidemiological
interventions is also vital. Involvement of community members measures of outcomes) as well as how much nursing care costs.
in research methods such as participatory action research can In addition, community/public health nursing research needs to
contribute to community empowerment (ANA, 2007; Reutter describe the specific interventions that best facilitate modification
etÂ€al., 1998). of behavior and promote health. What helps to prevent illness and
Because cost containment in health care continues to be a injury and to promote Â�well-being? What helps people work col-
national goal, it is important for community/public health laboratively to improve their Â�physical and social environments?
nurses to continue to document the cost of nursing care and the Community/public health nurses will continue to be challenged
savings that nursing care can provide (Deal, 1994). Home care by this inquiry Â�during the twenty-first century.
KEY IDEAS
1. Community/public health nurses synthesize their knowl- 5. Generalists work with community/public health nurse
edge of nursing and public health to promote the health of Â�specialists, other professionals, and community members
populations in communities. Nursing knowledge helps in to identify the populations or aggregates at greatest risk for
the understanding of problem solving and creative empow- compromised health.
erment, of human experiences and responses related to 6. General systems theory is useful in studying clients at
health and illness, and of relationships between people multiple ecological levels. Individuals, families, groups,
Â�
and their environments. Public health knowledge helps organizations, and communities are open systems that
make clear the magnitude of disease, disability, and pre- exchange energy with their environment to survive and
mature death in human populations and suggests methods develop. Population aggregates are not systems because the
of prevention. members are not related interpersonally. Instead, they have
2. Community/public health nurses seek to empower Â�persons one or more health-related characteristics in common.
in families, groups, organizations, and Â� communities to 7. Physical, social, cultural, spiritual, economic, and political
achieve their individual potentials and to care for one another. facets of our environment all have an impact on commu-
Empowerment is accomplished by using Â�interpersonal rela- nity health. Community/public health nurses need to be
tionships to create opportunities for people to promote their broadly educated to recognize human–environment inter-
own health. actions. Community/public health nurses seek healthful
3. Health promotion involves decreasing preventable diseases, environments while preserving natural resources.
disability, and premature death; reducing experiences of 8. Prevention is a complex public health concept linked
Â�illness, vulnerability, and suffering; and fostering experi- with the natural history of diseases. Primary prevention
ences of human caring, connectedness, and fulfillment. activities preclude the occurrence of a disease or injury.
4. Baccalaureate-prepared community/public health nurses Secondary prevention activities focus on early identifica-
(generalists) apply the nursing process with individuals, tion and treatment of diseases. Tertiary prevention seeks to
families, groups, and populations as guided by Public Health reduce Â�negative consequences of illness and restore health
Nursing: Scope and Standards of Practice (ANA, 2007). as much as possible.
9. Community/public health nurses use a variety of nursing the Â�greatest number” sometimes allows community/Â�
interventions. Identifying persons with unmet health and public health nurses to force clients to do something
social needs, ensuring access to health and social services, (take Â�antituberculosis medications), or not to do some-
teaching for health promotion, screening and case find- thing (abuse a spouse), to protect others. However,
ing, promoting healthful environments, providing and Â�education and empowerment are preferred to enforcement
coordinating direct care, and participating with others to and coercion.
influence community decisions and policy are especially 11. Mechanisms to ensure quality of nursing care include
important to community/public health nurse generalists. licensure, continued professional development, certiÂ�
10. Social justice is important in the promotion of commu- fication, quality assurance, research, and evidence-based
nity/public health. Concern for the “greatest good for practice.
CASE STUDY
Being Present
The community health nurse greeted a 30-year-old mother at the medication and indicated that she might find another Â�pediatrician
door of her apartment. They had met several times. The mother had a for the child.
Â�history of “crack” use, although she denied current use. She had had Because of her resourcefulness and persistence, the nurse was able
difficulty feeding her 2-year-old son because of his almost constant to find a second pediatric neurologist in another city, 40 miles away.
seizures. Transportation was arranged through volunteers, and the mother
The relationship between the mother and the community health nurse and son were seen by this physician. The child was hospitalized for
developed slowly. The nurse was aware that the child's pediatrician Â�regulation of the seizure medication regimen, and the mother agreed
would not prescribe strong antiseizure medication because he did to implantation of a gastrostomy tube in the child for feedings. Three
not trust the mother to give it appropriately and feared resultant liver months after the home visit described earlier, the mother had been
Â�damage in the child. The mother had refused to return to the pediatri- taught to feed the child, and his seizures were sufficiently controlled for
cian. The nurse knew that the only health service provider the mother him to be accepted into a special education program in the public school
had visited with regularity was the health department's well-child system. The mother was beginning to talk about seeking job training.
clinic where the nurse worked and which provided screening, educa- The nurse could have judged the mother for having used cocaine,
tion, and immunizations. The child's immunizations were also delayed which might have caused her child's health problems. The nurse
because of the seizures. could have labeled the mother as noncompliant when she refused to
The nurse spoke the mother's name, seated herself quietly, and took return to the first pediatrician. Instead, the community health nurse
in what was happening in the room. The mother was ironing and had was present to the mother; she was physically present in the home
age-appropriate toys next to her developmentally delayed son. The Â�several times and psychologically present to acknowledge the mother's
nurse said hello to the boy, commenting that he seemed to be inter- strengths and perspective of the circumstances. In addition, the com-
ested in the toy the mother had placed next to him. She Â�followed munity health nurse was spiritually there and could honestly say that
the mother's lead as they discussed how the mother was providing she liked the mother, despite all of her troubles. She felt genuine posi-
stimulation for her son's development. The nurse commented that it tive regard for the mother as a human being while not forgetting that
must be difficult to feed a child with frequent seizures;
Â� the mother her primary Â�professional goal as a “child health nurse” was to promote
replied that she could not take all day to feed him because she had the Â�well-being of the child. Her presence demonstrated her genuine
two other children to care for and she was afraid he would choke. caring and led to new possibilities for this family.
The nurse Â�realized that she would have similar feelings if the child â•‡â•‡ See Critical Thinking Questions for this Case Study on the
were hers. She acknowledged the mother's request to obtain seizure book's website.
L E A R N I N G BY E X P E R I E N C E A N D R E F L E C T I O N
1. Look through several copies of a major newspaper to find arti- 4. Select a public health problem of interest to you, for exam-
cles related directly or indirectly to human health. Describe ple, falls among older adults, and describe primary, second-
any inequalities in access to health care, access to a basic stan- ary, and tertiary prevention strategies.
dard of living, or exposure to environmental hazards. Identify 5. Using the same health problem you identified in item 4,
implications for community/public health nursing practice. Â�discuss how interventions might be directed toward individ-
2. Express your vision of a healthy family and of a healthy com- uals, families, groups, and the public. To whom would you
munity. List some of your commitments related to your target interventions, and why? Explore evidence of best nurs-
choice of nursing as a profession. As your experience in coming practices related to this health problem and proposed
munity/public health nursing broadens, consider modifying interventions.
your list of commitments. 6. Interview or accompany a community/public health nurse
3. Express your vision of an empowering work environment. to identify his or her professional responsibilities. To what
If you are a student, consider what an empowering clini- degree does the nurse provide care to individuals, families,
cal practice environment would be like for you. Identify or groups? How does the nurse use data about the public or
what commitments you are willing to make for this vision. aggregates to target care? How does the nurse participate in
Share your visions and commitments with your work group continuing professional development and improvement of
or learning group in an attempt to identify some common nursing care? What current research findings does the nurse
visions and commitments as a basis for partnership. use to strengthen evidence-based practice?
COMMUNITY RESOURCES FOR PRACTICE

American Association of Colleges of Nursing (AACN): http:// Minnesota Department of Health, Division of Community
www.aacn.nche.edu/ Health Services, Public Health Nursing Section (Information
American Nurses Association (ANA): http://www.nursingworld. about the Minnesota model for public health nursing
org/ practice, known as the “interventions wheel,” is found
American Nurses Credentialing Center (ANCC): http:// on the department's website.): http://www.health.state.
www.nursecredentialing.org/ mn.us/
American Public Health Association (APHA): http://www.apha.org/ National Institute of Nursing Research (NINR): http://www.
Association of State and Territorial Directors of Nursing ninr.nih.gov/
(ASTDN): http://www.astdn.org/ U.S. Department of Health and Human Services (USDHHS):
Institute of Medicine (IOM): http://www.iom.edu/ http://www.hhs.gov/
WEBSITE
http://evolve.elsevier.com/Maurer/community/
STUDY AIDS
Visit the Evolve website for this book to find the following study
and assessment materials:
• NCLEX Review Questions • Care Plans
• Critical Thinking Questions and Answers for Case Studies • Glossary
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CHAPTER
2
Origins and Future of Community/
Claudia M. Smith
FOCUS QUESTIONS
What are the distinctions among visiting nursing, district How did the government sponsorship of community/
nursing, public health nursing, home health care nursing, public health nursing contribute to the field's
and community/public health nursing? dichotomy?
What are some historical roots of such nursing? What are the distinctions between community-based care and
How did nursing leaders such as Florence Nightingale and population- or community-focused care?
Lillian Wald merge public health practice with nursing to How does health care reform offer the opportunity for
create public health nursing? community/public health nursing to regain its holistic
What led to the renaming of public health nursing as community perspective for human health?
health nursing, as well as to the return to public health nursing? How can the Healthy People goals and objectives for health
How have subspecialties in community/public health nursing promotion and disease prevention help guide community/
emerged from population-focused care? public health nursing practice?
What stimulated the expansion of community/public health What issues persist in defining community/public health
nursing into rural areas of the United States? nursing practice?
CHAPTER OUTLINE
Roots of Community/Public Health Nursing Expansion into Rural America
Visiting Nursing in Europe before 1850 Red Cross Rural Nursing Service
Birth of District Nursing in England: 1859 Metropolitan Life Insurance Company Visiting Nurse
District Visitors and Visiting Nurses in the United States Service
Trained Visiting Nurses in the United States Frontier Nursing Service
Associations for Visiting Nursing and District Nursing Government Employment of Public Health Nurses
Public Health Nursing: Nursing for Social Betterment Dichotomy in Public Health Nursing
Definition of Public Health Educational Preparation for Public Health Nurses
Nursing and Sanitary Reform Expanded Practice in Community Health Nursing: 1965 to 1995
Urban Health Reclaiming Public Pealth Nursing: 1995 to 2010
Military Health Community/Public Health Nursing: Creating the Future
Policy Reforms and Health Education Campaigns Health Care Reform
Population-Focused Care and Subspecialties Healthy People National Health Objectives
School Nursing Populations and Community/Public Health Nursing
Industrial Nursing Emerging and Reemerging Infections and Threats of
Child Health Nursing Terrorism
Tuberculosis Nursing Continuing Issues
KEY TERMS
Community health nursing Ecological perspective Public health nursing
Community/public health nursing Health disparities Visiting nursing
Determinants of health Primary health care
District nursing Public health
31
32 CHAPTER 2â•… Origins and Future of Community/Public Health Nursing
Public health nursing: Nursing for social betterment; nursing In the 1880â•›s, nonprofit visiting nursing associations were
care for the health needs of the entire population or public; formed in several U.S. cities to provide care to the ill and to teach
community-based, population-focused nursing health promotion and disease prevention. Some Â�associations
Community health nursing: Term developed in the 1960s assigned nurses by geographical districts, and others did not.
to expand the term public health nursing because the term Lillian Wald included visiting nursing and district Â�nursing
Â�public health had become linked only with nurses employed by within her broader concept of public health nursing. Public
Â�governments; a synonym for public health nursing health nursing is nursing for social betterment and includes
Because community health nursing is a synthesis of nursing Â�nursing in schools, in clinics, at work sites, and in commu-
and public health, an exploration of the evolution of each of nity centers, as well as in homes. Whether it is called pub-
these will strengthen our understanding of the roots of prac- lic health nursing or Â�community health nursing, the practice
tice. The care of the sick has always been influenced by the Â�combines Â�caring and activism to promote the health of the
meaning given to illnesses, injuries, and human suffering by public (Backer, 1993).
members of a given culture. Types and prevalences of injuries
and illnesses have also influenced care. Other roots of com- Visiting Nursing in Europe before 1850
munity health nursing include health promotion and disease During the Middle Ages, warfare, famine, and plagues Â�persisted
prevention and population-focused care from public health. in Europe and the Middle East. Hospitals existed for Â�military
Both nursing and public health have been concerned with personnel, and wealthy patients were cared for at home. People
the interrelationships among people and their physical and became concerned about providing care to the poor and
social environments. Â�less-well-off members of society. TableÂ€2-1 highlights some of
Public health nursing evolved from visiting nursing and the efforts to address the issue.
Â�district nursing. Public health nursing included home health The gradual movement toward societal concern for human
nursing. From the 1960s through the end of the twentieth welfare was hastened during the Industrial Revolution. As
century, the term community health nursing was often used in workers flocked to cities seeking employment, the cities expe-
place of public health nursing. The beginning of the twenty-first rienced dramatic overcrowding. Overcrowded slums, lodgings,
Â�century presents yet another transition. The terms Â�community jails, and workhouses became centers for disease. It was in this
health nursing and public health nursing are linked together in environment that reformers sought to prevent deaths through
community/public health nursing, and there is a movement to Â�improvement of living conditions.
return to the classic name public health nursing (American Scientific knowledge (cause and effect) and the concern
Nurses Association [ANA], 2007c; Quad Council of Public for the well-being of individuals provided the intellectual
Health Nursing Organizations, 1999). and Â� philosophical bases for responding to the dehumaniz-
Community/public health nursing in the United States ing conditions of industrialized, urban Europe. For some, the
has generally evolved from several programs developed in motivation for reform was the attempt to reconcile Christian
Western Europe, particularly Great Britain. Many people have principles with the poverty, suffering, and premature deaths
influenced the development of community/public health
Â� of poor Â�persons. Businessmen were beginning to realize that a
nursing. AÂ€Â�synopsis of their commitments, ideas, and activi- sick workforce affected production, and therefore, economics
ties provides an understanding of the foundation of contem- Â�provided another motivation.
porary community health nursing. When possible, the names
of specific nurses are included to demonstrate that the history Birth of District Nursing in England: 1859
of nursing is the result of the collective efforts of individual Rathbone, a Quaker, merchant, and philanthropist, is considered
nurses. Other community leaders are identified to demon- the originator of district nursing (Brainard, 1985; Gardner, 1936;
strate that early community/public health nurses worked in Monteiro, 1985). Rathbone was a visitor for the District Provident
partnerships to create services and obtain financial support. Society in Liverpool, England, and went to the homes of mem-
Inclusion of their names allows interested readers to engage in bers of his district every week. He believed that personal contacts
further research. with the poor could assist people out of poverty and that financial
relief alone was insufficient. He persuaded the Liverpool Relief
ROOTS OF COMMUNITY/PUBLIC Society to adopt a system whereby the town was divided into dis-
HEALTHÂ€NURSING tricts and subdivided into sections; after a paid relief worker had
assessed the situation initially, the “case” was turned over to the
Visiting nursing originated when concerned laypersons friendly visitor in the district for Â�ongoing assistance.
Â�provided care to the sick in their homes. In Europe, the Catholic
Sisters of Charity and Protestant deaconesses evolved from
During his wife's long illness, Rathbone employed a nurse,
groups of such lay nurses. In the United States, organized
Mary Robinson, to comfort and care for her. After his wife's
Â�visiting nursing tended to be provided by nonreligious organi-
death in 1859, Rathbone realized that if nursing care could be
zations such as benevolent and ethical societies.
such an asset to his wealthy family, it could be an even greater
District nursing was started in England in 1859 by William
asset to families whose suffering was compounded by poverty
Rathbone, who proposed to Florence Nightingale that visiting
and ignorance. His idea was to provide nursing care by dis-
nurses who had graduated from nursing school be assigned
trict, as welfare relief was provided. He employed Robinson
within a parish or district. In the United States, district nurses
for a 3-month experiment in nursing “sick poor” persons in
often labored in conjunction with physicians who worked in the
their own homes in a district of Liverpool (Brainard, 1985).
local dispensary. This was the forerunner of neighborhood or
In addition, the nurse was to instruct the families on how
city block nursing.
CHAPTER 2â•… Origins and Future of Community/Public Health Nursing 33
TABLEÂ€2-1â•…â•‡NURSING EFFORTS IN EUROPE BEFORE 1850

YEAR EVENT
Visiting Nursing
1617 Vincent de Paul founded the Society of Missionaries, a congregation of priests trained to work
among the poor in France. In addition to the accepted concept of material relief, he added human
sympathy and personal service. Concerned about the causes of poverty, he advocated employment
as a method of helping the poor care for themselves (Brainard, 1985).
1617 Vincent de Paul founded the Dames de Charite, an order of women who provided visiting nursing
services to the sick poor. These women were volunteers, not nuns, who provided care, medicines,
and feeding to the ill and comforted the dying and grief-stricken.
1822 Theodor Fliedner, a pastor in a small German village, visited richer Protestant parishes seeking
financial aid for his poor parishioners. His wife Frederika Fliedner started a women's society
for visiting and nursing the ill in their homes, based on the deaconess Mennonite groups
based in Holland.
1839 Pastor Fliedner started a hospital and training school for deaconesses. The students needed to be
25 or older, of good character and health, and from the working class.
1850 Institutes for training deaconesses were established in Paris, Austria, and Switzerland. Mrs. Fry,
a prison reformer in England, founded the Society of Protestant Sisters of Charity. These nurses
provided home nursing care to all classes, including the poor.
Workhouse and Hospital Nursing in England 1825-1850
1825 Hospitals: There were 154 hospitals maintained by private subscription (prepayment). Hospitals
were used for teaching. The middle and upper classes were cared for at home by privately
employed nurses and physicians. Hospitals were considered “death houses,” and fatality rates
were high (White, 1978). For example, 70% of patients with compound fractures died. Hospital
nurses were supervised by sisters. Sisters provided the more technical care—for example,
dressing changes and medication. Both sisters and nurses were supervised by matrons.
1825 Workhouses: Each parish had a poorhouse where the “poor sick” were looked after by other poor
persons in residence. English law allowed “the aged, infirm, handicapped, orphans, widows, and
poor sick” as valid candidates for poor relief (White, 1978, p. 7).
1834 Amendment to Poor Laws restricted poor relief to the most destitute poor (White, 1978).
1850 More than 50,000 older adults with illnesses lived in workhouses. Sickness was the basis for 70%
of poverty, and tuberculosis was rampant (White, 1978). Lack of able-bodied persons in poor
communities to care for the ill led to “pauper nurses,” who were allowed to live in workhouses to
care for the ill. There were 500 pauper nurses by 1850. There were an additional 248 paid nurses
in workhouses. The Poor Law Board redefined the duties of paid nurses to be comparable with
ward sisters in hospitals (White, 1978).
Data from Brainard, M. (1985). The evolution of public health nursing (pp. 120-121) New York: Garland; and White, R. (1978). Social change and the
development of the nursing profession: A study of the poor law nursing service 1848-1948. London: Henry Kimpton.
district nursing (Monteiro, 1985). With Rathbone's financial

to care for their own sick members and to ensure personal support, such a school was established the next year. A third
and home cleanliness. Brainard reported that at the end of objective was to provide nurses to care for the sick in private
1â•›month, Robinson felt hopeless about the intense “squalor” families (Brainard, 1985). By 1865, there were trained nurses
and asked to be relieved. Rathbone encouraged her to persist, in 18 districts of Liverpool (Brainard, 1985; Monteiro, 1985).
and at the end of 3â•›months, she was able to see relief from The district boundaries were often the same as parishes so
suffering and improved circumstances for some families. She that nursing care could be coordinated with the work of the
continued in this new field of work and thus became the first clergy. When a new district was established, partnerships were
“district nurse.” formed. Meetings were held among the clergy, physicians, resi-
dents, and philanthropists for education about the proposal,
Rathbone sought to expand the district nursing model to enlist cooperation, and to recommend individuals in need
by employing additional nurses in other areas of Liverpool. of care.
Two barriers immediately emerged: public resignation to The district nurse visited numerous homes of the “sick poor”
poverty and suffering and an insufficient number of trained for 5 to 6 hours per day. Brainard (1985) summarizes the nurse's
nurses. In 1861, he wrote to Florence Nightingale, who had duties (BoxÂ€2-1). Generally, district nurses did not provide direct
started a school to train nurses at St. Thomas's Hospital in care to persons with communicable diseases, to avoid transmis-
London in 1860, to request her assistance in training nurses sion from one household to another. Instead, nurses taught
for Liverpool. She was already engaged in a project for sani- family members how to perform necessary care and Â�provided
tary reform in India, which she directed from England, so she the necessary equipment “at the door.”
referred him to the Royal Liverpool Infirmary to request that The nurse was to provide nursing to the sick rather than
they open a school to train nurses for both the infirmary and to give relief in the form of money, food, clothing, or other
District Visitors and Visiting Nurses in the United States

BOXÂ€2-1â•…â•‡DUTIES OF DISTRICT NURSES IN
LIVERPOOL, ENGLAND: 1865 The first organized lay visitors to “sick poor” persons in
America were members of the Ladies’ Benevolent Society
• Investigate new referrals as soon as possible. of Charleston, South Carolina, founded in 1813 (Brainard,
• Report to the superintendent situations in which additional food or 1985). The society's formation was a response to the pov-
relief would improve recovery. erty and suffering brought about by a yellow fever epidemic
• Report neglect of patients by family or friends to the superintendent. and the trade embargoes Â�during the War of 1812. The soci-
• Assist physicians with surgery in the home. ety adopted principles that did not appear in England until
• Maintain a clean, uncluttered home environment and tend fires for heat. 40â•›years later. Membership Â� transcended church and color
• Teach the patient and family about cleanliness, ventilation, the lines, and patients’ religious beliefs were not interfered with.
giving of food and medications, and obedience to the physician's Although substantial amounts of food, clothing, fuel, bed-
orders. ding, and soap were distributed, money was not given out.
• Set an example for “neatness, order, sobriety, and obedience.”
The circumstances of “sick poor” persons were investigated,
• Hold family matters in confidence.
and attempts were made to furnish work for unemployed per-
• Avoid interference with the religious opinions and beliefs of
sons. Charleston was divided into districts that corresponded
patients and others.
• Report facts to and ask questions of physicians. to election wards. Ladies visited for 3â•›months. The society
• Refer the acutely ill to hospitals and the chronically ill, poor without existed until the Civil War. In 1881, it resumed its work, and a
family to infirmaries. trained nurse was employed in 1903.
In 1839, the Nurse Society in Philadelphia assigned lady visi-
From Brainard, M. (1985). The evolution of public health nursing tors by districts. Responsible women were assigned to act as nurses
(pp. 120-121). New York: Garland. (Original work published in 1922. under the direction of physicians and lady Â�visitors (Brainard,
Philadelphia: W. B. Saunders.)
1985). Although these nurses are considered “the first to system-
atically care for the poor in their homes” in the United States, they
were not trained. Neither did they visit multiple homes; rather,
Â�
charity. Nurses were not to make families dependent on them they stayed with one patient until Â�discharged by the physician.
by Â�providing the necessities that the head of the family would
ordinarily provide (Brainard, 1985; Monteiro, 1985). Trained Visiting Nurses in the United States
An essential point advocated by Rathbone and Nightingale Visiting nursing by trained nurses in the United States began
was that nurses should be trained. Nightingale wrote, “AÂ€District in the industrialized cities of the Northeast almost 20â•›years
Nurse must … have a fuller training than a hospital nurse, because after its inception in Liverpool (Waters, 1912). In 1877, the
she has no hospital appliances at hand at all" (and because Women's Branch of the New York City Mission sent trained
she is the only one to make notes and report to the Â�doctor), as nurses into the homes of poor persons; 2â•›years later, the
quoted by Monteiro (1985, p. 184). The nurses’ Â�relative autonomy Society for Ethical Culture placed one nurse in a city dispen-
was recognized. sary for the purpose of home visiting. Both assigned nurses by
The integration of the public health sanitary movement districts (Brainard, 1985).
and nursing can also be seen in Nightingale's comments that a It is not known whether the New York City Mission spon-
Â�district nurse must “nurse the room” and report defects in sani- taneously generated the idea of visiting nurses or whether
tation to the officer of health. Hygiene was seen as an empirical Â�members of their board had visited London (Brainard, 1985).
help for recovery from illness and prevention of disease. Thus, Frances Root, a graduate of the first class of nurses educated
environmental health nursing was born. at Bellevue Hospital, was the first trained visiting nurse in the
In 1874, Rathbone persuaded Nightingale to expand dis- United States in 1877. During the next year, the number of
trict nursing throughout London. The Metropolitan Nursing nurses expanded to five, and the salary of each was provided by
Association was established in 1875 with Florence Lees, a a charitable lady. The philosophy of the New York City Mission
Nightingale graduate, as president. Its purpose was to provide focused on fulfilling a religious call, providing material relief,
“nursing to the sick poor at home” (Monteiro, 1985, p. 183). An and caring for the ill. There was little focus on instruction in
evaluation of existing district nursing was undertaken. Surveys hygiene, sanitation, or prevention.
inquiring about nursing in their districts were sent to clergy and Felix Adler, founder of the Society for Ethical Culture, was
medical officers. Lees personally observed the nurses engaged influenced by the New York City Mission, but he wanted nurses
in district nursing. Finding wide variability in nursing practice, to provide care in a nonsectarian way. The nurses employed
the association sought to standardize the training for district by the Society for Ethical Culture received their patient assign-
nurses. Nurses were recruited from the class of “gentlewomen,” ments from physicians in dispensaries; each nurse visited in
and after 1â•›year of hospital training, they received 6â•›months of the district served by a dispensary. Teaching of cleanliness and
supervised district training (Brainard, 1985). proper feeding of infants and children were included as aspects
In 1893, at the International Congress of Nursing in Chicago, of preventive care.
Florence Craven (née Lees) spoke about district nursing as
requiring nurses of intelligence, initiative, and responsibil-
In 1893, Lillian Wald (age 26â•›years) and Mary Brewster
ity, with the ability to teach and the commitment to reduce
Â�organized the Nurses’ Settlement in New York City, also
the Â�suffering of poor persons. District nursing had crossed the
known as the Henry Street Settlement (FigureÂ€2-1). An
Atlantic from London. TableÂ€2-2 presents the milestones in U.S.
1891 graduate of the New York Hospital Training School
community health nursing, many of which are discussed in
for Nurses, Wald cared for neglected children for a year at
greater detail throughout the chapter.
TABLEÂ€2-2â•…â•‡DATES IN U.S. COMMUNITY/PUBLIC HEALTH NURSING HISTORY

YEAR EVENT
Visiting Nursing
1813 Ladies Benevolent Society first organizes visitation by women to the sick poor persons in Charleston, South Carolina.
1819 Hebrew Female Benevolent Society of Philadelphia organizes volunteer nurses to provide care to the ill.
1839 Nurse Society in Philadelphia assigns women visitors to care for the sick poor persons in their homes.
1861 Teachers Dorothea Dix and Clara Barton and other women organize a system of supplies and visiting nurses during the
CivilÂ€War.
1877 Women's Branch of the New York City Mission assigns the first educated nurses to visit the homes of the sick poor persons.
1885-1886 Visiting nurse associations are established in Boston, Buffalo, and Philadelphia.
1893 Nurses Lillian Wald and Mary Brewster organize the Henry Street Settlement in New York.
1895 First occupational health nurse, Ada Stewart, is employed by Vermont Marble Works.
1902 School nursing is established in New York City.
1903 First home care program for patients with tuberculosis is established by the Visiting Nurse Association of Baltimore.
1906 First infants’ clinic is established by the Visiting Nurse Association of Cleveland.
1908 First child health visiting program in a local health department is established in New York City.
1909 National survey of visiting nursing associations is conducted by Ysabella Waters: Visits no longer are limited to the poor;
nurses work with patients of more than one physician.
Rural Expansion
1909 Metropolitan Life Insurance Company employs visiting nurses for policyholders.
1910 Collegiate education in public health nursing is established at Columbia University, New York.
1912 National Organization for Public Health Nursing (NOPHN) is formed.
1912 Quarterly publication of the Cleveland Visiting Nurse Association and the forerunner of the journal Public Health Nursing is
given to the NOPHN.
1912 Red Cross Town and Country Nursing Service is established.
1916 First public health nursing text is written by Mary Gardner.
1918 National League for Nursing Education recommends that aspects of public health nursing be included in nursing education.
1919 Red Cross manages more than 2900 rural public health nursing services providing both care and prevention of illnesses
through their Town and Country Nursing Service.
1919 More than 1200 occupational health nurses are employed by industries.
1925 Frontier Nursing Service is established by Mary Breckinridge in Kentucky.
Federal Public Health Nursing
1934 First nurse (Pearl Mclver) is employed by U.S. Public Health Service.
1952 NOPHN is incorporated into the National League for Nursing (NLN).
Expanded Practice in Community Health Nursing
1965 Public health pediatric nurse practitioner graduate program is established by Loretta Ford at the University of Colorado.
1973 Federal Health Maintenance Organization Act recommends extended roles for nurses in primary care.
1974 Formation of Nurses' Coalition for Action in Politics (N-CAP), political action committee of American Nurses' Association (ANA).
1975 Certification of community health nurses is established by the ANA.
1980 ANA and the American Public Health Association (APHA) publish statements about public health and community health
nursing.
1984 A Consensus Conference on the Essentials of Public Health Nursing Practice and Education takes place.
1988 National Center for Nursing Research (NCNR) is established at the National Institutes of Health.
1991 ANA publishes Nursing's Agenda for Health Care Reform.
1993 National Institute of Nursing Research replaces the NCNR.
1995 ANA releases draft Scope and standards of population-focused and community-based practice.
1995 Institute of Medicine publishes Nursing, health, and the environment.
1996 APHA publishes The definition and role of public health nursing.
1997 Third-party reimbursement approved under Medicare and Medicaid for all nurse practitioners and advanced clinical
specialists.
Reclaiming the Name Public Health Nursing
1999 ANA publishes Scope and Standards of Public Health Nursing written by the Quad Council of Public Health Nursing
Organizations.
2003,2008 ANA publishes Nursing's social policy statement.
2004, 2012 Public Health Nursing Competencies written by the Quad Council.
2007 ANA publishes Public Health Nursing: Scope and Standards written by the Quad Council.
2007 Certification exam is revised for specialists in public/community health nursing.
2008 Alliance of Nurses for Healthy Environments (ANHE) is established.
there were 15 nurses; by 1909, there were 47 nurses on call;

and by 1914, there were 82 Â�affiliated nurses (Kraus, 1980).
In 1913, the Henry Street Settlement reached 22,168 Â�persons,
or 1048 more than all persons admitted that year to Mount
Sinai Hospital, New York Hospital, and Presbyterian Hospital
Â�combined (Kraus, 1980, p. 176).
Alleviation of human suffering and illness was profound.
The beneficial results in terms of creative nursing practice and
the inception of new modes of health care delivery are still with
us today.
Associations for Visiting Nursing and
District Nursing
In 1886, inspired by district nursing in England, ladies in
Boston and Philadelphia founded associations for the sole
Â�purpose of trained nurses providing care to “sick poor” persons
in their homes (Brainard, 1985; Gardner, 1936). The Women's
Education Association, encouraged by members Abbie Howes
and Phoebe Adams, supported the Instructive District Nursing
Association of Boston, so named to emphasize the importance of
education in nursing work (Brainard, 1985).
The association adopted principles for working with the
poor. For example, nurses were not to give money to patients
or interfere with patients’ religious beliefs and political Â�opinions
(Brainard, 1985). To prevent cross-infection, caring for patients
with contagious diseases was limited. Instruction on hygiene,
self-care, and prevention was as important as care of the ill.
Nurses reported to a single physician, who directed patient care.
As the association expanded, professional nursing supervisors
were employed, and nurses were expected to help Â�community
FIGUREÂ€2-1â•‡Lillian Wald (1867-1940), founder of the Henry residents with fund-raising activities to support the Â�association's
Street Settlement and the Visiting Nurse Service of New York
work. By 1920, more than 36,000 patients were seen by Â�association
City, first coined the term public health nurse. (Courtesy of Visiting
Nurse Service of New York City.) nurses each year; of these, 23% were Â�maternity cases.
In Philadelphia, the District Nurse Society, later named the
Visiting Nurse Society of Philadelphia, was established with
the sponsorship of Mrs. Williams Jinks and other ladies. Like
the New York Juvenile Asylum (Kraus, 1980). She entered the Boston association, the Philadelphia society had a twofold
the Women's Medical College and was asked to teach home Â�mission: to care for the sick and to “teach cleanliness and proper
nursing to a group of immigrant women. When she went care of the sick” (Brainard, 1985, p. 219).
to the home of a young girl who requested aid for her sick The society employed nurses and attendants and added
mother, Wald had an experience that changed the direc- supervisory nurses in the first year. Fees of $0.50 to $1 were
tion of her life. She left the medical college and recruited charged for each nurse visit, although services were provided
Brewster, a nursing school classmate, to live on the East Side, free to those unable to pay. Initially only for poor persons, vis-
a poverty-stricken neighborhood of Jewish immigrants. iting nurse services expanded around 1918 to include others in
Mrs. Solomon Loeb, the wife of a wealthy banker, agreed need of nursing care. Nurses provided home visits or were avail-
to support the two nurses and provided $60 per month for able for care of longer duration at an hourly fee ($1.24 to $1.75
each nurse and money for emergencies. During the sum- per hour) (Brainard, 1985, p. 224).
mer of 1893, they lived in the College Settlement (started In the United States, such care was generally known by the
in 1889). term visiting nursing rather than by the English term Â�district
nursing (Brainard, 1985). The term visiting nursing was Â�probably
Settlements were part of a movement among university- adopted because not all nurses were assigned to Â�districts. Many
educated young adults to reside in communities, to study types of organizations employed visiting nurses, including
the Â�communities’ problems through relationships with resi- nursing associations, churches, hospitals, industries, and Â�charity
dents, and to reform the squalid conditions of urban workers organizations. During the 1890â•›s, the number of visiting Â�nursing
(Kraus, 1980). Crowded tenements had insufficient ventila- associations dramatically increased, especially in northeastern
tion and no toilets or baths. Fire escapes were also crowded and midwestern cities.
with Â�sleeping Â�people. A police census in 1900 identified more In 1909, Ysabella Waters, a nurse with the Henry Street
than 2900 Â�persons Â�living in an area smaller than two foot- Settlement, undertook a national survey of organizations that
ball fields—approximately 1724 persons per acre (Kraus, employed trained nurses as visiting nurses. Waters reported
1980, p. 180). In this environment, Wald was committed to a dramatic increase in visiting nursing associations since
providing nursing Â�services to “sick poor” persons. By 1900, 1890. She noted that nurses served both the poor and those of
greater economic means. A visiting nurse no longer worked BOXÂ€2-2â•…â•‡DEFINITION OF PUBLIC HEALTH
primarily with one physician but could accept requests for
services from all physicians. Website Resource 2A depicts Public health is the science and the art of preventing disease,
rules for nurses that were included in Waters's book; these Â�prolonging life, and promoting physical health and efficiency through
rules incorporate the principles that first appeared in district Â�organized community efforts for the following purposes:
nursing. 1. Sanitation of the environment
2. Control of community infections
Public Health Nursing: Nursing for Social Betterment 3. Education of the individual in principles of personal hygiene
The demand for even more visiting nursing services led 4. Organization of medical and nursing service for the early diagnosis
Â�nursing leaders to consider the issue of standards for practice. and preventive treatment of disease
5. Development of the social machinery that will ensure a standard of
There was concern that untrained nurses would be hired to
living adequate for the maintenance of health for every individual
meet the expanding demand and that nursing might revert to
in the community
Â�pre-Nightingale practices. In 1911, Ella Crandall, professor in the
Department of Public Health and Nursing at Teachers College Data from Winslow, C.-E. A. (1984). The evolution and significance of
in New York, initiated correspondence with other Â�nursing lead- the modern public health campaign (p. 1). South Burlington, VT: Journal
ers to solicit their opinions about an “organization to protect the of Public Health Policy. (Original work published in 1923. New Haven,
CT: Yale University Press.)
standards of visiting nursing” (Brainard, 1985, p. 326).
A joint committee appointed by the American Nurses
Association (ANA) and the Society of Superintendents of
Training Schools and chaired by Lillian Wald met to consider health is a social activity that builds “a comprehensive Â�program
the issue. They sent letters to more than 1000 organizations of Â� community service” on the basic sciences of chemistry,
in the United States that employed visiting nurses, inviting Â�bacteriology, engineering and statistics, physiology, pathology,
each to send a representative to a special meeting at the next epidemiology, and sociology (Winslow, 1984, p. 1).
ANA meeting in June 1912. Eighty replies were received, and Although his original definition of public health focused
69 organizations agreed to send a delegate (Brainard, 1985; on the goal of physical health, by 1923, Winslow acknowledged
Fitzpatrick, 1975). that prevention and treatment of mental illness was an expand-
The report of the joint committee was accepted. A National ing sector of the public health movement (Winslow, 1984). In
Visiting Nurse Association was formed as a member of the 1945, Winslow predicted that “public health which was an engi-
ANA, and recommended standards for organizations that neering science and has now become a medical science must
employed visiting nurses were accepted (Brainard, 1985; expand until it is in addition a social science” (Winslow, 1984,
Fitzpatrick, 1975). p. x). In 1953, the American Public Health Association (APHA)
The name of the association was debated at length because encouraged “collaboration between public health workers
there had not been any agreement within the joint commit- and social scientists to better promote the utilization of social
tee. A majority had favored National Visiting Nurse Association, Â�science findings toward the solution of public health problems”
but Crandall led a vocal minority advocating incorporation of (Suchman, 1963, p. 22). In 1963, Edward A. Suchman, profes-
Wald's term public health nursing (Brainard, 1985; Fitzpatrick, sor of sociology at the University of Pittsburgh, described the
1975). The reasons for selecting visiting nursing included the application of sociology in the field of public health. He noted
fact that it was the term commonly recognized by the public. that both sociology and public health originated in the social
Public health nursing was a broader term, which encompassed reform Â�movement, that both deal with populations of individu-
all nurses “doing work for social betterment” and was not lim- als, and that both employ statistical methods. The connection
ited to those who primarily did home visiting to provide bedside between social context and public health remains. It is especially
care (Brainard, 1985, p. 332). Public health nursing was general Â�important in the area of preventive health.
enough to include nurses in schools, tuberculosis programs, Winslow (1984) specifically named nursing services as an
hospital dispensaries, factories, settlements, and child wel- essential part of the organized community efforts that will
fare organizations, in addition to those providing bedside care prevent disease, prolong life, and promote health. He was an
through home visiting. Crandall argued that the public health advocate for public health nursing, and in 1923, he agreed
movement would expand and that adoption of the term public with William H. Welch (the founder of the Johns Hopkins
health nursing provided a generic label under which new forms School of Public Health) that public health nursing was
of practice could evolve. The organization was finally named one of two unique contributions that the United States had
National Organization for Public Health Nursing (NOPHN). made to Â�public health. Winslow (1984, p. 56) acknowledged
The word for was consciously selected to allow the participa- Â�public health nurses as “teachers of health par excellence” and
tion of nonnurses in promoting the work of public health nurs- Â�recognized teaching as a responsibility additional to “care of
ing (Brainard, 1985; Fitzpatrick, 1975). In 1952, the NOPHN the sick in their homes.”
merged with the National League for Nursing (NLN), which If the environment is healthful, if medical and nursing
continues today. Â�services are provided to assist the ill, and if individuals are taught
about health-related behavior and responsibilities, does a com-
DEFINITION OF PUBLIC HEALTH prehensive community effort for health exist? No, according to
Winslow. There must also be “social machinery … [to] ensure
C.-E. A. Winslow (1877-1957), the leading theoretician of a standard of living adequate for the maintenance of health”
the American public health movement, provided a definition (Winslow, 1984, p. 1). The science and art of public health are
of public health in 1920 (BoxÂ€2-2). He asserted that public inherently concerned with standard of living.
Public health nursing, as a composite of nursing and public Â�

population to 19 per 1000 population after her reforms (Hays,
health, is committed to the existence of standards of living suf- 1989, p. 154).
ficient to maintain health. The fields of public health and pub- Initially, there was no system for battlefield care during the
lic health nursing originated in social reform that occurred as a American Civil War. Even with surgery, 90% of soldiers with
result of the collective commitment of individuals to the health abdominal wounds and 62% with other wounds died (Pryor,
and well-being of others. 1987, p. 94). More soldiers died of disease than of the effects of
Acknowledging this commitment can provide renewed wounds. The Sanitary Commission was a relief agency started
energy and clarity of purpose. Community health nurses who by northerners to supply the Union Army with equipment.
are empowered by this commitment can continue to have an Newspapers advertised for surgeons and male nurses.
impact on the social and political power structures. Although Nightingale's work was known in America, pub-
lic roles for women remained limited. Because of the magni-
NURSING AND SANITARY REFORM tude of the need, however, numerous women's groups traveled
to the battlefields to care for the wounded. Dix led a group of
Before 1890, the primary public health measures to control nurses in the Christian Commission, a branch of the Young
communicable diseases in Europe and the United States were Men's Christian Association (YMCA) (Pryor, 1987). She had
isolation of the ill (quarantine) and enactment of laws govern- gained national prominence for her work in reforming Â�prisons
ing food markets, water supplies, and sanitation (Duffy, 1990). and mental institutions, and she was appointed head of the
As a result of the Industrial Revolution, many people moved to Department of Female Nurses. Most of the nurses worked in
cities, where crowded conditions and poor sanitation helped to hospitals in Washington, DC.
spread communicable diseases. Barton also organized volunteers at the battlefields. Although
not a trained nurse, she found her life's purpose in caring for the
Urban Health wounded (Pryor, 1987). She tended wounds, cooked, and col-
Descriptive epidemiological studies laid the groundwork for lected relief supplies for the troops. She was an excellent orga-
sanitary reforms in England and the United States (Duffy, 1990). nizer and enrolled others in providing enough supplies to fill
In 1842, Edwin Chadwick published a report on the unsanitary several warehouses. For a while during the war, she continued
conditions among poor persons in the cities in Great Britain. to receive her salary as one of only a few women Â�employees
Lemuel Shattuck founded the American Statistical Society in of the U.S. Patent Office. She was committed to providing
1839 and identified high death rates among workers in Boston. relief in times of war and disaster and became an advocate for
His Report of the Sanitary Commission of Massachusetts in 1850 the International Red Cross, a relief organization started in
called for government to improve sanitary and social conditions Switzerland. In 1881, Barton was one of the founders of the
to reduce incidences of disease and death. In 1854, the English American branch of the Red Cross.
physician John Snow demonstrated that the cases of cholera in
an outbreak were linked to water from the same well. The germ Policy Reforms and Health Education Campaigns
theory of disease was only emerging. TableÂ€2-3 lists other public By the last quarter of the nineteenth century, the discovery of
health accomplishments in the United States. microbes had carried the sanitary movement into the “golden
age of public health” (1880 to 1910). General sanitary reforms
Military Health were supplemented by specific actions aimed at Â�preventing
During this time, Florence Nightingale in England and Dorothea communicable diseases. These included pasteurization of milk,
Dix and Clara Barton, both teachers, in the United States, con- surgical asepsis, and immunization. The germ theory of Â�disease
fronted the unsanitary conditions and high death rates from also gave new impetus to campaigns for adequate housing,Â�
disease among military personnel (Hays, 1989; Pryor, 1987). In public water and sewage systems, pure food and drugs, and
the 1850s, British troops entered the Crimean War in Turkey reporting systems for disease surveillance. Public health nurses
and also occupied India. The Civil War (1861 to 1865) erupted continued to be leaders in educating the public about disease
in the United States. prevention. As the demand for public health nurses increased,
Nightingale hypothesized that both environmental and specializations within community health nursing emerged.
behavioral factors increased the soldiers’ risk of infectious dis-
eases (Hays, 1989). In Turkey, she organized and managed the POPULATION-FOCUSED CARE AND
nurses who cared for wounded soldiers, and she instituted SUBSPECIALTIES
reforms in sanitation, lifestyle, and data collection for monitor-
ing diseases. Sanitary reforms included improvements in drain- Public health nursing was for the entire public. Nurses in most
age, laundries, hospital design, and kitchen cleanliness. She rural communities and nurses assigned by districts in urban
recommended a varied diet, reduced alcohol consumption, and areas continued to practice as generalists. Generalists worked
activities to improve the soldiers’ quality of life. Her Â�advocacy with families and incorporated health promotion and disease
led to the establishment of libraries, athletic programs, and prevention into care of the sick.
Â�service projects for the troops in India. At its first annual meeting in 1913, the NOPHN recog-
Nightingale proposed new ways of reporting and Â�analyzing nized seven specializations and interest areas within public
biostatistics about the health of the British military. Although health nursing: general visiting nursing, rural nursing, school
she never went to India, she established a uniform data nursing, tuberculosis nursing, infant welfare, mental hygiene,
Â�collection system that she managed from England. She estab- and industrial welfare (Fitzpatrick, 1975). No longer were
lished Â� population-based objectives and demonstrated that urban poor persons and military personnel the only target
annual mortality rates dramatically declined from 70 per 1000 Â�population groups.
TABLEÂ€2-3â•…â•‡DATES IN U.S. PUBLIC HEALTH HISTORY

YEAR EVENT
U.S. Beginnings
1793 First local health department in Baltimore, Maryland
1798 New York City street cleaning system established
1813 Federal law to encourage smallpox vaccination
1842 Massachusetts Registration Act to provide for collecting vital statistics
1850 Report of the Sanitary Commission of Massachusetts by statistician Lemuel Shattuck
1855 First state quarantine board in Louisiana
1869 First state board of health in Massachusetts
1872 American Public Health Association (APHA) established
1878 Federal Marine Service Hospital established for seamen with illnesses and disabilities
1881 American Red Cross founded by Clara Barton
1890 Federal Marine Hospitals authorized to inspect immigrants
Expansion of Local Health Departments
1894 First medical inspection of schoolchildren in New York City
1900 Health departments established in 38 states
1910 Tuberculosis programs included in local and state health departments
1912 U.S. Public Health Service (USPHS) established
1912 National Safety Council formed
1935 Federal Social Security Act to institute Social Security retirement, disability, and survivors’ benefits
1945 Federal Hill-Burton Act to fund building of community hospitals
Expansion of Access to Care
1963 Federal Community Mental Health Centers Act
1965 Amendments to Social Security Act to provide financial mechanisms to pay for health care for poor (Medicaid) and
older adults (Medicare)
1965 Regional Medical Program established to disseminate research findings to the public regarding prevention and
treatment of heart disease, cancer, and stroke
Health Planning and Cost Controls
1966 Comprehensive Health Planning Amendments to the Public Health Service Act
1974 National Health Resources Planning and Development Act to provide for a system of community-based health
planning for the entire nation
1980 First national health objectives published
1980 Smallpox eradicated throughout the world through the leadership of the World Health Organization
1983 Health Resources Planning and Development Act not renewed; national health planning abolished
1983 Prospective payment system instituted under Medicare
Strengthening Public Health and Prevention
1988 The Future of Public Health published by the Institute of Medicine of the National Academy of Sciences
1990 National Health Objectives for the Year 2000 published
1993 National legislation introduced for health care reform
1995 Public health responsibilities and essential public health services described by the Public Health Functions Steering
Committee (Centers for Disease Control and Prevention [CDC])
2000 Healthy People 2010 published
2003 Funds for public health infrastructure provided by the CDC to strengthen preparedness for bioterrorism and other
emergencies
2004 Institute of Medicine recommends health insurance for all in the United States by 2010
2008 First exam for Certification in Public Health (CPH) for graduates from Council on Education for Public Health
(CEPH)-accredited schools and programs
2010 Healthy People 2020 published
2010 Federal Patient Protection and Affordable Care Act (PL 111-148) of 2010 mandating health insurance
reforms
Two schemes of subspecialties emerged simultaneously in NOPHN surveyed public health nurses according to these two
public health nursing, especially in urban areas. One scheme classification systems (Gardner, 1936).
considered the aggregate of people served: school popula- Health supervision overlapped with the population classifiÂ�
tions and industrial workers. The second scheme considered cation because some nurses worked with a specific age
health problems: health supervision or preventive education, group to promote health and prevent illness. For example,
maternity, and illnesses (morbidity). Mental hygiene was not some nurses worked exclusively with mothers and children,
Â�specifically mentioned in either scheme. By the early 1930s, the and others worked with school or employed populations.
Maternity services encompassed prenatal care, labor and Industrial Nursing

delivery (including home deliveries by physicians or mid- Industrial nursing in the United States predated industrial
wives), and postpartum and neonatal care. As previously Â�nursing in England. The Vermont Marble Works is credited
Â�discussed, care of the ill in their homes was the basis for with having employed Ada Stewart, a trained visiting nurse, to
visiting nursing care. Morbidity care expanded to include care for sick employees and their families in 1895 (Brainard,
the care of those not Â�confined to bed, especially those with 1985; Gardner, 1936). Industrial nursing grew slowly and was
Â�tuberculosis, Â�gonorrhea, and syphilis. started independently in firms by the employer, employee asso-
ciations, or both (Gardner, 1936).
School Nursing With the start of World War I in 1914, industrial nursing
School health nursing evolved as a specialty in visiting nurs- positions increased (Brainard, 1985). Federal government
ing in London in 1892 and in New York in 1902 (Brainard, contracts for war-related goods stimulated manufacturing
1985; Gardner, 1936). In London, the first school nurse vis- Â�businesses and industrial nursing positions. Productivity was
ited a school on a weekly basis to oversee nutrition and important. The National Safety Council had been formed in
Â�remedy minor ailments. By 1898, the London School Nurses’ 1912. Industrial nursing was beneficial because factory effi-
Society was Â�organized as a private charity. Five nurses served ciency was improved if workers were at work and healthy
500 Â�elementary schools, with each visiting four schools per (Gardner, 1936). Gardner (1936) suggested that philanthropy,
day and Â�examining 100 children (Brainard, 1985, p. 264). industrial justice, and fear of union movements were other
Medical inspection of schoolchildren in the United States was motives for starting industrial nursing services. By 1919, there
instituted in Boston in 1894, long after such systems were ini- were more than 1200 industrial nurses in 871 industries in the
tiated in France (1837), Germany, England, Russia, Chile, and United States (Brainard, 1985, p. 294).
Egypt (Gardner, 1936). Physicians excluded schoolchildren Employee health was the initial concern and was addressed
who had untreated Â�communicable diseases from school. by providing advice and first aid to individual employees, teach-
ing employees collectively about safety and sanitation, visiting at
home to care for and instruct employees with illnesses as well as
Wald noticed that the children excluded from school often their families, and initiating other public health Â�services in the
did not receive medical treatment and so remained out of communities (Gardner, 1936). Ella Crandall in 1916 Â�advocated
school for long periods but transmitted microorganisms that nurses also be involved directly in the environmental safety
to other children while playing in the streets. Nurses from and sanitation of plants as well as “social service for employ-
the Henry Street Settlement were determined to prove that ees, including recreation, vacation homes, education, relief and
children could remain in school, receive treatment, and general fitting of the man to the job” (Brainard, 1985, p. 295).
not increase the transmission of disease. In 1902, more Occupational health nursing, as it is called today, continues (see
than 10,000 children were excluded from New York City ChapterÂ€9).
schools; in 1903, after the school health nursing services
had been introduced, slightly more than 1000 children were Child Health Nursing
excluded (Gardner, 1936). Daily treatment of Â�illnesses such Among the humanitarian reforms during the nineteenth
as Â�ringworm and impetigo by the school nurses not only Â�century was the beginning of concern for the health and wel-
reduced illnesses but also dramatically reduced absenteeism. fare of infants and children. In 1817, the Englishman John Davis
wrote a book in which he explored the causes of mortality in
As a result of such successes, the New York Board of children and suggested that “benevolent ladies” visit homes to
Health employed 12 nurses to continue the work. According to instruct mothers, inspect children, and report on their condi-
Brainard (1985, p. 270), these nurses “were called the first Public tions (Brainard, 1985; Gardner, 1936). Little came of his idea.
Health Nurses.” Concurrently, he founded a dispensary especially for children
The goal of protecting school-aged children from com- in London.
municable diseases expanded to include screening and In Paris in 1844, the first day nursery for infants (la crèche)
examination for other treatable conditions such as defi- was started. A nurse cared for 12 infants in a poor community,
cits in growth, vision, and hearing. School nurses focused and a physician visited daily (Brainard, 1985). In 1876, a soci-
on the Â�correction of Â�potentially handicapping conditions. ety for nursing mothers established shelters in Paris to care for
Children were taught hygiene in schools by nurses as they poor women during the last few weeks of their pregnancy.
provided first aid. During the first quarter of the twenti- Breast-feeding was promoted, infants were observed on
eth century, nurses worked with elementary school teachers a monthly basis, and social work services were provided
and parent associations to Â�incorporate more group health (Brainard, 1985; Gardner, 1936). However, a high rate of
education. Nursing for high school Â� populations was to infant mortality persisted.
emerge later. The pasteurization of milk allowed clean milk supplies for
School nursing was introduced in other cities, often mothers who could not breast-feed. In 1892, milk stations
because the local visiting nurse association would “loan” were established in New York City and Hamburg, Germany, to
a nurse to Â�demonstrate the value of the service (Brainard, Â�provide sanitary milk supplies for sick infants (Brainard, 1985).
1985). Frequently, either the local health department or the However, there was little accompanying instruction with regard
board of education became interested in continuing the to infant feeding.
Â�service. Today, school nursing remains an important part of In the same year in Paris, Boudin provided the foundation for
Â�community health nursing practice in many communities (see the modern movement to combat infant mortality (Brainard,
ChapterÂ€30). 1985). After infants were discharged from Â�maternity Â�hospitals,
they were seen regularly on an outpatient basis for 2â•›years. Their and that the pathogen could be killed by exposure to sunlight
growth was monitored, breast-feeding was encouraged, and and boiling, prevention became possible. To prevent the spread
hygienic bottle-feeding was taught to mothers who could not of disease, persons with tuberculosis were instructed to collect
breast-feed. In 1894, Dufour prepared artificial feedings accord- sputum for proper disposal, avoid sleeping with others in close
ing to medical formulas and distributed them to the poor of quarters, and avoid sharing eating utensils.
Paris for use when breast-feeding could not be Â�carried out Tuberculosis nursing originated in the United States in
(Brainard, 1985). 1903 when William Osler, professor of medicine at the Johns
From the beginning of district nursing in England and visit- Hopkins University School of Medicine, hired Reiba Thelin to
ing nursing in the United States, nurses devoted much effort to provide home care and instruction to patients with tuberculosis
the care of women, infants, and children. This was a part of their in Baltimore (Brainard, 1985). Thelin had never done Â�visiting
generalized practice. nursing before and resigned after a year to study at the Henry
Specialized infant nursing began in the United States in 1902, Street Settlement. Mrs. Osler was also an ardent Â�supporter of
the same year as school nursing. In that year, special nurses the antituberculosis movement; she sent letters to all Baltimore
were employed solely to visit sick children in a district of New residents, soliciting $1 to support the tuberculosis nurses
York City, and other nurses visited infants born in the summer (Brainard, 1985). The money went to the visiting nurse associa-
months of 1902 and 1903 (Brainard, 1985). tion to pay for nurses especially assigned as tuberculosis nurses.
Following the French and German models, the Infants’ Similarly, the visiting nurse associations in other urban areas
Clinic was established in 1906 by the Visiting Nurse Association provided tuberculosis care.
of Cleveland and the Milk Fund Association (Brainard, 1985). The National Tuberculosis Association was founded in
Infants were examined until age 15â•›months by physicians in 1904. Its members soon recognized that there was much over-
dispensaries; nurses provided home visits every 2 to 3â•›weeks lapping and confusion in the provision of tuberculosis care;
to Â�promote breast-feeding, supervise formula preparation and some Â�programs were privately sponsored, and others were
feeding when necessary, and support mothers to follow medical sponsored by municipalities. By 1910, coordination and stan-
advice. These nurses specialized in teaching mothers to properly
Â� dardization of tuberculosis programs were recommended, and
care for their infants. Visiting nurse associations around the the cities and states took over the sponsorship of antituber-
country began to hire nurses solely for infant welfare work. culosis Â�programs (Brainard, 1985). By the 1930s, Â�tuberculosis
Local government became involved in 1908, with the for- nursing had become a part of the generalized practice of
mation of the Division of Child Hygiene in the New York City nurses employed by health departments (Gardner, 1936), but
Department of Health. Nurses visited all newborns and sick more than 500,000 cases of tuberculosis still existed. Public
infants in 89 districts (Brainard, 1985). After the annual meeting health nurses cared for those with advanced disease, conducted
of the American Academy of Medicine in 1908, nurses met with Â�tuberculin skin testing to identify infection in children, and
physicians, social workers, and laypersons to form the American taught effective ventilation practices and sputum disposal as
Association for the Study and Prevention of Infant Mortality effective preventive actions.
(Brainard, 1985). Through the advocacy of Wald, Â�visiting nurses Currently, health departments are mandated to Â� control
were recognized as being qualified to work in infant dispensa- communicable diseases within their jurisdictions. Drug-
Â�
ries (the forerunners of well-child clinics) to instruct mothers resistant tuberculosis, human immunodeficiency virus (HIV)
on how to prevent illnesses (Brainard, 1985). infection, sexually transmitted diseases (STDs), and diseases
In 1912, the federal government created the Children's caused by new infectious agents are of special concern today
Bureau, which sought to reduce morbidity and mortality (see ChapterÂ€8).
among the children of the United States. This body established
policy to promote prenatal care and home visits to mothers and EXPANSION INTO RURAL AMERICA
children, vaccination and immunization, provision of sanitary
milk, and prompt medical care, especially for physical defects Wald advocated that public health nursing services also be pro-
(Gardner, 1936). With World War I, death rates among adult vided to rural Americans (Bigbee & Crowder, 1985; Hamilton,
males increased, and birth rates fell. Saving the lives of children 1988; Haupt, 1953). Consequently, the Visiting Nurse Service of
thus became especially important for families (Gardner, 1936). the Metropolitan Life Insurance Company (1909) and the Red
Currently, promotion of maternal and child health remains Cross Rural Nursing Service (1912) were established. Economic
an important goal of local and state health departments (see support from business and private philanthropic sources
ChapterÂ€29). Measures of maternal and child health such as now existed for nationwide systems of public health nursing
infant mortality rates, rates of low birth weight, and childhood (FigureÂ€2-2).
immunization rates are used as indicators of quality of care.
Red Cross Rural Nursing Service
Tuberculosis Nursing Originally called the Town and Country Nursing Service, the Red
Tuberculosis was a dreaded disease in the 1870â•›s in the United Cross Rural Nursing Service (RNS) established more than 1000
States. It was known to be communicable and incurable. local nursing services, one of which led to the establishment of
Tuberculosis was the primary cause of death among young public health nursing services on American Indian reservations
and middle-aged adults (Gardner, 1936). Fresh air, rest, and (Bigbee & Crowder, 1985). The services were funded totally by
healthy food had been recommended by physicians throughout local Red Cross chapters or by local chapters in Â�partnership with
the nineteenth century, but no one knew why the treatments other private and government agencies. Traveling nurses were
worked. When Robert Koch discovered in 1882 that tuberculo- sent by the national Red Cross to local communities for several
sis was caused by a microorganism transmitted through sputum months to stimulate interest.
and gave immunizations (Hamilton, 1988). To stimulate the

creation of nursing services where there were none, the MLIC
provided scholarships for nurses to attend college and university
programs (Haupt, 1953). Statistics showed that public health
nursing care resulted in decreased mortality and improved
health among its policyholders.
The MLIC service ended in 1953 because the diminish-
ing outcomes no longer justified the rising costs (Hamilton,
1988). By then, immunizations had reduced deaths from com-
municable diseases. The numbers of home visits had decreased
because patients were now cared for in community hospitals,
which were started as a result of the federal Hill-Burton Act
(1945). Simultaneously the costs for home visits had risen,
partly because of the cost of increased education of nurses.
Funding from the Red Cross and the MLIC resulted in new
instructive visiting nurse associations throughout the country.
The nurses continued to combine preventive work with care for
the ill in their homes. Some visiting nurse Â�associations entered
into contracts with the MLIC. Other associations formed joint
ventures and started demonstration projects (Buhler-Wilkerson,
1985). In joint ventures, another voluntary organization
such as the Red Cross provided finances; in Â�demonstrations,
Â�experimental programs were piloted on a small scale until their
FIGUREÂ€2-2â•‡ A public health nurse immunizes farm and migrant
worth was proved, at which point someone else such as a local
workers in the 1940s. (From Library of Congress, Washington, DC.)
health department would take over the project. Until the 1920s,
most public health nurses were employed by not-for-profit,
The RNS supported high professional qualifications for its nongovernmental agencies.
nurses, including graduation from a 2-year nursing school,
registration (in states requiring it), previous public health Frontier Nursing Service
experience or postgraduate education, and membership in a As a nurse–midwife, Mary Breckinridge made an extraordi-
professional association (Bigbee & Crowder, 1985). nary contribution to the health of women and children in
The national Red Cross provided scholarships and loans the Â�underserved rural area of eastern Kentucky through the
for nurses to obtain postgraduate education in public health Â�establishment, in 1925, of the Frontier Nursing Service, which
nursing. The RNS designed a model curriculum for postgrad- continues to this day (FigureÂ€2-3). (See the Case Study at the
uate courses in rural public health nursing (4 to 8â•›months’ end of the chapter for more details about her life and Â�nursing
duration). The courses were first offered at Teachers College leadership.) Traveling on horseback through mountainous
in New York City in 1913. Financial support for the RNS dwin- areas, nurses provided general nursing care, bedside nursing,
dled during the 1920s because of economic depression and and midwifery to thousands of persons each year.
the emergence of public health nursing programs in local and
state health departments. However, hundreds of rural Â�counties GOVERNMENT EMPLOYMENT OF PUBLIC
still did not have public health nursing services (Bigbee & HEALTHÂ€NURSES
Crowder, 1985).
By 1900, 38 states had established health departments (Hanlon
Metropolitan Life Insurance Company Visiting & Pickett, 1984, p. 33). As the government took a more active role
NurseÂ€Service in public health, more nurses were employed by state and local
The Visiting Nurse Service of the Metropolitan Life Insurance governments, local health departments, and boards of Â�education.
Company (MLIC) was the prototype for business contracting As previously discussed, public hygiene Â�measures implemented
for public health nursing services (Hamilton, 1988). The MLIC during the golden age of public health had Â�successfully reduced
insured poor industrial workers who had high death rates. Lee morbidity and mortality rates from infectious diseases in urban
Frankel of the company proposed that insurance agents provide areas. Water was filtered, milk was pasteurized, garbage was
health and safety teaching to their policyholders. When Wald removed, and housing codes were instituted. The rural sani-
persuaded him that public health nurses would be better health tation movement of the 1920s Â�stimulated the Â�development of
teachers, a 44-year partnership began between the company and local health departments.
public health nurses. Insurance agents provided publicity. C.-E. A. Winslow (1984, p. 58) asserted that “the new Â�public
The MLIC contracted with existing visiting nurse associÂ� health movement” was to be based on “hygienic instruction,
ations to avoid duplication of services and to strengthen plus the organization of medical service for the detection
Â�community-based agencies (Haupt, 1953). During its peak year, and early treatment of incipient disease.” Some physicians
in 1931, more than 750,000 policyholders received more than advocated that a new kind of public health worker who
Â�
four million home visits in more than 7000 cities in the United Â�possessed knowledge of health, education, and social work be
States and Canada (Hamilton, 1988; Haupt, 1953). Nurses also Â�developed as a “health visitor” to perform the preventive activ-
Â�collected baseline health data in communities, started clinics, ities Â�normally carried out by public health nurses (Fitzpatrick,
prevent disease and provide health education to families of

servicemen living near military installations (Fitzpatrick,
1975, p. 65). Emphases were on childhood immunization,
control of STDs, and maternity care. As of 1984, 8.3% of all
employed registered nurses in the United States were working
in community health (101,430 registered nurses) or occupa-
tional health (22,890 registered nurses) (ANA, 1987, p. 101).
About 36% were employed by local health departments, 30%
by boards of education, and 21% by home health agencies.
More than 66% of nurses in community health were govern-
ment employees.
By 1996, the percentage of community health nurses
who were government employees had dropped to 40% (U.S.
Department of Health and Human Services [USDHHS], 1997).
Although the total number of government-employed commu-
nity health nurses increased between 1984 and 1996, the num-
bers of community health nurses employed in home health
care increased at a faster rate. Therefore, although there are
more community health nurses in government employment
today than in the 1980s, they comprise a smaller Â�percentage
of all community health nurses. (See ChapterÂ€1 for the current
distribution of community health nurses by work site.)
DICHOTOMY IN PUBLIC HEALTH NURSING

Early in the twentieth century, there was growing competition
between health departments and nongovernmental organiza-
FIGUREÂ€2-3â•‡ Mary Breckinridge, founder of the Frontier Nursing
Service, on her horse Babette in the 1960s. (Courtesy of Frontier tions. Visiting nurse associations feared that health departments
Nursing Service, Wendover, Kentucky.) might take over. At the same time, there was conflict between
the public health practitioners in health departments and the
medical profession. Private physicians feared loss of income if
1975). Winslow advocated for the public health nurse, who was health departments engaged in treating patients in addition to
already established in the homes. “Unlike the social worker, she preventing illnesses. Thus, health officers made decisions that
knew the human body,” its reactions, and “hygienic conduct of limited “publicly supported nurses to the prevention of disease,
life”; unlike the physician, who focused on pathology, “she was leaving the care of the sick to the visiting nurse associations”
trained to see the body as a whole” (Buhler-Wilkerson, 1985, (Buhler-Wilkerson, 1985, p. 1159).
pp. 1156-1157). The public health nurse was to be the educa- These decisions obviously acknowledged a place for nursing
Â�
tor for personal hygiene. both in health departments and in visiting nurse associations.
In 1916, the NOPHN supported “public health nursing However, the tragedy of these decisions was that they split the
under government auspices” as a means of extending health care nursing care of the ill from preventive nursing activities. Public
services to more people (Fitzpatrick, 1975, p. 48). By the mid- health nursing was no longer whole. Buhler-Wilkerson (1985)
1920s, more than 50% of public health nurses were Â�government asserted that it was this division that prevented public health
employees. By the late 1930s, all 48 states had public health nurs- nursing from achieving its potential as a delivery Â�system for
ing programs (Roberts & Heinrich, 1985). Many of the services comprehensive health care. Many nursing leaders in the 1920s
provided by the RNS were taken over by local health depart- attempted to maintain a “framework that would allow the
ments. The federal government also stimulated the increase in public health nurse to care for both the healthy and the sick”
public health nurses. Growth of state health departments was (Buhler-Wilkerson, 1985, p. 1159). In some communities,
a result of the federal Sheppard-Towner Act of 1921, which Â�partnerships developed between the health department and the
sought to improve maternal and child health. Â�visiting nurse association to provide both types of nursing care
Because of the Great Depression, many people were unem- through a “combined” administrative structure. Most of these
ployed. The Federal Emergency Relief Act of 1933 identi- structures, however, did not survive.
fied bedside nursing care of poor persons as a relief service. In 1929, the NOPHN stressed that public health nursing was
Federal money was made available for contracting with non- a nonprofit community service:
governmental visiting nurse associations to provide such
services. The Civil Works Administration included relief proj- Public health nursing is an organized community non-
ects for unemployed nurses themselves. By employing nurses profit service, rendered by graduate nurses to the individual,
in governmental agencies, the Civil Works Administration Â�family, and community. This service includes interpretation
stimulated tax-supported public health nursing programs and application of medical, sanitary, and social procedures
(Fitzpatrick, 1975). for the correction of defects, prevention of disease and the
During World War II, the U.S. Public Health Service promotion of health; and may include skilled care of the sick
Â�temporarily employed 200 nurses and 35 supervisors to help in their homes. (Fitzpatrick, 1975, p. 102)
This definition included government-sponsored services as Â�

prepare generalists in public health by affiliating with visiting
well as private, nonprofit services such as visiting nurse associa- nurse associations and adding lectures in sociology, psychology,
tions. Preventive services were a necessary component of Â�public and public health nursing (Fitzpatrick, 1975). Electives in pub-
health nursing, and skilled care of the ill in their homes was lic health nursing were also encouraged in training schools.
Â�permitted but not required. By 1918, the NLNE had agreed on a standard curriculum
In 1934, the NOPHN and the APHA definitions of public Â� that incorporated “social aspects of nursing” into the third year
health nursing were more general and included all nursing of basic diploma training schools (Fitzpatrick, 1975). Field
Â�services that assisted with the “public health program.” Â�practice was resisted by training schools because the students
were needed to staff hospitals. The NLNE and the NOPHN
Public health nursing includes all nursing services organized divided the duties of overseeing the incorporation of public
by a community or an agency to assist in carrying out any health nursing content into curricula. The NLNE oversaw basic
or all phases of the public health program. Services may be training schools, and the NOPHN was responsible for postgrad-
Â�rendered on an individual, family, or community basis in uate and staff education (Fitzpatrick, 1975).
the home, school, clinics, business establishment, or the office Despite the belief of the leadership that additional knowl-
of the agency. (Fitzpatrick, 1975, p. 127) edge and experience were necessary for public health nurses,
By then, however, most public health programs were govern- few nurses working in public health had the extra education.
ment sponsored. Correspondence courses were developed for those working
The division in public health nursing in the United States in the field who were academically unprepared. The NOPHN
occurred as a result of a basic schism within the health care endorsed the courses as appropriate staff education for those
system: the private sector versus the government-sponsored who had had 4â•›months of public health nursing experience
(public) sector. (See ChapterÂ€3 for more about the health (Fitzpatrick, 1975). Most public health nurses received addi-
care system.) To manage the competition and conflict tional information about their practice from publications sup-
between the two sectors, diagnosis and treatment of the ill ported by the NOPHN.
remained the domain of private physicians, and health pro- In 1924, after baccalaureate schools of nursing had become
motion and disease prevention were the domain of state and more prevalent, Alma Haupt, director of the MLIC Visiting
local health departments. This division of responsibility was Nurse Association and a member of the NOPHN Education
relatively clear and remained so until 1965, when, with the Committee, proposed that public health nursing content be
enactment of Medicare and Medicaid legislation, the gov- integrated into undergraduate education as a part of each spe-
ernment sector began paying for the care of ill older adults cialized course such as obstetric nursing. Each graduate would
and poor persons. be able to “organize care, make nursing assessments, appreciate
the home conditions of patients and learn about community
EDUCATIONAL PREPARATION FOR PUBLIC resources [and] the concept of health as a community responsi-
HEALTH NURSES bility” (Fitzpatrick, 1975, p. 101). To avoid overburdening pub-
lic health agencies with students, however, hospital schools were
Before 1935, most public health nurses were trained nurses to place their students in clinics, with only observations in pub-
who learned about public health nursing from their on-the- lic health nursing agencies (Fitzpatrick, 1975).
job experiences. By 1959, 20% of public health nurses had an Substantive increases occurred between 1935 and 1950 in
Â�academic degree. the percentage of public health nurses with adequate academic
In the early 1900s, some hospital schools placed students in preparation. Baccalaureate nursing programs were encouraged
private homes to provide nursing care and to increase Â�revenues to include 8-week affiliations in public health agencies that met
for the hospitals. However, most nurses in public health the NOPHN standards; students were to “study health and sick-
learned through apprenticeships with visiting nurse associa- ness in one family over time” and understand the neighborhood
tions. In 1906, the Boston Instructive District Visiting Nurses factors that “influenced a family's health and socioeconomic sit-
Association developed a course for its nurses. For 4â•›months, uation” (Fitzpatrick, 1975, p. 129). The number of postgraduate
nurses were closely supervised in their practice and received courses approved by the NOPHN increased from 16 in 1935 to
room and board but no salary (Brainard, 1985). 26 in 1940 (Roberts & Heinrich, 1985, p. 1164). By 1950, 1 in 5
In 1910, Teachers College of Columbia University established of the 25,000 public health nurses had one or more academic
the Department of Nursing and Health for postgraduate work degrees; 56% of all supervisors and 70% of state-employed
for trained nurses. Western Reserve University in Cleveland and supervisors had degrees (Fitzpatrick, 1975, p. 193).
Simmons College in Boston soon followed their lead (Brainard,
1985). By 1922, there were 15 postgraduate schools of public EXPANDED PRACTICE IN COMMUNITY HEALTH
health nursing (Goodnow, 1928, p. 240). Knowledge of hygiene NURSING: 1965 TO 1995
and sanitation; prevention and control of health problems such as
tuberculosis and infant mortality; sociology; and social Â�psychology Several forces converged to promote the emergence of the term
were valuable to nurses promoting health (Brainard, 1985). community health nursing. Hanlon and Pickett (1984) attribute
The NOPHN believed that effective nursing care for fami- the use of the term to the fact that numerous private, not-Â�for-
lies was based on good quality general nursing. The National profit agencies evolved in the 1960s to address health needs that
League for Nursing Education (NLNE) advocated that special- were not being met by local governments (the publicly spon-
ists in public nursing be prepared through university-sponsored sored agencies). As discussed previously, public health nursing
courses for nurses who had graduated from training schools. had come to be associated with government-sponsored services;
The NLNE also advocated that training schools for nurses now that other agencies also were addressing the health needs of
neighborhoods and population groups, an expanded term was public health nursing, nurses from the Minnesota Department
needed. The term community health nursing included nursing of Health (1997, p. 7) assert that population-based public health
sponsored by both private, nonprofit organizations and govern- practice is aimed at disease prevention and health promotion
mental agencies (Hanlon & Pickett, 1984). For-profit agencies to “improve the health status of entire identified populations.”
were not mentioned as being related to community health nurs- Here, the word based does not refer to physical setting but means
ing. Simultaneously, the ANA began to develop the following “on which the care is founded.” As discussed in ChapterÂ€1, the
divisions of nursing practice: community health, gerontologi- APHA (1996, p. 4) also describes public health nursing as “nurs-
cal, maternal and child health, medical-surgical, and psychiatric ing practice directed toward a population.”
and mental health. Each division was to describe its scope and In 1999, the ANA replaced the 1986 ANA Standards of
standards of practice. Community Health Nursing Practice with the Scope and Standards
Creation of the Division of Community Health Practice proof Public Health Nursing Practice. These Â�standards returned to
moted the widespread use of the term community health nursing the classic term public health nursing. This Â�document continued
(USDHHS, 1985). The division included nurses working within to distinguish public health nursing as Â�community- or popula-
a variety of community-based settings, including health depart- tion-focused care, as was discussed earlier in this chapter. The
ments; schools; work sites; private physicians’ offices; Â�private, author of these standards was the Quad Council of Public Health
nonprofit clinics; visiting nurse associations; and for-profit Nursing Organizations, which comprises four associations: (1)
home health agencies. Therefore, the term included nurses the ANA Council for Community, Primary, and Long-Term
employed by governmental, private nonprofit, and private for- Care Nursing Practice; (2) the Public Health Nursing Section of
profit agencies. For-profit (proprietary) home health agencies the APHA; (3) the Association of Community Health Nursing
began to increase in number after 1965 when Medicare made Educators; and (4) the Association of State and Territorial
skilled nursing care (home health care) financially accessible Directors of Nursing. June 2012 was the 100th anniversary of
to homebound older adults (see ChaptersÂ€28 and 31). Today, the adoption of the term “public health nursing.”
Â�agencies providing visiting nurses to care for the ill in their In 2007, the Quad Council authored the most recent stan-
homes are no longer sponsored primarily by the government dards, Public Health Nursing: Scope and Standards of Practice
and Â�nonprofit private agencies. (ANA, 2007c). (See ChapterÂ€1.) Dialogue about community/
The term community health nursing, in some respects, reunited public health nursing practice continues. Whatever the terms
nursing both for the promotion of health and prevention of dis- used, the possibility exists for population-focused nursing in
ease and for the care of the ill in their homes. However, dur- the twenty-first century to recapture the vitality and wholeness
ing the last half of the 1990s, an attempt emerged to distinguish that existed in public health nursing in the late 1800s.
community health nurses who had education and experience in
nursing and public health practice from other nurses included COMMUNITY/PUBLIC HEALTH NURSING:
within the ANA Division of Community Health Practice CREATING THE FUTURE
(ANA, 1995; Baldwin etÂ€al., 1998; Zotti etÂ€al., 1996). All nurses
within the Division of Community Health Practice provide The essence of public health is “organized community efforts”
Â�community-based care, that is, care outside an institution such as that ensure “conditions in which people can be healthy”
a hospital or nursing home (Quad Council, 1999). As discussed (Institute of Medicine [IOM], 1988, pp. 7, 41). Promotion of
in ChapterÂ€1, many of these nurses Â�provide Â�individual-focused safe environments, timely immunization, sound nutrition,
care, and/or family-focused care and do not have the educational attention to maternal and fetal health, and responsible behaviors
preparation required for population- and community-focused and self-care, as well as provision of health care services, helps
care. Therefore, perhaps a Â�better name for this ANA practice create healthful conditions (Wallace, 2008). Social and health
division would be Division of Community-Based Practice rather care needs cannot be met solely by making sure that everyone
than Division of Community Health Practice. has financial access to medical care (IOM, 1988). Community
health nurses as public health personnel are experts in “health
RECLAIMING PUBLIC HEALTH NURSING: problem identification, disease and disability prevention, and
1995 TO 2010 health promotion” (IOM, 1988, p. 153). Community/pub-
lic health nurses are exemplars in “outreach and case finding,
The question that remains is: What name should be used for direct service delivery, and management of needs of multiprob-
those community-based nurses who have education and experi- lem clients” (IOM, 1988, p. 153).
ence in providing population- and community-focused care in
addition to care of individuals and families? Some authors sug- Health Care Reform
gest that the term community health nurse be reserved for these Nursing's Agenda for Health Care Reform (ANA, 1991) called
practitioners (Zotti etÂ€al., 1996). Others use the term commu- for a health care system that supports more nurses as primary
nity/public health nurse to distinguish those community-based care providers. Primary health care includes essential health
nurses who provide population- or community-focused care care that is universally accessible to individuals and families
(Association of Community Health Nursing Educators, 1995; within communities (ANA Council of Community Health
Baldwin etÂ€al., 1998). Nurses [ACCHN], 1986b). Primary health care includes health
Baldwin and colleagues (1998) recommend that the terms Â�promotion and disease prevention as well as a basic Â�package
community health nursing and public health nursing be aban- of Â�services for treatment of illnesses and injuries. In 1997,
doned. They suggested that the term population-focused nursing third-party reimbursement under Medicare and Medicaid was
or population health nursing be used to designate nurses whose expanded to all nurse Â�practitioners and clinical nurse specialists
practice is population focused. Although they retain the term (Keepnews, 1998).
In 2004, the Institute of Medicine recommended that HEALTHY PEOPLE National Health Objectives
health insurance be available to all persons in the United The Healthy People effort led by the USDHHS uses science-
States by 2010. The federal Patient Protection and Affordable based information to outline the national planning process for
Care Act (PL 111-148) of 2010 mandates health insurance health promotion and disease prevention in the United States.
reforms designed to improve quality and affordable care for Started in 1979 and currently projected to 2020, this compre-
all Americans (see ChaptersÂ€3, 4 and 6). Even when almost hensive plan sets goals and objectives required to improve the
everyone has financial access to a basic package of health care health and well-being of the nation. The following are the four
services, people still need to learn to gain access to that care, basic goals for Healthy People 2020 (USDHHS 2010):
to cope with personal responses to their health status, and to 1. Attain high-quality, longer lives free of preventable disease,
understand how their own behaviors can improve their well- disability, injury, and premature death.
being. These concerns are all within the domain of nursing 2. Achieve health equity, eliminate disparities, and improve
practice. A variety of models for delivering nursing care in a health for all groups.
changing health care system are under exploration (ACCHN, 3. Promote quality of life, healthy development, and healthy
1986a). Community/public health nurses, especially those behaviors across all life stages
employed by government and charged with the health of 4. Create social and physical environments that promote good
entire populations, need to become more visible and vocal as health for all.
leaders for health (IOM, 2010). To achieve these goals, nearly 600 objectives were Â�developed
We can look to nursing in other countries for nursing care to serve as a basis for action plans. These objectives are
delivery models that may fit our changing circumstances. For Â�organized under 42 topics or focus areas as presented in the
example, since the 1970s, some community health nurses in Healthy People 2020 box at the top of page 47. There are two
Canada and the United Kingdom have been employed by types of Â�objectives: measurable and developmental. Measurable
their governments but “attached” to work with primary care Â�objectives Â�provide direction for action and include a baseline
physicians and their enrolled patients (Ciliska etÂ€al., 1992; measure, targets for 2020, and sources of data. Developmental
McClure, 1984). As more Americans join health plans in objectives set a vision for a desired health outcome but do not
which they designate a primary care provider, similar nurs- include Â�specific Â�targets because adequate baseline data are not
ing care delivery models might become appropriate in the available (USDHHS, 2010). Each topic has a lead federal agency
United States. responsible for Â�developing and overseeing that topic; there are
Both universal access to primary health care services and a total of 18 agencies (see http://www.healthypeople.gov/2020/
public-focused health services are needed. Public health about/Â�leadFederalAgencies.aspx).
nurses are addressing the challenge issued by Philip Lee The objectives were based on a projected profile of the U.S.
(1993), Assistant Secretary of Health and Human Services, to population in 2020 and on knowledge of the existing health
public health leaders. His challenge was to (1) help develop Â�status of the public. The 2020 population is expected to be
data Â�systems to monitor how well primary health care ser- larger, older, and more diverse racially and ethnically. (See the
vices support the health of populations, (2) engage in research Healthy People 2020 box at the bottom of p. 47.)
about health care delivery and prevention, and (3) provide Healthy People 2020 builds on plans from previous decades, is
more primary health care workers (including Â�community based on an ecological model of health, and has a renewed focus
health nurses, nurse practitioners, and midwives) in under- on health disparities that are influenced by multiple determi-
served areas. He also called for more flexible outreach, nants. An ecological perspective of health recognizes that indi-
Â�support, and translation services to population groups previ- viduals live in and interact with their environments. In Healthy
ously underserved. As new relationships are defined among People 2020, the term health disparities means any Â�difference
public health departments and personal health care deliv- in health outcomes among populations. Determinants of
ery organizations, including managed care organizations and health include factors that influence the health of an individual
medical homes, community/public health nursing responsi- or population. These factors may be categorized as individual
bilities will continue to evolve. biology/genetics, individual health behavior, social and physical
Community/public health nurses already are carrying out environments, access to health care, and policies (FigureÂ€2-4).
the core public health functions of assessment, policy develop- Interventions that modify health determinants can lead to
ment, and assurance (see ChapterÂ€29). Community-wide ser- improved health status and reduction or elimination of health
vices continue to be needed for the prevention and control of disparities among populations.
(1) communicable diseases and environmentally induced ill- New for many topics in Healthy People 2020 are links to
nesses and injuries such as HIV infection and violence; (2) intervention strategies that address clinical care of individuals,
Â�
premature deaths, especially among infants; and (3) chronic evidence-based community-focused interventions, and con-
diseases and conditions such as obesity. Community/public sumer health information. The Guide to Clinical Preventive
health nurses can stand on a century of nursing history to Â�create Services developed by the U.S. Preventive Services Task Force
nursing Â�services for the future. (USPSTF) (2011) recommends individual-focused interven-
Knowledge of the structure and financing of U.S. health care tions such as screening and counseling for health prevention
is necessary if quality nursing is to exist in a climate of cost con- in primary care settings. The USPSTF is an independent panel
tainment (AACN, 2008; Quad Council, 2011) (see ChaptersÂ€3 of experts supported by the USDHHS Agency for Healthcare
and 4). Making health insurance coverage available to more Research and Quality (AHRQ). Community-focused inter-
people is not the same as transforming the health care system ventions are recommended in The guide to Community
into one that advocates health promotion and social betterment Prevention (CDC, 2011) which is an evidence-based docu-
(Anderson, 1991). ment developed through a systematic review of existing
HEALTHY PEOPLE 2020

Objective Topic Areas
Access to Health Services Human Immunodeficiency Virus

Adolescent Health* Immunization and Infectious Diseases
Arthritis, Osteoporosis, and Chronic Back Conditions Injury and Violence Protection
Blood Disorders and Blood Safety* Lesbian, Gay, Bisexual, and Transgendered Health*
Cancer Maternal, Infant, and Child Health
Chronic Kidney Disease Medical Product Safety
Dementia, including Alzheimer's Disease Mental Health and Mental Disorders
Diabetes Nutrition and Weight Status
Disability and Health Occupational Safety and Health
Early and Middle Childhood* Older Adults*
Educational and Community-Based Programs Oral Health
Environmental Health Physical Activity
Family Planning Preparedness*
Food Safety Public Health Infrastructures
Genomics* Respiratory Diseases
Global Health* Sexually Transmitted Diseases
Health Communication and Health Information Technology Sleep Health*
Health Care–Associated Infections* Social Determinants of Health*
Health-Related Quality of Life and Well-Being* Substance Abuse
Hearing and Other Sensory or Communication Disorders Tobacco Use
Heart Disease and Stroke Vision
*New topics not included in Healthy People 2010.
From U.S. Department of Health and Human Services. (2010). Healthy People 2020. Retrieved September 10, 2011 from http://www.healthypeople.
gov/2020/topicsobjectives2020/default.aspx
HEALTHY PEOPLE 2020 Goals

Profile of the American People in the Year 2020
• The total population of the United States will have grown to nearly
Objectives
342 million people from 310 million in 2010.
• The population will be older, with the median age being 38.1â•›years
(in 1990, it was 33â•›years). Persons 65â•›years and older will constitute
16% of the population; 6.6 million people will be 85â•›years or older, Determinants of Health
and 135,000 of them will be 100â•›years or older.
• A slightly smaller percentage of the population will be children Policies and Interventions
and youth younger than 18â•›years of age (82 million compared
with 75 Â�million in 2010, but 23.9 % of the population compared
with 24.25 % in 2010). Behavior
• Racial and ethnic compositions will be more diverse. The propor-
tion of non-Hispanic whites will continue to decline, in part due to Physical Social
deaths among older people. The proportion of African Americans, environment Individual environment
Hispanics, and others (including American Indians, Native Alaskans,
Asians, and Pacific Islanders) will increase to 40%. The Hispanic
population will have grown to almost 20%. Biology
Data from U.S. Census Bureau. (2008). U.S. National Population

Projections 2010 to 2050: Summary Tables (Based on Census 2000). Access to Quality Health Care
Retrieved September 14, 2011 from http://www.census.gov/population/
www/projections/summarytables.html.
research by the Â� independent Task Force on Preventive

Health Services, appointed by the Director of the Centers for Health Status
Disease Control. FIGUREÂ€2-4â•‡ Determinants of health: Healthy people in healthy
There is no single national plan for achieving all of the communities. (From U.S. Department of Health and Human Services.
national health objectives. Each Healthy People plan undergoes [2000]. Healthy People 2010: Understanding and improving health.
a period of public comment. The national health objectives Washington, DC: U.S. Government PrintingÂ€Office.)
HEALTHY PEOPLE 2020

Leading Health Indicators
Topics Indicators Objectives
Access to Care Proportion of the population with access to 1. Increase the proportion of persons with health insurance (AHS 1)
health care services 2. Increase proportion of persons with a usual primary care provider (AHS 3)
3. (Developmental) Increase the proportion of persons who receive appropri-
ate evidence-based clinical preventive services (AHS 7)
Healthy Behaviors Proportion of the population engaged in healthy 4. Increase the proportion of adults who meet current federal physical Â�activity
behaviors guidelines for aerobic physical activity and for muscle-strengthening
Â�activity (PA 2)
5. Reduce the proportion of children and adolescents who are considered
obese (NWS 10)
6. Reduce consumption of calories from solid fats and added sugars in the
population aged 2â•›years and older (NWS 17)
7. Increase the proportion of adults who get sufficient sleep (SH 4)
Chronic Disease Prevalence of and mortality from chronic 8. Reduce coronary heart disease deaths (HDS 2)
disease 9. Reduce the proportion of persons in the population with hypertension
(HDSÂ€5)
10. Reduce the overall cancer death rate (C 1)
Environmental Determinants Proportion of the population experiencing a 11. Reduce the number of days the Air Quality Index (AQI) exceeds 100 (EH 1)
healthy physical environment
Social Determinants Proportion of the population experiencing a 12. (Developmental) Improve the health literacy of the population (HC/HIT 1)
healthy social environment 13. (Developmental) Increase the proportion of children who are ready for
school in all five domains of healthy development: physical development,
social-emotional development, approaches to learning, language, and cog-
nitive development (EMC 1)
14. Increase educational achievement of adolescents and young adults (AH 5)
Injury Proportion of the population that experiences 15. Reduce fatal and nonfatal injuries (IVP 1)
injury
Mental Health Proportion of the population experiencing 16. Reduce the proportion of persons who experience major depressive
positive mental health Â�episodes (MDE) (MHMD 4)
Maternal and Infant Health Proportion of healthy births 17. Reduce low birth weight (LBW) and very low birth weight (VLBW)
(MICH 8)
Responsible Sexual Behavior Proportion of the population engaged in 18. Reduce pregnancy rates among adolescent females (FP 8)
responsible sexual behavior 19. Increase the proportion of sexually active persons who use condoms
(HIV 17)
Substance Abuse Proportion of the population engaged in 20. Reduce past-month use of illicit substances (SA 13)
substance abuse 21. Reduce the proportion of persons engaging in binge drinking of alcoholic
beverages (SA 14)
Tobacco Proportion of the population using tobacco 22. Reduce tobacco use by adults (TU 1)
23. Reduce the initiation of tobacco use among children, adolescents, and
young adults (TU 3)
Quality of Care Proportion of the population receiving quality 24. Reduce central line–associated bloodstream infections (CLABSI) (HA 1)
health care services
Note: The numbering of the objectives is directly from Healthy People 2020.
From Institute of Medicine. (2011). Leading health indicators for Healthy People 2020—Letter report. Washington, DC: National Academies of Science.
are used by federal, state, and local governments, by nonprofit its charge, the IOM (2011) was asked to select 12 priority topics
groups and businesses interested in the health of Â�communities, from Healthy People 2020 as well as 24 Â�objectives and indicators
and by communities themselves. Most states and territo- that are critical to the nation's health needs (see Healthy People
ries develop their own Healthy People plans based on the fed- 2020 box). Community/public health nurses are instrumental
eral plan. Local jurisdictions may use federal and state plans to in addressing these national priorities.
guide their prioritization of topics and objectives. Not all of the
national objectives are relevant in every community. Populations and Community/Public Health Nursing
Federal government funding can be targeted toward regional To make progress toward our national vision of healthier peo-
and national priorities for health promotion and disease ple and communities, community/public health nurses must
Â�prevention. Healthy People 2020 objectives can also be used understand our historical roots. Earlier community health
to measure progress of federally funded programs such as the nurses recognized that people are whole human beings within
Preventive Health and Health Services Block grants. As part of complex social and physical environments. The betterment of
human communities remains the goal of community health health nurses will be instrumental in Â� preventing work site
nursing. However, our specific objectives change with social and Â�exposures to specific toxins and in teaching other nurses and
environmental conditions, the types of illnesses present, and the the public about such hazards.
needs of specific populations. How do we organize and deliver public health nursing ser-
Older adults, adolescents, persons from low-income groups, vices in the public sector of health care? As local health depart-
and homeless people are just some of the populations that can ments are reorganizing to focus more on core public health
benefit from community/public health nursing care. For exam- functions, public health nursing is also Â�reinvigorating itself. In
ple, older adults experience illnesses more than young Â�persons some local health departments, public health Â�nursing Â�practice
do and are, therefore, in need of information on how to main- is moving away from Â�primary health care clinical practice to
tain their well-being and independence in the presence of strengthen its Â�population-focused Â�practice (Kosidlak, 1999).
chronic diseases and disabilities. For instance, in Los Angeles County, California, 200 of 500
Attitudes and knowledge about health and h Â� ealth-promoting public health nurses were reassigned from categorical pro-
behaviors are learned within the family and community. Schools grams such as maternal child health or tuberculosis con-
and peer groups are important social networks for Â�children and trol to geographically-defined service planning areas (Avila
adolescents. Although children tend to be physically healthier & Smith, 2003). As district Â�public health nurses, they develop
than adults, issues of spiritual and emotional well-being faced a Â�community assessment Â�database for their districts, expand
by them are important. Obesity, teen Â�pregnancy, HIV Â�infection, practice beyond Â�disease Â�control, Â�provide nursing consultation
substance abuse, and violence are public health priorities in the community, and Â�participate in public health planning
among youth. Community/Â�public health nurses working with and Â�community-level interventions.
families and in schools will Â�continue to confront these chal- Community/public health nurses have demonstrated
lenges (ANA, 2011). that nursing care can be provided in a variety of other
Poverty is stressful. Poor persons tend to have poorer Â�settings in which various populations spend much of their
health compared with their wealthier neighbors. The Â�growing day (ANA Council, 1986a) such as medical daycare centers,
numbers of poor persons, especially women, children, and child Â�daycare centers, shelters for the homeless, prisons, and
the homeless, require coordinated assistance to meet their faith Â�communities (Alexander-Rodriguez, 1983; ANA, 2005,
Â�multiple needs. Sustained relationships are necessary for their 2007a). Community/public health nurses also provide com-
Â�empowerment (Schorr, 1989). Poverty rates tend to be higher municable disease and safety consultation to in-home daycare
in rural and inner-city communities, where fewer health care Â�providers (Lie, 1992). With the expected increases in the num-
services are available. Although the largest number of the ber of Â�persons with chronic illnesses and the number of older
poor in the United States are white, nonwhite populations adults, hospice Â�programs will become even more important
suffer higher rates of poverty. Community/public health (ANA, 2007b).
nurses have a long history of advocating for those who have
not had equal access to health care and a basic standard of Emerging and Reemerging Infections and
living, and they are challenged to continue to pursue justice Threats of Terrorism
(see ChapterÂ€1). A major activity of the governmental sector of health care is
Rates of neonatal and infant illnesses and deaths are an the control of communicable diseases in populations. The
important measure of a community's health. Infant mortal- appearance of new infectious diseases, the reemergence of
ity continues to decline in the United States. However, infant old Â�infectious diseases, and the threat of bioterrorism are rea-
mortality is much higher among African Americans, Puerto sons that interest and support for communicable disease con-
Ricans, and some American Indian tribes than among whites. trol have been increasing in recent years (Heymann, 2009).
More than 100â•›years ago, community health nurses demon- Examples of new diseases include Lyme disease, for which the
strated their ability to reduce mortality among newborns and infectious agent was identified only in 1982, a global epidemic
infants. Although communicable diseases are no longer the of severe acute respiratory syndrome (SARS) that occurred in
primary causes of death, community/public health nurses 2003, and the 2009 pandemic of H1N1 influenza. International
have shown their ability to work with parents to reduce the migration of diseases such as West Nile fever and malaria has
rates of low birth weight in neonates and to prevent child expanded. Tuberculosis, once thought to have been controlled,
abuse and accidents (Brooten etÂ€al., 1986; Olds etÂ€al., 1993). reemerged in the United States as a secondary infection in
Special research opportunities exist for community/pub- persons with acquired immunodeficiency syndrome (AIDS).
lic health nurses to identify interventions that work best to The anthrax exposure of postal workers in the Washington,
reduce infant mortality among various socioeconomic, racial, DC, area Â�during 2001 underscores the need for effective pub-
and cultural populations. lic health Â�measures to respond to bioterrorism (see ChapterÂ€8).
Population-focused health promotion and primary Â�prevention Community/public health nurses, especially those working
will be provided at community sites where individuals spend for local and state health departments, are involved in devel-
much of their time. Work sites will continue to be Â�important oping plans for Â�community-level preparedness and response
places to assist people in changing their lifestyles and in reducing to Â�outbreaks of communicable diseases from natural causes or
their risks of heart disease, cancer, diabetes, obstructive pulmo- Â�terrorism (see ChapterÂ€22).
nary disease, and alcoholism. Community/public health nurses Specifically, new electronic surveillance systems have been
and other public health professionals will have opportunities developed to help health departments identify and moni-
to promote measures for more healthful work environments, tor outbreaks of communicable diseases. Community/public
including improvement of indoor air quality. Occupational health nurses are active in the effort to inform the public about
risks and have helped develop an appropriate public health nurses. Health care insurance reform is bringing changes in
response to a bioterrorist attack. This strategy involves the the organization and distribution of health care. Where will
stockpiling of effective antimicrobial agents and an efficient sys- community/public health nurses fit in the scheme? Should
tem for distributing these supplies to the affected areas. Because community health nurses continue to be employed by others?
of the Â�limited supply of personnel and funding, a tension exists Will more community/public health nurses consider start-
between the use of these resources for homeland security and ing private businesses and practices in which they contract
for other Â�on-going, important public health problems. with larger health care entities to provide community health
Â�nursing care?
CONTINUING ISSUES How do we continue to provide quality community health
nursing care? There are many nurses, especially in the subspecialty
The challenge continues for community/public health nurses to of home health care, who do not have formal community health
reunite various aspects of their practice, with focus on all levels nursing education. How can technological competence be linked
of prevention. What is a practical balance between providing with competence in family-focused and population-focused care?
care for the ill in their homes and providing health promotion These questions are similar to those that nurses in the 1920s asked
and primary prevention within the community? Community/ themselves: How do we best provide on-the-job training, intern-
public health nurses continue to use their knowledge of epide- ships, formal education, and continuing education?
miology to identify vulnerable subpopulations within the entire How can we work more effectively for social betterment in our
population. Much of the community/public health nursing care communities? For vulnerable populations to become empow-
is provided to human beings as individuals and as members ered, we must engage in sustained relationships that focus on
of families, groups, and organizations. The collective health of the wholeness of persons and their communities (Erickson,
individual humans contributes to the health of the entire pub- 1996; Schorr, 1989). Community/public health nurses have
lic. In addition, a network of social relationships contributes to known this for almost 150â•›years. Therefore, to truly improve the
the degree of connected caring. In community health nursing, health of a community, community/public health nurses must
there is always a tension among the various perspectives. Unlike provide holistic care, especially in underserved urban and rural
some planners and statisticians, however, community/public communities. More nurses might need to return to district or
health nurses can attach human faces and personal stories to neighborhood nursing (Avila & Smith, 2003). We also need to
the numbers. Unlike many other nurses who choose to focus pay attention to the suffering of all members of a community
predominantly on the health of individuals, community/public and respond to their needs. We need to commit to staying in
health nurses think in terms of the health of populations. nurse–client relationships for a while. We need to be more vocal
Private businesses, rather than state and local govern- and more visible in sharing our ideas about what works with
ments, employ an increasing percentage of community health other community leaders.
KEY IDEAS
1. Community/public health nursing has its roots in nursing Â� Company (1909) and the Red Cross Rural Nursing Service
and public health. The challenges of community/public (1912). in 1925, Mary Breckinridge founded the Frontier
health nursing evolve as changes occur in population char- Nursing Service in Kentucky, which exists even today.
acteristics, scientific knowledge and theory about health and 8. Public health nursing was originally sponsored by finan-
illness, prevalent illnesses and causes of death, societal values, cial donations from the wealthy. As public health nursing
and economic and political systems. demonstrated its effectiveness, it became institutionalized
2. Nursing's roots include visiting and district nursing to care in health departments of local and state governments. The
for the ill in their homes, health teaching and promotion holism of public health nursing, with its focus on both care
with families, and “nursing the environment.” and prevention of sickness, was broken when health depart-
3. Public health's roots include the provision of a sanitary ments sought not to threaten physicians’ practices. Health
environment and the prevention of disease through immu- departments took on the responsibility for health promo-
nization and personal responsibility for hygiene. tion and disease prevention, and visiting nurse agencies
4. Population-focused nursing started with an interest in continued with care of the ill in their homes (also called
urban poor populations and British and American military home health care).
personnel during the mid-1800â•›s. 9. The term public health nursing had become associated
5. In 1912, visiting nurses in the United States named them- primarily with the work of those nurses employed by
Â�
selves public health nurses because they provided care to all Â�government. Public health nurses working in new commu-
members of the community—to the entire public—and nity centers and for-profit home health agencies also needed
were committed to social betterment. to be included. Therefore, the term community health nurs-
6. As additional populations were identified as being at risk of ing emerged in the 1970s as the new name for public health
illnesses and in need of nursing care, subspecialties of pub- nursing.
lic health nursing emerged. These included maternal and 10. Because the term community health nursing can encom-
child health, school health, and occupational health. pass all nurses working in community-based settings,
7. Under the leadership of Lillian Wald, public health nursing some Â�community health nurses have proposed clarifying
expanded into rural communities with the creation of the that community health nurses are population focused or
Visiting Nurse Service of the Metropolitan Life Insurance Â�community focused.
11. With health care reform and the development of national public health nursing to the public. Issues of Â�organizing and
health promotion goals, there are new opportunities to delivering community/public health nursing services are
reunite care and prevention within community/public health ongoing. The term public health nursing has reemerged to
nursing. New models are emerging to deliver Â�community/ mean community-based, population-focused nursing care.
CASE STUDY
Mary Breckinridge: A Public Health Nursing Leader
Mary Breckinridge (1881-1965) initiated a study of the health needs of 7806 persons in 1675 families were cared for; this included bedside
29,000 people in three counties in eastern Kentucky in 1923. She rode nursing provided in 459 cases of serious illness.
more than 700 miles on horseback to interview 53 “granny women” The nurses at the outlying stations lived in comfortable quarters,
or midwives, young mothers, schoolteachers, and those in charge with two nurses per station and a housekeeper–cook. One nurse was
of missions. assigned general duty and one midwifery. Each nurse was assigned a
Her family had lived in Kentucky since 1790 and had been in public district and could cover 80 square miles per day. Six weeks of vaca-
service since the time of Thomas Jefferson. Her father was minister tion were earned each year, preferably taken in two 3-week periods.
to Russia under President Grover Cleveland. She spent 12 winters in The work itself was demanding. The nurse had to be independent,
Washington, DC, as a girl and 2â•›years in Russia with French and German capable of extensive horseback travel, unstopped by vagaries of
governesses. A great-aunt established schools for mountain children in weather, and available to respond to emergency illnesses. The nurses
the southern United States. To prepare for service Mary “took the stiff were Â�committed to the people they served as well as to their own
training as a nurse at St. Luke's Hospital in New York.” Â�professional practice.
Following the death of her husband, she married again, but the sÂ� econd Mary Breckinridge enlisted others to assist in addressing the
marriage was unhappy, and two children died. She went to France to Â�multitude of problems she had identified. She organized a local
care for children there during World War I. Her thoughts returned to Â�committee of mountaineers so that she could work with the Â�people
Kentucky, where neonatal and maternal deaths and epidemics of hook- rather than for them. She involved her relatives, physicians, experts
worm, diphtheria, smallpox, typhoid, and tuberculosis ravaged the pop- in public health, and the Kentucky State Board of Health in plan-
ulation. Her assessment emerged from her commitment to demonstrate ning the organization. The nurses avoided involvement in the moun-
“what intelligent nursing could do to safeguard the lives of mothers taineer clan wars and served anyone who was wounded or in
and children on our many forgotten frontiers” in the United States. To need. Breckinridge collaborated with federal and state authorities,
be able to address the health needs she had identified, she studied the Rockefeller Foundation, and the Johns Hopkins and Vanderbilt
in London to become licensed as a nurse–midwife. She returned to Â�universities. The American Child Health Association participated in
Kentucky in 1925 to provide trained nurse-midwives “to deliver women attempts to eradicate hookworm infestations in people. Graduates
in childbirth and safeguard the lives of little children, to care for the of the Forestry Department of Yale University were invited to survey
sick of all ages and take measures to prevent disease, and to work for logging practices and revitalize the forests to improve employment
economic conditions less inimical to health.” opportunities and thus reduce poverty.
The Frontier Nursing Service was thus created. By 1931, “the staff Mary Breckinridge was a pioneer in community assessment,
included two assistant directors, three supervisors, relief nurses, three Â�population-based planning, and partnership building. She created a
nurses and a physician in a small hospital … and 21 nurses in the system for rural nursing and used research to demonstrate its effec-
field.” One nurse's report indicated that she had made rounds for 11 tiveness. Her vision remains fulfilled in the Frontier Nursing Service,
hours a day and during the week had visited 143 persons. In addition, which continues today.
patients were seen at the centers. All services were provided for only See Critical Thinking Questions for this Case Study on the
$10.92 per year per individual served. In the year ending May 1931, book's website.
Data from Poole, E. (1932). Nurses on horseback. New York: Macmillan.
1. After reading the Case Study above regarding the work of Â�
community/public health nurse. Focus on similarities
Mary Breckinridge, describe how she displayed the leader- and differences.
ship characteristics described in ChapterÂ€1. 4. Identify the Healthy People objectives applicable to a
2. Read the biography of a noted community/public health Â�population or aggregate to which you belong such as young
nurse. Identify the health problems and the communities adult Asian women; urban African American adult men;
with which the community/public health nurse worked. rural, low-income white women. Note your thoughts and
Reflect on the degree to which both care of the ill and health feelings as you consider the objectives.
promotion and primary prevention were included in the 5. Discuss which populations/aggregates should receive the
nurse's practice. Describe how the social and physical envi- most nursing attention. Does your answer differ depending
ronment affected the clients and nursing practice. Identify on whether you consider the community in which you live,
the expressed and implied ethical commitments and values your state, or the entire nation?
of the nurse. 6. Identify client needs that are not likely to be solved by
3. Interview a retired community/public health nurse and Â�financial access to medical care. Envision how community/
Â�compare her or his experiences with those of a Â�contemporary public health nursing care might address these needs.

Alliance of Nurses for Healthy Environments: http://e-Â�commons. Henry Street Settlement House (New York City): http://www.
org/anhe/ henrystreet.org/
American Nurses Association: http://www.nursingworld.org/ Frontier Nursing Service (Kentucky): http://www.frontiernursing.org/
American Public Health Association: http://www.apha.org/
Healthy People 2020: http://www.healthypeople.gov/2020/default.aspx
WEBSITE
STUDY AIDS WEBSITE RESOURCES

Visit the Evolve website for this book to find the following study The following item supplements the chapter's topics and is also
and assessment materials: found on the Evolve site:
• NCLEX Review Questions 2A: Rules for Nurses from the Instructive Visiting Nurse
• Critical Thinking Questions and Answers for Case Studies Association of Baltimore, Maryland (1912)
• Care Plans
• Glossary
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Author. http://www.cdc.gov/h1n1flu/cdcresponse.htm. 1676-1678.
CHAPTER
3
The United States Health Care System
Frances A. Maurer
FOCUS QUESTIONS
What are the basic features and components of the U.S. health How is the private sector of health care delivery organized?
care system? What type of private-sector organization is the major provider
What distinguishes the U.S. health care system from those of of health care services?
other developed countries? What are the major problems with the current health care
Why do community/public health nurses need to understand delivery system?
the health care system? How have problem-solving strategies impacted health care
What are the differences between direct and indirect services services, personnel, and costs?
and public- and private-sector health care services? What are the significant changes in health care delivery in the
What are the two competing foci of care? Is one focus of care past decade and today?
more prevalent today? What are some of the ongoing and new proposals for health
Which agencies have the most important roles in health care care reform?
issues at the federal, state, and local levels?
CHAPTER OUTLINE
Our Traditional Health Care System Focus of Care: Public Sector
Key Features of the U.S. Health Care System Public and Private Sectors, 1965 to 1992
Distinctions from Other Health Care Systems Medicare and Medicaid
Components of the U.S. Health Care System Cost Concern and Containment Efforts
Organizational Structure Efforts at Health Planning
Management and Oversight Competing Focuses of Care: Prevention or Cure
Financing Mechanisms Emphasis on State Control and Administration of Health
Resources Programs
Health Services Rising Number of Uninsured
Consumer Public and Private Sectors Today
Direct and Indirect Services and Providers Continuing Shift in Federal and State Relationships
Public and Private Sectors Power Conflicts within the System
Public Sector: Government's Authority and Role in Health Care Specialization and Fragmentation
Federal Government Quality-of-Care Concerns
State Governments Strategies Employed to Address Problems
Local Governments A National Health Care System?
Private-Sector Role in Health Care Delivery Single-Payer System
For-Profit Providers and Organizations All-Payer System
Role of Insurance and Other Third-Party Payers Universal Coverage and State Efforts
Managed Care Universal Coverage and Federal Efforts: The Patient
Voluntary Component of the Private Sector Protection and Affordable Care Act, 2010
Public and Private Health Care Sectors Before 1965 Integrated Delivery Systems: The Present Reality
Providers of Health Care Vested Interests
Focus of Care: Private Sector Challenges for the Future
54
CHAPTER 3â•… The United States Health Care System 55
KEY TERMS
Decentralization Home care Secondary prevention
Direct care providers Indirect care services Tertiary prevention
Direct care services Out-of-pocket expenses Third-party reimbursement
Free market Primary prevention Universal coverage
Gross domestic product (GDP) Private sector Vested interests
Health care system Public sector Wellness centers
The United States is in the midst of dramatic changes in the Few people really stop to think about the health care system
organizational structure and delivery of health care. Mergers and the organizational structure that delivers care until they
and acquisitions have consolidated medical service providers have an unsatisfactory personal experience with the system.
into fewer, but larger, corporate models (Harrington, 2011). Consumer and health professional dissatisfaction is building,
Managed care has become a popular form of health care deliv- leading to critical questions about the current system, identifi-
ery service. Technology has expanded the boundaries of treat- cation of areas for change, and suggestions about how the sys-
ment for difficult medical conditions and increased the costs of tem might be changed.
treatments. State and federal budgets crises are forcing reduc- Most Americans, including most health care professionals,
tions in government support for health care services, at a time have tended to view the health care system as inflexible and
when the number of people without health insurance continues unchangeable. The system is, in fact, responsive to outside influ-
to climb. Quality-of-care issues are a rising public concern. The ence (FigureÂ€3-1). Changes and modifications do occur, albeit
costs of care, the problems of access to care, and the increasing slowly and incrementally because the system is so large. For
concerns over the quality of health care have renewed the debate example, the role of nurse practitioners was gradually expanded
over the question whether this country should adopt some form over a long period. Discontent periodically builds to such a
of national health coverage for all citizens. peak that significant change occurs in a relatively short time.
In 1994, President Bill Clinton attempted national health For example, dissatisfaction with the financial burdens and lim-
care reform. Although there was popular support for change, ited access to medical care for older Americans led to the enact-
there was also vigorous opposition. A significant public rela- ment of the Medicare program in 1965. Concern over health
tions campaign led by health industry providers such as health care costs in the 1990s led to an increasing reliance on man-
maintenance organizations (HMOs), hospitals, pharmaceutical aged care organizations as health care providers. Currently, the
companies, and other health-related businesses was successful in country is again experiencing dissatisfaction with health care
defeating the initiative (Gold, 1999; Navarro, 1995). Ironically, delivery (Mechanic, 2008; Patel & Rushefsky, 2006; Shi, Singh,
since then, there has been a substantial shift toward managed & Tsai, 2010.).
health care, one of the principal recommendations of President Primary prevention, the promotion of healthy behaviors
Clinton's Task Force (White House Domestic Policy Council, and reduction of health risks, has once again become a popu-
1993). The main difference is in oversight responsibilities. The lar concept. Former Congressman Newt Gingrich (2002), who
Clinton Task Force envisioned oversight as a public-sector helped defeat the Clinton health care plan, is now espousing a
function, but today, it remains primarily a private-sector cor- more preventive, consumer-focused delivery system. President
porate responsibility. More recently, the Patient Protection and George W. Bush and the U.S. Congress passed a prescription
Affordable Care Act of 2010, commonly called the Affordable drug plan for Medicare recipients. Most recently, the Obama
Care Act, has proposed incremental changes to services, public administration's Affordable Care Act is intended to increase the
oversight, and increased emphasis on prevention in health care
delivery in the United States. Although the law has been enacted
Science and
and some changes have already occurred, vigorous opposition technology
to the law has resulted in court challenges. In June 2012, the Culture Economics
(values) (money)
U.S. Supreme Court upheld the law. Today, the U.S. health care
delivery system remains a system in transition. Public concerns
about access and quality of care have produced piecemeal legis-
lative attempts to protect consumers’ rights and improve health
services, evoking opposition from vested interests and Health care system
persons with a different philosophy of health care delivery and
systems organization. Epidemiology Governance
A health care system is the organizational structure in which (information (policy)
systems)
health care is delivered to a population. What kind of health care
system does the United States have? What are its component People Health professionals
(consumers) and organizations
parts? This chapter examines the current structure and princi- Vested
pal areas of concern of the U.S. health care system. At the end of interests
the chapter, potential directions for further change are explored. FIGUREÂ€3-1â•‡ Influences on the health care system.
56 CHAPTER 3â•… The United States Health Care System
number of persons covered by some type of health insurance, states, and the federal government all share the responsibilities
increase the accountability of providers, and improve the qual- for the regulation and provision of services to the population;
ity of health care services. Once again, there exists a window of health care services are no exception. The United States has a
opportunity for health care change. delivery system in which funding, planning, regulation, and ser-
Health care professionals bear a responsibility to know and vice delivery are influenced by city, county, state, and federal
understand the system in which they function because it has government policies, as well as by the policies of nongovern-
considerable impact on both their behaviors and the health mental organizations such as businesses.
behaviors of the people they serve. Nurses should be cognizant
of the issues that affect their nursing practice both in the work- Laissez-Faire Philosophy
place and in the broader context of the entire health care system. The free market economy of the United States encourages a lais-
Beyond its influence on their personal nursing practice, com- sez-faire approach. There is no centralized planning structure. In
munity health nurses must understand the impact of the system a free market, private enterprise is allowed to develop goods and
on individual clients, groups, and communities. services as it chooses and to offer them to the clientele, or mar-
Currently, health care is neither available nor accessible to ket, it selects. In the health care service market, private individu-
everyone. Millions lack health insurance and are unable to pay als, groups, or corporations can plan, offer, and deliver health
for basic services. Every day, community health nurses see peo- care to the target groups they wish to serve. Hospital owners
ple who are denied basic services and others with serious ill- or managers, physicians, and philanthropists, not government,
nesses delaying treatment because of cost concerns. Because the determine the organizational structure of the U.S. health care
professional practice of nursing is built around the promotion system. As with any business operation, payment is expected
of health, the prevention of illness, and the restoration of health for service provided. In this country, a portion of the popula-
to all in need, it is hard for community health nurses to see peo- tion cannot pay for service. For those unable to pay, the ques-
ple in need and know that, for some, they can offer no solution tion whether health care is a right or a privilege becomes critical.
to the difficulties in accessing health care. Debate on this question has raged since the nation's inception
Ultimately, the real impact of any health care system must be (Feldstein, 2012; Gebbie, 2007; Lindblom, 1953; Marshall, 2011;
measured in terms of the people it serves: How healthy is our Papadimos, 2007; Reinhardt, 2009; Wilensky, 1975). Those who
population? How does our health status compare with that of espouse a totally free market system support a laissez-faire atti-
other nations? Does our health care system prevent premature tude toward health care services. They consider health care a
death and disability and provide good care to most of its citizens? privilege, rather than a right, and would not support govern-
Nurses need basic information about the health care system so ment intervention to ensure health care for those who cannot
that they can make informed judgments about the efficacy of the pay. Those who consider health care a right, rather than a privi-
current system and the impact of suggested reforms. lege, would support action aimed at providing health care ser-
vices to all.
OUR TRADITIONAL HEALTH CARE SYSTEM In this country, health care is provided to the population by
a combination of private and public means. Our leaning toward
When compared with health care systems in other developed a free market economy has encouraged the development of a
countries, the delivery network in the United States seems dis- private, entrepreneurial delivery system and personal responsi-
organized and confusing (Sultz & Young, 2011). The U.S. health bility for medical expenses (Sultz & Young, 2011). This private
care system has been defined as “a system without a system,” subsystem serves middle- and upper-income Americans who
“a fragmented system,” and “a nonsystem” (Geyman, 2008; can afford to pay for their care.
Harrington & Estes, 2008; Shi & Singh, & Tsai, 2010). There Public concerns, however, do not allow a totally laissez-faire
is no central organization that plans and links the various ele- approach. Most Americans (65%) support the idea of basic
ments into an integrated and purposeful whole. Some argue health care services for all (Pew Research Center, 2009). The
that as disjointed and decentralized as it might be, it is still a public health community's commitment to the ethical position
system—a system that continues to evolve in response to soci- of providing the greatest good for the greatest number supports
etal and market pressures (Patel & Rushefsky, 2006). universal access to care rather than the laissez-faire approach.
Government has gradually undertaken to provide some support
Key Features of the U.S. Health Care System to those persons who cannot afford to pay for health care. The
Three prominent features of the U.S. health care system help public subsystem tends to care primarily for the poor and spe-
explain, to some degree, the structure of the system and the cial populations.
manner in which it evolved. These features include highly
decentralized governance, a strong emphasis on a laissez-faire Abundant Resources
philosophy, and an abundance of economic resources. Although the United States is a wealthy country, its eco-
nomic resources for health care are limited. However, it spends
Decentralization more on health, in actual dollars, than do most other coun-
Consistent with other aspects of governance in the United tries. In 2009, health care expenditures were $2.5 trillion, or
States, legal governance and regulation of the health care deliv- 17.6% of the gross domestic product (Centers for Medicare
ery system are highly decentralized. The U.S. government was and Medicaid Services [CMS], 2011c). The United States has
designed by individuals whose previous experiences led them to devoted large sums of money to research and has led the way
mistrust a highly centralized, autocratic system. Their Â�solution in the Â�development and use of complex and expensive medical
was a decentralized federated system with checks and balances procedures and Â�equipment, for example, organ transplantation,
at each level. With decentralization, local communities, the inÂ€vitro fertilization, and magnetic resonance imaging (MRI).
Decentralized governance, mass expenditures, and a free health care than does any other developed country (Rodwin,
market philosophy have helped shape the existing health care 2005; Torrens, 2008). Most countries commit more public
system. As various aspects of the system are examined in this funds to provide more services while spending less of their
chapter, it would be useful to attempt to identify how each of gross domestic product (GDP) on health care services. GDP
these elements has an impact on a particular area of practice or is a measure of all goods and services sold in the United States.
delivery of care to population subgroups. ChapterÂ€4 provides a more detailed discussion of health care
spending and services in other countries.
Distinctions from Other Health Care Systems If the U.S. health care system provided a better standard
Most developed countries have national health care programs of health compared with the systems of other countries, the
administered by their governments. The U.S. health care system differences in the expenditure of public funds would be more
is unique. It has neither a national health care plan nor a cen- understandable. That is not the case, however. Comparison
tral administration to deliver health care to its people (Patel & of infant mortality and life expectancy for eight selected
Rushefsky, 2006; Shi, Singh & Tsai, 2010; Kover & Knickman, countries indicates that the United States ranks lowest in
2011). In ChapterÂ€5, various health care models used by other life expectancy and highest in infant mortality (FigureÂ€3-2).
developed countries are discussed. In fact, the United States ranks last among 19 industrial-
ized nations in life expectancy and infant mortality (Central
Health Planning Intelligence Agency [CIA], 2011). In addition, the United
Countries with national health care systems engage in more States has a higher infant mortality rate than Andorra, Cuba,
comprehensive health care planning. Central planning is pos- Malta, Slovenia, and South Korea.
sible because government has the means to influence services
either by providing direct care or by reimbursing the cost of care COMPONENTS OF THE U.S. HEALTH CARE SYSTEM
for most of its citizens.
In contrast, the United States has engaged in little central The U.S. health care system is complex, and it is difficult to
health planning, although the federal government is becoming reduce all of its elements, influences, and decision makers into
more involved in national health planning and has established a simple diagram. FigureÂ€3-3 provides a basic model that iden-
national health objectives. These objectives are only guidelines tifies the essential components that form the basis of the U.S.
and do not have the force of law. Currently, those segments of health care system. The model illustrates some of the interre-
the health care system not directly under federal control are free lationships. Each component is affected by, and has impact on,
to ignore or meet the objectives as they choose. the others. Ultimately, the system does link the consumer to
health care services.
Health Insurance and Health Status
The most frequent criticism of our health care system is that Organizational Structure
delivery of “basic” (primary and preventive care) services is In health care, structure significantly influences function.
not readily available to the entire population (McKinsey and Structure determines how goods or resources are acquired and
Company, 2007; Sultz & Young, 2011). Despite large health care how services are distributed or provided. The organizational
expenditures, a significant segment of the population does not structure of the U.S. health care system is a disjointed combi-
receive care. At least 59.1 million Americans have no health nation of public and private agencies, including government
coverage (Morbidity and Mortality Weekly Report [MMWR], (federal, state, county, city, and local) and voluntary, Â�charitable,
2010). The U.S. government provides less public funding for entrepreneurial, and professional agencies and organizations.
Canada Canada
France France
Japan Japan
Netherlands Netherlands
Sweden Sweden
United Kingdom United Kingdom
United States United States

75 76 77 78 79 80 81 82 83 0 2 4 6 8
A Life Expectancy at Birth in Years B Infant Mortality Rate per 1000 Live Births
FIGUREÂ€3-2â•‡A, Life expectancy at birth, selected countries, 2011. B, Infant mortality rate
per 1000 live births, selected countries, 2011. (Data from CIA—The World Factbook. [2011]. World
health statistics. Retrieved September 30, 2011 http://www.cia.gov/library/publications/The-world-
factbook/rankorder/2102rank.html & 2091rank.html.)
Organizational Structure
Public (government — federal/state/local)
Private (for profit/nonprofit)
Oversight and Management
Health Care Services

Direct and indirect care
Resource
Public and private providers
Personnel Recipient of
Health promotion and disease
Facilities Health Care:
prevention
Equipment The Consumer
Treatment of disease
Supplies
Rehabilitation/special needs
Hospice/adult day care
Finance Mechanism
Out-of-pocket
Private insurance
Managed care organizations
Public insurance
Public funding
HEALTH CARE DELIVERY SYSTEM

FIGUREÂ€3-3â•‡ Components of a health care delivery system.
All of these agencies are involved in decisions that have an government, federal agencies usually manage specific programs
impact on the delivery of health care. Agencies sometimes oper- by delegating day-to-day administration and oversight to local
ate with competing or overlapping objectives and functions. authorities. However, the federal agencies devise guidelines or
Because of the absence of a central organization, gaps exist in criteria that must be met by the specific program. For example,
services and in population groups served. (It is helpful to keep the Women, Infants, and Children (WIC) Program has multiple
this concept in mind as the discussion continues.) levels of managers and requirements. The WIC Program man-
agers in the field, who actually provide services to target groups,
Management and Oversight must comply with criteria that have been set at the federal and
The three key features of our health care system were identified state levels. The WIC Program field director (county, city, or geo-
earlier. Two of these are important to the management aspect graphical district operation) reports to the state agency respon-
of health care. Both decentralized governance and a laissez-faire sible for the program. The state manager, in turn, reports to an
philosophy have created the environment within which over- official in the U.S. Department of Agriculture. That individual,
sight functions. A single overseer or manager is lacking, as is a in turn, answers to both the President (executive branch) and
central plan for organizing and delivering health care. Instead, the Congress (legislative branch) to ensure that Â�management
multiple levels of government interrelate and interact with directives and budgeting requirements are followed.
multiple levels of private-sector management in a bewilder-
ing arrangement. For example, in the State Children's Health Variety of Private Management Styles
Insurance Program (CHIP), there is both federal and state fund- Management, planning, and oversight methods of private orga-
ing and oversight. The health care services the children receive nizations vary widely. They include centralized and decentral-
come from physicians, hospitals, managed care organizations, ized, democratic and autocratic, and laissez-faire and extremely
and other health care providers. Those providers, in turn, must regulated management efforts. Most private facilities oper-
conform to Medicaid and CHIP regulations and reviews. ate with a board of directors that influences the planning and
administrative processes.
Multiple Levels of Government Private facilities and organizations must comply with applica-
Within government itself, there are planning, legislative, and ble federal, state, and local regulations, which place constraints
regulatory management efforts at the federal, state, county, on how they may operate, the types of services they may pro-
and city levels. Each layer directs services within its scope of vide, and whether they may continue to offer services. State
Â�operation. Because of the decentralized nature of American Â�licensing is an example of regulatory activity. For instance, states
conduct inspections and issue licenses for nursing homes and The reasons for the expected physician shortage include an
home care agencies. If the homes are not able to meet state stan- aging physician work force, geographical maldistribution of
dards, they are penalized through fines or are forced to close. physicians, specialization, and an increased demand as a result
Failure to meet licensing standards can also result in loss of of the Affordable Care Act. Health care reform will attempt to
revenue because some reimbursement mechanisms are tied to expand coverage to 32 million uninsured Americans. Physicians
continued licensure. tend to concentrate in urban areas rather than in rural areas.
New England and the mid-Atlantic states have the highest
Financing Mechanisms ratios of physicians to population, and the South Central and
The financing of health care services is discussed in detail in Mountain states have the lowest. The shortage of primary care
ChapterÂ€4. In brief, financial support is derived from a vari- physicians is, in part, the result of higher wages for doctors who
ety of sources, both private and public (see FigureÂ€3-3). Private choose to specialize (Alliance for Health Reform, 2011). Most
sources include personal payments from individuals and fami- physicians (about 76%) specialize; only 12.4% are engaged in
lies, private insurance payments, corporate payments, and char- primary care practice (American Medical Association, 2009).
itable contributions. Public sources are composed of federal, In contrast, other developed countries restrict specialty prac-
state, and local government revenues directed toward health tice, and 50% to 70% of physicians are engaged in primary
care services. care. Only a few American physicians specialize in community
health medicine.
Resources Registered Nurses. Registered nurses constitute the larg-
Health care resources are essential for the effective functioning est group of health care professionals. There are 2.6 million
of the health care system. These include (1) health care profes- licensed registered nurses in the United States (U.S. Department
sionals, that is, personnel who run the system; (2) facilities such of Labor, Bureau of Labor Statistics, 2011a). Most are salaried
as hospitals and other structural elements from which care is employees. Hospitals remain their largest single employer,
provided; and (3) health care supplies and equipment. Because although hospital-based nurse employment continues to
space is limited, only some of the relevant resources for health decline (FigureÂ€3-4). Government data are not current for all
care delivery are highlighted in this chapter. Community health sources of nurse employment. FigureÂ€3-4 represents employ-
nurses need to know about health care resources, including the ment areas found in a 2008 sample survey. Community-based
supply of other health care professionals, because resources employment opportunities for registered nurses continue to
influence the availability and accessibility of health care services expand, although the proportion practicing in community/
to those in need. public health has declined (see ChapterÂ€1). Approximately 8%
of registered nurses practice some form of community health
Personnel nursing. Another 11% work at ambulatory care facilities that
People are a crucial health care resource. Considerable variety offer some community-related services.
in education, skill, and practice setting exists among health care Federal government estimates project a decline in the pro-
professionals. TableÂ€3-1 presents some of the most common portion of registered nurses practicing in hospital settings and
health care professionals, their accessibility (supply), and their an increased need for registered nurses prepared in community-
average salary levels. type practice, including public health and ambulatory care. If
Physicians. In the 1960s, both federal and state governments health care reform initiatives continue to stress community-
offered financial support to medical schools and eased certifi- and home-based care, the need for community-based nursing
cation requirements for foreign-trained physicians to increase services will create additional demand.
the number of practicing physicians. These actions did increase There have been cyclical shortages in the supply of Â�registered
the supply of physicians. Currently, there are 217 physicians nurses, but there is serious concern that the current shortfall may
per 100,000 population (estimate based on U.S. Department of be more protracted and difficult to remedy (Unruh & Fottler,
Labor, Bureau of Labor Statistics, 2011a). The projected supply 2008). In the past, shortages have been alleviated by a combina-
is not adequate to meet the needs of the population through tion of increase in salaries and increased enrollment of students
2025 (Health Resources and Service Administration [HRSA], in nursing programs. Today, enrollment in Â�nursing programs is
2007; Alliance for Health Reform, 2011). not expanding to meet the growing need. This is coupled with
TABLEÂ€3-1â•…â•‡ COMPARISONS OF SELECTED HEALTH CARE PROFESSIONS

ESTIMATED SUPPLY PER
PROFESSION NUMBER 100,000 POPULATION AVERAGE SALARY ($)
Physician 661,400 217 186,044*
Dentist 141,900 46 142,870
Optometrist 34,800 11 96,320
Pharmacist 269,900 88 121,230
Physician assistant 74,800 24 69,410
Registered nurse 2,600,000 855 62,450
*Average salary for primary care physicians.
Data from U.S. Department of Labor, Bureau of Labor Statistics. (2011). Occupational outlook handbook: 2010-2011 edition. Washington, DC: Author.
Other**** (3.9%) Academic Education (3.8%)

Nursing home extended care (5.3%)
Ambulatory care*** (10.5%)
Hospital (62.2%)
Public/Community health** (7.8%)
Home health (6.4%)
* Percents may not add to 100 due to rounding

** Public/community health includes school and
occupational health
*** Ambulatory care includes medical/physician
practices, health centers and clinics, and other
types of non-hospital clinical settings
**** Other includes insurance, benefits, and
utilization review
FIGUREÂ€3-4â•‡Employment settings of registered nurses.* (Data from U.S. Department of Health and
Human Services, Health Resources and Services Administration, Bureau of Health Professionals, Division of
Nursing. [2010]. Findings from the National Sample Survey of registered nurses, 2008. Washington, DC: Author).
an aging registered nurse workforce. The average age of regisÂ� the current supply. The demand for optometrists is expected to
tered nurses in the workforce is 46â•›years (HRSA, 2010). These grow because of the needs of aging baby boomers.
two factors may increase the length and severity of the current Allied Health Professionals. During the past several decades, a
shortage period. variety of new health care workers have emerged to assist the more
Nonphysician Practitioners/Extenders. Nonphysician practi- established professional groups in providing care to the popula-
tioners/extenders are professionals who are trained to provide tion. A list of selected allied health workers, with the approximate
primary care in place of physicians and are either physician's numbers in each category, is given in FigureÂ€3-5. Their specialized
assistants or advanced nurse practitioners. Physician's assistants occupational activities are wide ranging. The allied health worker
are usually nonnurses with advanced education and certification. most often involved in substantial direct client care is the licensed
Advanced nurse practitioners include nurse anesthetists, practical nurse (LPN) or licensed vocational nurse. Historically, the
nurse clinical specialists, nurse practitioners, and nurse mid- practical nurses assisted registered nurses, but licensed vocational
wives. In most states, the Nurse Practice Act allows independent and practical nurses have assumed responsibilities once thought
practice and direct reimbursement for nurse practitioners and to be the sole domain of professional nurses. In some states and
nurse midwives, although some limitations persist (Fairman clinical situations, LPNs administer medications, manage units,
etÂ€al, 2011; Lugo etÂ€al, 2007). Of the approximately 233, 148 and take verbal orders from physicians. LPNs have limited expe-
Â�physician extenders, approximately 68% are nurse practitioners rience in public health settings, although they are employed in
(HRSA, 2010; U.S. Department of Labor, 2011a). Many non- ambulatory care and home health agencies.
physician practitioners serve populations that do not attract Nursing aides provide personal care services in a variety of
physicians, especially the poor and chronically ill (Brewer, 2005; settings. They work under the direct supervision of registered
Sultz & Young, 2011). Advanced nurse practitioners are espe- nurses or LPNs. Some aides are certified through a formal edu-
cially good at working with the chronically ill because of their cation process, but many receive only informal instruction on
background in health teaching and their interest in health pro- the job. Nursing aides are poorly paid, which makes it difficult
motion and health maintenance. Nurse practitioners and nurse for agencies to retain competent, reliable employees.
midwives are commonly employed in community health cen-
ters and other community agencies. Studies indicate that phy- Facilities
sician extenders compare favorably with physicians in the Health care is provided in a wide variety of inpatient and outpa-
quality of care Â�delivered and patient satisfaction with service tient facilities. Some of these are listed in BoxÂ€3-1. The types of
(see ChapterÂ€4). care delivered in facilities can be limited or wide ranging, simple
Other Professionals. The supply of dentists, pharmacists, and or complex, and tailored to specific conditions or to a broad
optometrists is sufficient to meet the demand into the future. span of health concerns.
Most do not work in public health. Dental care is expensive; as BoxÂ€3-2 outlines pertinent information about and services
a result, the poor and the uninsured frequently do not receive provided by selected health care facilities. There are 5795 Â�hospitals
dental care. If dental care were to become part of the Medicare/ in the United States. Approximately 86% of these are short-stay
Medicaid programs, then the demand for dentists would Â�outstrip general hospitals (U.S. Census Bureau, 2012, TableÂ€172). More
Dental hygienist
Dietitians/nutritionists
Licensed practical/vocational nurses
Nursing/psychiatric aides
Medical assistants
Occupational therapists
Physical therapists
Radiologic technologists
Nuclear medicine technologists
Respiratory therapists
Speech pathologists/audiologists
Clinical laboratory technologists/technicians
Emergency medical technicians/paramedics
0 100 200 300 400 500 600 700 800 1500

In Thousands
FIGUREÂ€3-5â•‡ Supply of allied health care professionals. (Data from Occupational outlook handbook,
2010-2011. [2011]. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics.)
than 80% of U.S. hospitals are nonprofit or government owned.

BOXÂ€3-1â•…â•‡TYPES OF HEALTH CARE
Nursing homes are the fastest growing segment of this market.
FACILITIES Earlier hospital discharges and an ever-increasing population of
Inpatient older adults are the reasons for rapid growth of nursing homes.
General hospitals There are 15,700 nursing homes, three times the number of
Special hospitals acute care hospitals (U.S. Census Bureau, 2012, TableÂ€194).
Psychiatric residential treatment centers Before 1960, mental care/psychiatric hospitals were separate
Nursing homes: facilities operated primarily by state and local governments.
Skilled nursing facilities Starting in the 1960s, efforts to provide persons with psychiat-
Intermediate care facilities ric disorders with the least restrictive environment resulted in a
Resident care facilities large number of discharges from these institutions. ChapterÂ€33
Other types of residential homes: provides a more detailed discussion of the changes in mental
Adult homes health services. Deinstitutionalization has resulted in the clos-
Halfway houses ing of facilities, and/or reduced bed capacity.
Outpatient Primary care in clinics has always been provided to serve
Hospital-based clinics and emergency rooms poor populations, but it is now becoming popular with other
Local health departments and clinics consumer groups. The greatest number of new ambulatory
Specialty programs and services care clinics have been set up to attract middle-class consumers
Alcoholism programs and services rather than clients from low-income groups or those receiving
Birth centers public assistance. Consumers who find the clinics particularly
Drug programs and services attractive are those with no regular physician and want quick
Mental health programs and services treatment for a specific complaint. Hospitals, health care cor-
Women's clinics porations, or physicians in group partnership generally sponsor
Family planning centers the new facilities.
Ambulatory care walk-in facilities Payment at the time of service is a common feature of the
Physician practices: newer clinics. Many do not process insurance forms as direct
Solo payment. Consumers are usually expected to file health insur-
Group ance and Medicare claims to receive reimbursement for out-
Partnership of-pocket expenses (those expenses paid for directly by the
Professional corporations consumer), which may be covered by their insurance carrier.
Short-stay surgical centers Wellness centers promote healthy behaviors and assist con-
Renal dialysis centers
sumers in eliminating or reducing risky behaviors. Wellness centers
Rehabilitation centers
(also known as health promotion centers) and alternative Â�medicine
Hospice/respite care
services are geared toward niche markets, primarily middle-class
Home health agencies
Wellness and health promotion centers
and wealthy individuals who can afford to pay. Health insurance
Workplace health services and employers pay for limited numbers of these services. Some
examples of services paid for by insurance are employer-Â�sponsored
BOXÂ€3-2â•…â•‡ SELECTED HEALTH CARE FACILITIES AND SERVICES

Hospitals • State and local government facilities provide the bulk of care for
• Short stay (30â•›days or less) or long stay (more than 30â•›days). patients who cannot afford private care.
• Provide generalized or specialized health care services.
• Control or ownership is nonprofit, for-profit, or governmental. Ambulatory and Community Care Facilities
• Nonprofit hospitals are controlled by local communities or vol- • Ambulatory care facilities provide a broad range of services as well
untary organizations (e.g., a religious or charitable organization). as health care professionals under one roof.
They operate at no profit, and expenses must equal revenues each • There are several types: hospital sited, hospital-sponsored offsite,
fiscal year. Most offer limited service to nonpaying clients. and independent non–hospital affiliated.
• Proprietary hospitals are privately owned, for-profit enterprises. • General hospitals provide primary care to patients who do not require
They do not generally accept nonpaying clients. hospital admission. Recently, to reduce costs and entice new custom-
• Publicly owned hospitals are owned and operated by various levels ers, outpatient services have been promoted heavily as a substitute
of government such as the state, county, or city; a few are run by fed- for inpatient care. Hospitals are now engaged in home health, reha-
eral agencies. Most were set up to serve indigent clients, although bilitation, health promotion, and other enterprises such as sponsoring
they accept paying clients. Some publicly owned hospitals, espe- walking clubs and mediation classes.
cially in larger cities, are teaching hospitals or hospitals with ties • In addition to hospital outpatient clinics, there are public health,
to medical schools. Two of the more widely known are Cook County employer-sponsored, school health, charitable, private proprietor–
Hospital in Chicago and Bellevue Hospital in New York City. owned, and health maintenance organization–operated clinics pro-
viding ambulatory care.
Long-Term Care Facilities
• Provide care to the chronically ill or to those needing rehabilitation Wellness or Health Promotion Centers
after discharge from a general hospital. Types of facilities include • Might be hospital based or free standing.
long-term care hospitals, nursing homes, and rehabilitation centers. • Programs offer primary and secondary prevention health-
The bulk of nursing homes are proprietary, for-profit establishments. promoting activities.
• Some are narrowly focused on a single issue such as smoking
Residential Care Facilities Â�cessation, breast cancer screening, or pregnancy.
• Have both a health focus and a social welfare focus. • Others have a broader focus, identifying all health risks to Â�individuals and
• Examples include homes for older adults, custodial residential designing programs tailored to promote or enhance individual health.
schools for persons with visual and hearing impairments, hospice
care for the terminally ill, halfway houses for persons with mental Alternative Medicine Service
disorders, and residential units for alcohol and drug abuse treatment. • Services include acupuncture, aromatherapy, herbal medicine, Â�meditation,
and healing touch.
Psychiatric Care Hospitals
• Both publicly and privately managed, provide both short- and long- Home-Based Care
term care to persons with mental disorders. • Provides care to those with acute and chronic diseases in their homes.
• Since 1960, there has been growth in privately owned and operated • Includes occupational and rehabilitation therapy, custodial care, and
psychiatric care facilities. Service is directed primarily to persons skilled nursing care.
who can afford to pay.
exercise programs, smoking cessation programs, and stress Â�reduction Medications are the largest single category. Drugs are a
programs. In the alternative medicine area, acupuncture is the most multibillion-dollar industry. In 2009, $293.2 billion was spent
frequently covered service. on drugs and other nondurable medical supplies (U.S. Census
Home care, which is care of the client in his or her own Bureau, 2012, TableÂ€136). Approximately 75% of the drugs
home, has surged as the number of older adults grows. Home sold are prescription medications. Prescription drugs are pro-
care is popular because it is cost efficient and often preferred to tected by patent for 17â•›years. Drug companies derive greater
other types of care (see ChapterÂ€4). Today, there are more than profits from the sale of brand name (patent) drugs, so there is
10,581 home care and hospice agencies in the United States, clear incentive to protect and maintain patent rights as long as
serving over 7.2 million clients (National Association for Home possible. Most companies, although they could, do not manu-
Care and Hospice, 2010). Approximately 86% of hospices are facture generic versions of their own patent drugs until after the
independently run, and the remainder are operated by home 17-year patent limit has expired.
health agencies, hospitals, or skilled nursing facilities.
Health Services
Equipment and Supplies Perhaps what is more important than the system is the final
Health equipment and supplies are another health resource. product. What does the system provide for consumers (refer to
Materials used in the diagnosis and treatment of specific ill- FigureÂ€3-3)? Torrens (2008) asserts that a complete and com-
nesses, prosthetic devices, eyeglasses, hearing aids, and drugs prehensive health system should provide certain essential health
constitute just a partial list of the types of equipment in this cat- care services including the following:
egory. The industry is enormous. For example, in 2009 the cost • Health promotion/disease prevention
of durable medical equipment was $34.9 billion (U.S. Census • Emergency medical care
Bureau, 2012, TableÂ€136). • Ambulatory care
• Inpatient care food and water sources and by community planning decisions
• Long-term care regulating the number of hospital beds or the type of equip-
• Services for social and psychological conditions ment employed in these facilities. The difference is that many
• Rehabilitative services of us are not consciously aware of the indirect services and how
• Dental services they affect our health.
• Pharmaceutical services
• Transportation to services, as needed PUBLIC AND PRIVATE SECTORS
The U.S. health care system contains most of these elements.
However, not every community or individual has easy access to Direct health care services in the United States are delivered in a
all service elements, and health care services are not well inte- two-tiered system of public and private providers. The private
grated and coordinated. Critics contend that care and consumer sector is composed of private organizations, both for-profit
needs do not match well. Care is often inappropriate, and ser- businesses and nonprofit organizations. For the most part, pri-
vices are unevenly and unequally distributed (Commonwealth vate enterprise provides direct services of personal health care
Fund Commission on a High Performance Health System, 2006; to Americans who can pay, either directly (out of pocket) or
Fiscella & Williams, 2008; Torrens, 2008; Sultz & Young, 2011). through third-party payers (private health insurance plans).
Some of these providers, particularly hospitals managed by
Consumer churches and other philanthropic endeavors, provide a certain
The consumer is the recipient of services delivered by the sys- number of services to community members who cannot pay.
tem. Ideally, services should be planned and implemented to The public sector consists of services provided by public
benefit the client. It is the consumer who is most affected by funds and public organizations. Services are largely provided by
the operational efficiency or inefficiency of health care delivery. some type of governmental agency. The public sector is con-
The consumer and the health care services should be the cerned with both direct and indirect services. Involvement with
focus of the health care professions. The consumer is the most direct services is an attempt to provide care for those who cannot
vulnerable component and is the most likely to be hurt by inef- pay and for certain other target groups for whom government
fective functioning of the system. For example, health care is legally required, or feels compelled, to provide health care,
providers might relocate or refuse certain patients (Medicaid for example, veterans and American Indians. The large numbers
patients) to maintain their incomes or to increase their profit of indirect services that are within government's purview exist
margins. The consumers left behind or denied care are not the because the private sector is not interested in providing them.
primary focus in the provider's decision process. Refer to the Funding for public services comes from local governments and
section in ChapterÂ€4 on free market failure for a discussion communities and state and federal agencies. Charitable organi-
on how the shortcomings of the system might have a negative zations, although part of the private sector, might also provide
impact on consumers. limited public-sector services.
Some critics suggest that client care is secondary to profit
(Catholic, 2009; Cohen & Piotrowska-Haugstetter, 2007; PUBLIC SECTOR: GOVERNMENT'S AUTHORITY AND
Feldstein, 2012; Shi & Singh, 2011a). The health care system is ROLE IN HEALTH CARE
a large business. Improving a population's health is not always
the focus when planning and providing services and selecting Each of the three levels of the U.S. government assumes some
the consumer groups to whom services will be provided. Profits of the responsibilities for health care. Indirect services make up
and services are competing goals. Health care professionals a major portion of services provided by government. In keep-
and management personnel often derive greater benefits than ing with a free market economy, government usually does not
the consumer by way of generous salaries, benefits, stock prof- attempt to provide services in areas in which private enterprise
its, and professional prestige (Krauss, 1977; Patel & Rushefsky, provides care satisfactorily.
2006; Reinhardt, 2009; Smith-Dewey, 2010). Various levels of government ensure care for certain popu-
lation groups not covered by private-sector services. State and
DIRECT AND INDIRECT SERVICES AND PROVIDERS local governments are more involved in direct care. Federal,
state, and local governmental agencies are frequently involved
In any delivery system, there are direct and indirect services and in the administration of a single program or basic service such
direct and indirect providers. Direct care services are health as the WIC Program or the CHIP, discussed earlier. How they
services delivered to an individual. Physical therapy, nursing are involved, or the exact role each agency plays, is generally the
care, and doctors’ visits are examples of direct services. Direct distinguishing element.
services are provided in a variety of settings, including hospitals,
public health clinics, and, in the case of home health, the client's Federal Government
home itself. The personnel who provide these types of services The authority for the federal government's involvement is
are considered direct care providers. Most health care person- derived from the Constitution of the United States. Although
nel in the United States are engaged in direct care. it is not explicitly stated, federal authority is assumed from the
Indirect care services are those health care services that are charge to provide for the general welfare and from the federal
not personally received by the individual, although they influ- role in the regulation of interstate commerce. The federal govern-
ence health and welfare. Health planning by community agen- ment has the power to collect and spend monies for general wel-
cies, monitoring and regulation of environmental hazards, fare and to regulate businesses and organizations that conduct
and inspection of public-use facilities are examples of indi- operations in more than one state. The federal role in health care
rect health services. Health is certainly affected by pollution of has expanded, although actual implementation of programs is
commonly delegated to the states. Ultimately, the federal gov- U.S. Department of Health and Human Services
ernment is responsible for protecting the health of its population. The federal agency with the most health-related responsibili-
Although all three branches of government make health- ties is the U.S. Department of Health and Human Services
related decisions, the President and his or her staff (executive (USDHHS). This department has more than 69,839 employ-
branch) and Congress (legislative branch) make the major ees and an annual budget of $854.1 billion dollars (U.S. Census
policy decisions. These two branches set the tone for delivery Bureau, 2012, Tables 499, 471). Although the USDHHS is
of health care. They dictate which groups will be served and responsible for some direct services, most of its activities involve
the manner of service. Both branches are subject to political indirect care, including health care planning and resource devel-
pressures that influence the decision-making process. opment, research, health care financing, and regulatory over-
Once the policy is decided, federal agencies are responsi- sight. The USDHHS either carries out these services or delegates
ble for oversight and implementation. These agencies regulate the responsibility and funding for services to other public and
and interpret health care law, administer services mandated private organizations. The two largest public-sector health pro-
by law, and are responsible for the supervision of compliance grams, Medicare and Medicaid, are supervised by the USDHHS.
with health laws and regulations. Federal agencies are primarily The organizational chart in FigureÂ€3-6 illustrates some of the
involved in indirect services. specific responsibilities of the USDHHS. The Â�responsibilities
The Executive Secretariat Secretary
Deputy Secretary Office of Intergovernmental

Office of Health Reform and External Affairs (IEA)
(OHR) Chief of Staff
Office of Security and
Office on Disability
Strategic Information (OSSI)
(OR)
Office of the Assistant Center for Faith-Based

Secretary for and Neighborhood
Administration Administration for Children Centers for Medicare & Partnerships
(ASA) and Families Medicaid Services (CFBNP)
(ACF) (CMS)
Program Support Center Office for Civil Rights

(PSC) (OCR)
Food and Drug
Administration on Aging
Administration*
(AoA)
(FDA)
Office of the Assistant
Departmental Appeals
Secretary for Financial
Board
Resources
(DAB)
(ASFR) Agency for Healthcare Health Resources and
Research and Quality Services Administration*
(AHRQ)* (HRSA)
Office of the Assistant Office of the General
Secretary for Health* Counsel
(OASH) (OGC)
Agency for Toxic Substances
Indian Health Service*
and Disease Registry*
Office of the Assistant (IHS)
(ATSDR) Office of Global Affairs*
Secretary for Legislation
(OGA)
(ASL)
Centers for Disease Control

Office of the Assistant National Institutes of Health*
and Prevention* Office of Inspector
Secretary for Planning (NIH)
(CDC) General
and Evaluation
(OIG)
(ASPE)
Substance Abuse & Mental

Office of the Assistant Health Services
Secretary for Administration* Office of Medicare
Preparedness and (SAMHSA) Hearings and Appeals
Response* (OMHA)
(ASPR)
Office of the Assistant Office of the National

Secretary for Public *Designates a component of Coordinator for Health
Affairs the U.S. Public Health Service. Information Technology
(ASPA) (ONC)
FIGUREÂ€3-6â•‡Organizational chart for the U.S. Department of Health and Human Services.
Retrieved on September 14, 2011 from http://www.hhs.gov/about/orgchart/.
of the USDHHS are varied and complex; because of space FDA approval is necessary before experimental drugs can be
Â�constraints, only some offices and their functions are described tested and marketed in the United States.
in this chapter. Public health and political science texts can pro- • The Health Resource and Services Administration (HRSA)
vide a more in-depth discussion of the USDHHS for those who conducts health care resource planning and provides access
wish to investigate this area. to essential health care services for people who are poor or
The USDHHS provides both public health and welfare ser- uninsured, or who live in rural and urban neighborhoods
vices. Public health functions are provided by the following without health care services. It provides comprehensive pri-
agencies: mary and preventive services through community-based
• The National Institutes of Health (NIH) funds and conducts health centers (3000 sites) that serve nine million clients
research, including nursing research, which is financed each year. HRSA funds training of health personnel and
through the National Center for Nursing Research. The provides support services for people with human immu-
NIH can be used as a referral source for clients who require nodeficiency virus /acquired immunodeficiency syndrome
experimental care. (HIV/AIDS).
• The U.S. Food and Drug Administration (FDA) establishes • The Substance Abuse and Mental Health Services AdminisÂ�
and enforces safety standards for food, drugs, and cosmetics. tration (SAMHSA) coordinates and funds Â�programs in both
BOXÂ€3-3â•…â•‡SCOPE OF SERVICES PROVIDED BY THE CENTERS FOR DISEASE CONTROL

AND PREVENTION (CDC)
Center for Global Health • National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Provides leadership, coordination, and support for the CDC's global Prevention
health activities. Partners with other countries on some projects. Provides national leadership in preventing and controlling human
immunodeficiency virus/acquired immunodeficiency syndrome
National Institute for Occupational Safety and Health (HIV/AIDS), viral hepatitis, sexually transmitted diseases (STDs),
Ensures safety and health of all people in the workplace through and tuberculosis (TB). Works to develop and implement collabora-
research and prevention. tive public health interventions nationwide.
Office of Noncommunicable Diseases Injury and Office of Public Health Preparedness and Response
Environmental Works to improve preparedness for and response to new and complex
Includes the following agencies: infectious disease outbreaks. Lead agency to manage and coordinate
• National Center on Birth Defects and Development Disabilities: response to emerging infectious diseases, and integrate and improve
Provides national leadership for preventing birth defects and devel- clinical laboratories.
opmental disabilities and for improving the health and wellness of
people with disabilities. Office for State, Tribal, Local and Territorial Support
• National Center for Chronic Disease Prevention and Health Focused on providing support to improve public health at all levels.
Promotion:
Prevents premature death and disability from chronic diseases and Office of Surveillance, Epidemiology, and Laboratory
promotes healthy personal behaviors. Services
• National Center for Environmental Health/Agency for Toxic Provides scientific services, expertise, skills, and tools to support
Substances and Disease Registry: national efforts to promote health; prevent diseases, injury, and disabil-
Provides national leadership in preventing and controlling disease ity; and prepare for emerging health threats.
and death resulting from the interactions between people and their Includes the following agencies:
environments. • Office of Surveillance, Epidemiology, and Laboratory Sciences
• National Center for Injury Prevention and Control: • Laboratory Science Policy and Practice Program Office
Prevents death and disability from nonoccupational injuries, includ- • Public Health Informatics and Technology Program Office
ing those that are unintentional and those that result from • Public Health Surveillance Program Office
violence. • Epidemiology and Analysis Program Office
• Scientific Education and Professional Development Program Office
Office of Infectious Diseases • National Center for Health Statistics:
Prevents illness, disability, and death caused by infectious diseases in Provides statistical information that will guide actions and policies to
the United States and around the world. improve the health of the American people.
Includes the following departments: Provides leadership in health marketing science and in its application
• National Center for Immunization and Respiratory Disease to impact public health.
Immunization program that brings together vaccine-preventable dis-
ease science and research, and immunization activities. Office of the Director
• National Center for Emerging and Zoonotic Infectious Diseases Manages and directs the activities of the CDC; provides overall direction
Program identifies, investigates, diagnoses, treats, and works at pre- to, and coordination of, the scientific and medical programs of the CDC;
venting zoonotic, vector-borne, food-borne, water-borne, mycotic, and provides leadership, coordination, and assessment of administra-
and related infections. tive management activities.
Data from the Centers for Disease Control and Prevention, Atlanta, GA.
areas. Most programs are community based, and some are BOXÂ€3-4â•…â•‡OFFICE OF PUBLIC HEALTH AND
based in community health agencies. SCIENCE (OPHS)
• The Agency for Toxic Substance and Disease Registry
(ATSDR) is responsible for preventing health-related prob- The following programs and offices are part of the OPHS, which
lems associated with toxic substances. reports to the Assistant Secretary for Health:
• The Indian Health Service (IHS) provides direct health care • Advisory Committee on Blood Safety and Accountability
services to the American Indian and Alaskan Native popu- • Commissioned Corps of the U.S. Public Health Service
lations and oversight of health care services administered • National Vaccine Program Office (NVPO)
by the American Indian tribes. This agency provides care to • Office of Disease Prevention and Health Promotion (ODPHP)
approximately 1.5 million persons. • Office of HIV/AIDS Policy (OHAP)
• The Centers for Disease Control and Prevention (CDC) • Office for Human Research Protections (OHRP)
is the primary source of information on communicable • Office of Minority Health (OMH)
• Office of Population Affairs (OPA)
diseases and is a vital resource for all public health per-
• Office of Research Integrity (ORI)
sonnel. BoxÂ€3-3 details the scope of services provided by
• Office of the Surgeon General (OSG)
the CDC. • Office on Women's Health (OWH)
• The Agency for Healthcare Research and Quality (AHRQ) • Medical Reserve Corps
is the lead agency for sponsoring and conducting research • Presidential Advisory Council on HIV/AIDS
to improve the quality of health care, reduce costs, • President's Council on Physical Fitness and Sports (PCPFS)
improve patient safety, and increase access to Â�essential • Regional Health Administrators (RHAs)
services.
Three other divisions of the USDHHS concentrate on
providing welfare-related services:
• The Centers for Medicare and Medicaid Services (CMS), for-
merly the Health Care Finance Administration (HCFA), has This probably played a role in the reorganization decisions.
as its primary responsibility the oversight of the Medicare C. Everett Koop emphasized the importance of public aware-
and Medicaid programs, which constitute 91% of the federal ness of AIDS; Antonia Novello highlighted the effects of sub-
budget for personal health care services (U.S. Census Bureau, stance abuse, especially the effects of alcohol and tobacco
2012, TableÂ€474). It also administers CHIP. ChapterÂ€4 pro- on adolescents; Joycelyn Elders directed efforts to address
vides detailed program information and explores the role of adolescent sexual behavior. This created so much contro-
the CMS in administering these programs and ensuring the versy that she was forced to resign. Richard Carmona served
quality of care provided to individuals served by Medicare as Surgeon General from 2002 to 2006. He testified before
and Medicaid. Congress that his efforts to address health care concerns
• The Administration for Children and Families (ACF) were suppressed by the Bush administration, including those
administers state and federal welfare programs: Temporary related to inequality of health care, global health problems,
Assistance for Needy Families (TANF), national child sup- the health status of prisoners in U.S. correctional facilities,
port enforcement, and Head Start. It also provides funding and the mediocre performance of abstinence-only programs
assistance for child care, adoption, and foster care. (Lee & Kaufman, 2007). Dr. Carmona also testified that he
• The Administration on Aging (AoA) advocates for older resisted efforts to include health content that was primar-
Americans. It administers federal programs under the Older ily political, rather than scientifically supported, as well as
American Act, including the Meals on Wheels and home res- efforts to eliminate content on health issues not supported
idency assistance programs. by the administration. Dr. Carmona was not nominated for
a second term. The current Surgeon General is Vice Admiral
Office of Public Health and Science and the Surgeon General Regina Benjamin.
In 1996, a reorganization of the USDHHS established all the
agencies previously under the direction of the Public Health Other Federal Agencies
Service (PHS) as independent agencies. The Office of Public Several other federal agencies provide health-related services.
Health and Science (OPHS) performs the old administra- BoxÂ€3-5 lists the most important of these and some of their
tive functions of the PHS and is responsible to the Office of health care responsibilities. Note that most provide indirect ser-
the Assistant Secretary for Health (BoxÂ€3-4). That reorganiza- vices and play an important role in the health and welfare of
tion and a subsequent reorganization dramatically reduced the the U.S. population. Imagine the potential for outbreaks of food
influence and position of the Surgeon General, who now has poisoning if there were no inspection of the food, meat, and
little power in terms of directing health care policy. Before the poultry produced for public consumption. The current rash of
reorganizations, the Surgeon General had responsibility for the environmental problems such as air and water pollution, toxic
CDC, the FDA, the IHS, and the NIH, and other departments, dumps, and food pollutants point to the need for continued,
including the U.S. Public Health Service Commissioned Corps. vigilant health monitoring.
Today, the Surgeon General serves in an advisory and educa- Some federal agencies, including the Department of Veterans
tional capacity for public health matters but has no authority to Affairs (VA) and the Department of Defense (DOD), provide
formulate health care policy. direct health care to specific populations. The VA is an indepen-
Several recent Surgeons General have attempted to impact dent agency that reports directly to the President. It is Â�responsible
health care policy by publicizing selected health care issues. for providing health care to certain groups of military veterans,
BOXÂ€3-5â•…â•‡SAMPLE LISTING OF OTHER FEDERAL AGENCIES INVOLVED IN HEALTH MATTERS

(NOT PART OF U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES)
Department of Agriculture Department of Labor
• Develops dietary guidelines for national nutritional policy. • Occupational Safety and Health Administration (OSHA) provides
• Does research and provides prevention data in areas of improved crop technical assistance and enforces health and safety standards in the
and animal protection. workplace.
• National School Lunch Program enforces food safety regulations; • Mine Safety and Health Administration (MSHA) inspects mines and
grades meats and other foods. enforces health and safety standards.
• Administers the Food Stamp Program.
Environmental Protection Agency (EPA)
Department of Defense • Controls air and water quality and pollution standards.
• Provides direct and indirect medical services to military members and • Oversees solid waste and toxic substances disposal.
their families. • Regulates pesticides.
• Provides environmental health services to military communities. • Oversees radiation hazard control.
• Oversees noise abatement.
Department of Housing and Urban Development
• Provides mortgage insurance for hospitals and long-term care facilities. National Science Foundation (NSF)
• Constructs rural hospitals and neighborhood clinics. • Provides money for health research.
Department of Justice U.S. Department of Veterans Affairs

• Operates facilities for the health care of federal prisoners. • Provides health care for military veterans.
especially those who have service-connected injuries, receive hospitals; ensure quality of service through licensure and regula-
Â�veterans’ pensions, are 65â•›years or older, are medically indigent, tion of health care practitioners and facilities; and attempt to con-
or all of these. Therefore, the VA serves as a source of care for trol health care costs and regulate insurance companies (Sparer,
Â�veterans who have exhausted other health care resources. 2011; Sultz & Young, 2011). States play a major role in directing
The VA operates hospitals that provide inpatient and outÂ� and supervising public health activities for their citizens, includ-
patient medical, surgical, and psychiatric services. It also oper- ing disease control, sanitation, and environmental oversight.
ates satellite and independent clinics and offers limited nursing Because state governments have diverse organizational
home and residential facilities. The VA is a large direct care sys- structures, there is no single way in which health care services
tem with 153 hospitals, 956 community-based clinics, 134 com- are organized and supplied by the states. Health care concerns
munity living centers, 90 domiciliary residential rehabilitation are spread throughout various state agencies.
treatment programs, and 232 veterans centers (nursing home
units). The VA served 5.5. million beneficiaries in 2006 (U.S. The State Health Agency
Department of Veterans Affairs, 2011). Each state has a state health agency that is the principal agency
The DOD provides both direct and indirect care to 1.5 for health care services for that state. Roles and responsibili-
million active-duty military members and to an additional ties of state health agencies vary. Some have vast authority over
approximately two million military dependents (family mem- most aspects of health care, whereas others share power with a
bers), as well as limited care to retired military personnel number of other agencies or organizations. FigureÂ€3-7 presents
and their dependents (DOD, 2011). The DOD also provides a hypothetical state health agency with considerable authority.
Â�indirect care for family members of military personnel and Most states provide the listed health care services either through
retirees through the TRICARE (formerly Civilian Health and state health agencies or through other state agencies. In states
Medical Program of the Uniformed Services [CHAMPUS]) where the state health agency is the state health department, the
insurance program. director might hold the title health officer or health commissioner.
The wars in Iraq and Afghanistan have stressed the ability of According to the Association of State and Territorial Health
both the DOD and the VA to provide care to wounded active and Officers (ASTHO), most state health agencies are actively
retired military personnel. Walter Reed Hospital in Washington, involved in the following areas: (1) personal health, (2) com-
DC, was the main focus of media reports related to health munity health, (3) environmental health, (4) health resources,
care service deficits. However, there is concern that the entire (5) health education, (6) health planning and policy develop-
military health care system is overburdened and Â�underfunded, ment, (7) enforcement of public health laws, (8) laboratory
which could severely compromise the ability to care for all military services, (9) general administration and services, and (10)
personnel and their families in the years to come. funding to local health departments not allocated to program
areas. The service areas are linked to the 10 core functions of
State Governments public health (Association of State and Territorial Directors of
States derive their authority to govern from the Constitution, Nursing, 2002). ChapterÂ€29 expands on the core functions and
which reserved for the states all power not specifically given to services of public health agencies. Most direct care is aimed at
the federal government. States play a broad role in health care. poor and high-risk groups. Local health departments may share
They finance the care of the poor and those with disabilities, in providing some of these services if directed to do so by the
primarily through the Medicaid program; operate state mental state authority.
Governor
Department of
social services
State health agency

(see detail below)
Hypothetical state health agency
State health Board of

agency health
Disease Local health Hospital and Laboratory State center of Medical care
control services technical services services health statistics
• Community health • Hospital licensing • Central laboratory

• Dental health services • Vital records • Maternal and child
nursing and certification health
• Nutrition services • District laboratory • Health resources
• Community • Emergency statistics • Prevention of mental
• Venereal disease medical services services
sanitation retardation
• Immunizable • Health data
• Community health • Narcotics and analysis • Crippled children’s
diseases dangerous drugs
education services
• Communicable • Radiologic health
diseases • District health units • Special Supplemental
• Chronic diseases • City and county Food Program for
health units Women, Infants, and
• Veterinary public Children (WIC)
health
FIGUREÂ€3-7â•‡ Hypothetical state superagency incorporating the health department.
Other Health-Related State Activities such endeavors. The WIC Program and the CHIP are programs
Other state agencies outside the state health agency have health- in which authority is shared. Most of the Â�responsibility for health
related responsibilities. For example, Departments of Education care at the local level resides in the local health department.
are responsible for school health programs and health Â�education Some local health departments provide ambulatory health care
policy. Licensing of health care professionals is usually the pur- services for poor persons, especially in areas where other provid-
view of the state board of licensing and examination for that spe- ers offer limited services to these groups (Milio, 2002; National
cific profession. Vocational rehabilitation, occupational health, Association of County and City Health Officials [NACCHO],
health planning, and selected environmental health responsibili- 2011). Funding of local health departments is shared by local,
ties might be found outside the scope of the state health agency. state, and federal governments. Federal funding is usually in the
The National Commission on Community Health Services form of grants for specific programs (Sultz & Young, 2011). Most
(1967) recommended consolidation of all official health ser- of the burden for operating local health departments is assumed
vices into a single agency to streamline bureaucracy, reduce by local governments (Milio, 2002; NACCHO, 2011).
duplication of efforts, and potentially cut costs. Now, more than Like state governments, local units do not consolidate all
50â•›years later, there has been little progress toward implement- health care services in the local health department. Many vari-
ing this recommendation, and it is not likely that we will see ants of organizational structure exist. Mental health and envi-
substantial consolidation of health-related services in the near ronmental health services such as waste disposal, air pollution
future. As a result, the states’ health care responsibilities, includ- control, and water-quality control are commonly under the
ing environmental health, are still divided among an extensive auspices of other local agencies. School health programs might
and bewildering number of departments, commissions, agen- be the responsibility of the local school district rather than the
cies, and boards. local health department. Communities that operate general
public hospitals and other such facilities frequently have sepa-
Local Governments rate organizational and funding structures for those facilities.
The state government creates local governments and delegates
authority to the local unit, which can be a city, village, town- PRIVATE-SECTOR ROLE IN HEALTH CARE DELIVERY
ship, county, or special district. State legislatures determine the
responsibilities and roles of local units, including the definition Private-sector health care concentrates primarily on providing
of the unit's role in health care. health care services to individuals and families. The private sec-
The local governments perform many of the direct personal tor is composed of both for-profit and nonprofit organizations,
services. Maternal and child health programs are examples of although most are for profit.
For-Profit Providers and Organizations employers, government programs, or self-purchase (U.S. Census
For-profit providers and organizations are business arrange- Bureau, 2011).
ments that provide services for a payment. For-profit pro-
viders concentrate on direct care and services. Providers, Managed Care
for example, include health care professionals (physicians, Managed care combines two functions: health insurance and
nurses, dentists, and others), nursing homes and hospitals, delivery of health care services. Managed care organizations
drugstores and medical supply companies, and pharma- have all or most of the following features:
ceutical companies. They range in size from small enter- • Prepayment arrangements
prises such as physicians in solo practice, to moderate-sized • Negotiated discounts from service providers and suppliers
businesses such as independent hospitals, to large con- • Agreements for preauthorizations for certain procedures
glomerates such as managed care organizations and health • Audit of performance
insurance companies. There are several types of managed care arrangements.
In BoxÂ€3-6, various models and their distinguishing features
Role of Insurance and Other Third-Party Payers are described.
Health insurance companies pay for an individual's health care The common thread in these managed care arrangements
in return for a prepayment or premium. Blue Cross (for hospi- is restrictions on the traditional fee-for-service reimburse-
tal fees) and Blue Shield (for doctor fees) were among the first ment method, with contracts binding on both the plan's
prepaid health insurance plans. These two plans are operated health care providers and the consumers. The goals of man-
on a nonprofit basis. They are included in the discussion of for- aged care are to lower costs and ensure that maximum value is
profit organizations because they are not charitable organiza- received from the resources used to produce and deliver health
tions and charge a fee for services. After Blue Cross and Blue care. These goals are achieved by improving the efficiency of
Shield proved insurance to be a viable method for financing delivered services and by influencing the behavior of providers
health care services, commercial insurance companies began to and consumers through rewards and penalties. For example, if
offer competing plans. a consumer goes to a health care provider not covered by the
The financing of health care by an insurance company rather plan, he or she will pay more out of pocket than if an in-plan
than by the individual is called third-party reimbursement. provider were used.
The federal and state governments also assume the role of a third- Health maintenance organizations (HMOs) are the oldest
party reimburser when they pay health care providers through model of managed care and the most restrictive with regard to
Medicare and Medicaid. By the 1960s, health insurance plans consumer choices. An individual's provider of choice must have
had become one of the largest payers of hospital and physician a contract with the HMO. If a client uses providers outside the
charges (see ChapterÂ€4). Currently, approximately 83.7% of the organization, the client will pay a large co-payment or might not
U.S. population has health insurance coverage, either through be compensated for the cost of care. Most cost savings with HMOs
BOXÂ€3-6â•…â•‡TYPES OF MANAGED CARE ORGANIZATIONS
Health Maintenance Organizations (HMOs) rate to members. There is a fixed premium (insurance cost). Members
HMOs are networks or groups of providers who agree to provide certain might, in addition, be expected to pay a portion of the cost of selected
basic health care services for a single yearly fee (capitation). The con- services. Clients may use non-PPO providers, but they must pay more
sumer pays the same amount for coverage regardless of the amount and out of pocket to do so.
type of services provided. There are five HMO models differentiated by
the method used to engage physicians and other health care providers Point of Service (POS)
in terms of organization and payment: POS plans are a hybrid of the PPO concept. These are networks for pro-
Staff: Providers are salaried employees. viders. The consumer selects a primary care physician from network
Group: Providers are a single multispecialty group under contract to providers to act as his or her primary care physician. The physician
provide services to HMO clients. Services might be delivered in acts as a gatekeeper who determines the consumer's need for special-
HMO facilities or in clinics operated by the provider group. ized health care services and referrals. Consumers need the gatekeep-
Network: Providers are two or more independent groups under con- er's permission to seek other services, and they will incur additional
tract to provide services to HMO members. expense if they do not get the primary physician's approval before
Independent practice association (IPA): Contracts are with solo pro- seeking other care.
viders (physicians and small single-specialty group practices).
There is a large panel of participating providers. Health Care Networks
Mixed: HMO contracts with more than one type of provider. There There are corporations with a consolidated set of facilities and ser-
might be salaried providers, single-practice physicians, and large vices for which consumers or employers pay a specific monthly fee.
groups under contract. Clients select a single provider method for The services offered are intended to be comprehensive, and consumers
their health care needs. are expected to receive all care within the network or from providers
arranged by the network. A network includes the following components:
Preferred Provider Organizations (PPOs) a major hospital, several smaller hospitals, a long-term care facility, a
Preferred provider organizations have a looser organizational structure rehabilitation center, a home health agency, and a subacute care cen-
and are a more recent development. They contract with a network of ter. Examples of health networks are Helix Health Care System and
providers (doctors, hospitals, and others) to provide service at a Â�discounted MedAtlantic Health Care.
Data from the Centers for Disease Control and Prevention, Atlanta, GA.
come from efforts to reduce hospitalization rates. HMO Â�members functions of voluntary agencies, which are still valid today. These
have fewer hospital admissions and spend fewer days in the basic functions are summarized in two basic concepts:
Â�hospital per episode of hospitalization (Harrington & Estes, 2008). 1. Creativity: Efforts to address unmet health care needs
Preferred provider organizations (PPOs) are the fastest • Efforts to improve or design new methods to meet recog-
growing of the managed care arrangements. Their share of nized health care needs
health plan participants has increased. They are especially pop- • Efforts to plan and coordinate health care activities to
ular among employer-provided health plans. Fifty-five percent avoid overlap and conflict between public and private
of workers are enrolled in PPOs (Kaiser/Health Research and initiatives
Education Trust [HRET], 2011). 2. Advocacy: Promotion of health legislation to benefit the
public interest
Growth in Managed Care • Promotion of public health programs and defense against
Managed care is expanding primarily because organizations political interference or funding reductions
have demonstrated that services can be provided at a lower cost • Provision of health education to the public and support
with managed care than with other types of health care pro- for professional education
vider arrangements. Refer to ChapterÂ€4 for a discussion of how An agency might concentrate on one function or be involved
costs are affected by these health care service options. Managed in a number of different functions, depending on its stated
care models are especially popular with employers because they mission.
reduce the employers’ cost of providing health care benefits to There are several types of health-related voluntary agencies.
employees. In 2011, 89% of employed persons were insured The most common are agencies supported by contributions from
through a managed care plan (Kaiser/HRET, 2011). the general public (e.g., the American Heart Association), phil-
anthropic trusts (e.g., the Robert Wood Johnson Foundation),
Voluntary Component of the Private Sector and health care professional organizations (e.g., the American
Voluntary agencies have long been a part of the U.S. health care Public Health Association). The largest group and the most
system. What exactly is a voluntary agency? All private-sector familiar to the general public are agencies that receive their sup-
organizations, whether for-profit or nonprofit, provide volun- port from citizen donations and fundraising campaigns. BoxÂ€3-7
tary services to some extent. They all originate through some provides examples of each type of voluntary agency.
sort of private initiative and are not compelled by government Specialized agencies usually rely on public donations from
sanction to organize or provide health care services. In more a large number of contributors. Most attempt some type of
common usage, the term voluntary, with respect to health care fundraising campaign, including mail or media, door-to-door
agencies, usually applies to nonprofit agencies. solicitations, and telethons. So many organizations have made
There are many hundreds of voluntary nonprofit Â�agencies— public appeals for support that a number of charities have
thousands if voluntary nonprofit hospitals are included. banded together in a united appeal process. The United Way
This section focuses on nonhospital-type voluntary agencies and Community Chest efforts are an attempt to limit requests
involved in health care. for contributions and to consolidate efforts.
Goals and Types of Voluntary Agencies Distinctions from Other Types of Organizations
Voluntary agencies engage in a variety of health-related Â�activities. Voluntary agencies have operational freedoms that other types
The classic work by Gunn and Platt (1945) identified the basic of organizations do not. They are less constrained by laws and
BOXÂ€3-7â•…â•‡ TYPES OF VOLUNTARY AGENCIES
Agencies Supported by Private Funds health, and assistance to health departments located primarily in
The goals of publicly supported organizations vary greatly, but many are rural or isolated areas. The Robert Wood Johnson Foundation, the
clearly health related. Most have very specific purposes. Some exam- Milbank Memorial Fund, the Rockefeller Foundation, the W. K. Kellogg
ples are the following: Foundation, and the Carnegie Foundation are a few of the philan-
• Agencies that concentrate on a specific illness, disease, or body organ thropic organizations with a primary interest in health care. Community
(e.g., American Heart Association, American Diabetes Association, Resources for Practice at the end of the chapter provides information on
American Cancer Society) how to find out about these organizations and their special interests.
• Agencies concerned with providing services to specific target groups,
such as children, older adults, or persons who are homeless (e.g., Professional Organizations
National Society for Crippled Children, National Council on Aging) Professional organizations are funded by membership fees. Professional
• Hospice organizations that target the terminally ill and their families organizations are concerned with health issues, especially those
• Agencies that concentrate on a certain type of health-related service involving the well-being of their members. They do not provide direct
or phase of health (e.g., Planned Parenthood Federation of America, health care services. Activities include the following:
National Safety Council, Visiting Nurse Association) • Providing continuing education
• Establishing and improving standards and qualifications for profes-
Foundations and Private Philanthropies sional practice
Foundations are established and funded by private donations. These • Encouraging research
philanthropic organizations are involved in a number of health-related • Safeguarding the independence and interests of the professional
areas, including basic research, professional education, Â�international membership by lobbying
regulations and can move quickly to initiate new programs or their interest to blocks of people or target groups and
change existing ones. They enhance creativity in care and are families. Public health concentrated on reducing the risks of
often the initiator of new programs, research, or services to illness and death from specific diseases among family mem-
underserved groups. Although voluntary organizations contrib- bers and target groups, for example, maternal and child
ute to health care, they play a very small role in the delivery of health services and clinics for sexually transmitted diseases
services to the nation's population. If charitable giving is used as (STDs). Population-based efforts were deemphasized during
an indirect measure of impact, then their efforts provide a mere this period.
0.8% of the total health care budget in 2010 (Giving USA, 2011).
PUBLIC AND PRIVATE SECTORS, 1965 TO 1992
PUBLIC AND PRIVATE HEALTH CARE SECTORS
BEFORE 1965 The year 1965 is commonly viewed as a turning point in U.S.
health care delivery services. In the 1960s, two issues became of
Before 1965, there was a two-tiered system of health care deliv- paramount importance: (1) public recognition that access and
ery in the United States. People who could afford it paid for quality of care were disproportionate, particularly with respect
health care either out of pocket or through health insurance to the poor and older adults, and (2) rising health care costs.
programs. People who could not afford to pay or lacked health Attempts to solve these two problems resulted in implementa-
insurance relied on the charity of individual health practitio- tion of a number of strategies.
ners, organizations, or limited government funded care.
Medicare and Medicaid
Providers of Health Care In 1965, federal legislation aimed to facilitate access to health
Initially, physicians provided care in their offices or in the care services and to reduce or eliminate the two-tiered system
individual's home, and nursing care was provided by fam- of health care. Medicare (for older adults) and Medicaid (for
ily members and visiting nurses in the home. As other types the poor) were created. ChapterÂ€4 provides a detailed discussion
of health care professionals emerged (pharmacists, dentists, of these programs and cost-containment efforts. Providers who
podiatrists, radiologists), they set up their practices using a had avoided older adults and the poor were encouraged to treat
similar business model of reimbursement. The greatest excep- them because payment for service was now guaranteed. As pro-
tion was nurses who were employed primarily by physicians viders willingly mingled middle-class, privately insured patients
and hospitals. Few nurses engaged in independent practice. with government-insured patients, the boundaries of the two-
Over time, hospitals became the principal caregivers for the tiered health care system began to blur.
seriously ill. In 1960, most general hospitals were nonprofit
community hospitals, primarily serving paying clients. Publicly Cost Concern and Containment Efforts
owned hospitals provided health care for most nonpaying per- Cost became an issue of increasing concern even as access
sons. The state and local governments assumed the responsibil- and equity of care were being addressed. Personal health care
ity for most of the public health activities directed at citizens expenditures had steadily increased since the time before
and communities as well as the bulk of inpatient psychiatric World War II, leading to the initial attempts at cost cutting.
care for the poor with mental disorders. Third-party payers (government and insurance companies),
employers, and unions were the driving force behind the cost
Focus of Care: Private Sector saving initiatives, as these large organizations were immedi-
An individual-centered focus on acute illness is the historical ately and directly affected by escalating costs (Califano, 1986;
method of health care delivery in the United States. Physician Feldstein, 2012).
practice and institutional health facilities depended on the treat- At the beginning, the general public and the providers of
ment of persons with acute problems. An individualized, acute care were not as concerned about the costs of health care ser-
care focus in health care services meant that most of the energy vices. Insurance served as insulation from the actual costs of
was spent at the level of secondary prevention (treating illness) care. The direct effect of out-of-pocket medical expenses was a
and tertiary prevention (eliminating or reducing the long-term greater concern. Health care providers were essentially satisfied
effects of an illness or disability). This emphasis is evidenced by because they received adequate compensation from the insur-
the growth of hospitals, clinics, and other facilities and services ance companies.
with the focus on acute care and disabilities. The enactment of Medicare and Medicaid legislation opened
the way for federal efforts at cost containment. The USDHHS
Focus of Care: Public Sector had oversight of both programs and directed the CMS to initi-
In the past, community health officials and policies emphasized ate efforts at containing costs. Subsequent amendments to these
primary prevention aimed at avoiding accidents, illnesses, and two acts expanded the authority of the CMS to contain costs.
diseases. By the 1960s, public health efforts had significantly Since hospitals were the area with the most dramatic increase in
reduced the dangers of many life-threatening health problems. costs, they were the focus of cost containment. Overall expendi-
Sanitation, food inspection, and other environmental controls, tures on hospital care rose from $8.09 billion to $305.3 billion
combined with immunization efforts, reduced the more com- between 1960 and 1992. A substantial portion of that increase
mon hazards for a large percentage of the population. Lower was the result of improvements in treatment and technology.
mortality rates were accepted as the norm. Funding support and Cost-containment measures slowed the growth of hospital costs
public interest for primary prevention activities ebbed. compared with other health care services. For example, reduc-
In response to a lack of interest in population-Â�centered ing a patient's length of hospital stay had a dramatic impact on
health care services, public health practitioners redirected reducing hospital costs (Sultz & Young, 2011).
Efforts at Health Planning and sociologists argued that it would be more efficient to
Throughout the late 1960s and the 1970s, Congress initiated correct poverty, because poor health was significantly associ-
efforts aimed at increasing the level of health planning for the ated with a deprived standard of living (Blum, 1981; Brown,
country. Website Resource 3A offers a brief synopsis of the 2001; McKeown, 1976). They pointed to evidence from devel-
two most important laws that culminated in the inception of oping countries that showed a direct correlation between
health systems agencies (HSAs). The HSAs and other health improvements in the health status of the population and
planning agencies were charged with assessing the health sta- improved economic status.
tus of populations in their areas, identifying specific health care Comparisons of standard measures of health in developed
needs, developing plans to ensure adequate services and treat- countries indicated that the performance of the United States
ment of expected health problems, and strengthening preven- was mediocre. People began to question this country's emphasis
tive measures to reduce the incidences of diseases. on acute care. Milio (1981, 1983) and others argued that health
Opposition to health planning boards was strong. Especially status should not be measured in terms of presence or absence
resistant were vested interests, groups whose professional prac- of disease and high or low death rates. The aim should be to
tices or finances might be affected by the decisions of the boards. promote health and maintain as many people as possible in a
For example, the American Hospital Association (AHA) and disease-free state with a higher quality of life. It is more cost
the American Medical Association (AMA) both opposed these effective to place emphasis on prevention rather than on care or
measures (Pickett & Hanlon, 1990). Under President Reagan, treatment of illness (Banta & deWit, 2008; Shi & Singh, 2011a).
government support eroded as he was philosophically opposed A strong preventive component directed toward eliminating or
to health planning because it set limits on the “free market” postponing illness is necessary to improve the health status of
delivery system. Funding for HSAs was eliminated by the 1982 a population.
budget, which effectively dampened the move toward national
health planning (Patel & Rushefsky, 2006; Sultz & Young, 2011). Health Planning and the Relationship to Prevention
Many states have maintained some of the oversight and review During the 1960s and 1970s, support grew for increasing the
functions, transferring these activities to other agencies. emphasis on prevention rather than treatment of illnesses. Local
and regional planning agencies such as the HSAs were involved
Competing Focuses of Care: Prevention or Cure in the planning efforts. As an example of regional planning, a
During these years, two competing concepts of care fought for health care plan for those with cardiac disease would include
supremacy. The debate was between curative, illness-oriented both an adequate supply of cardiac hospital beds (curative; sec-
(secondary and tertiary) care and preventive (primary) care. ondary prevention) and aggressive health teaching aimed at
reducing the population's risk of developing heart disease (pre-
Consumer and Professional Support for Prevention Focus ventive; primary prevention).
Public health personnel had long supported a proactive The focus on prevention-related activities also increased at
approach, emphasizing preventive health practices. It was not the federal level. Growing research evidence supported the idea
until cost became a significant concern that public opinion that preventive measures were less costly than treatments of
shifted again, to a more historical public health focus on plan- specific illnesses. National goals that were intended to improve
ning and delivering health care (Fleury etÂ€al., 1996; USDHHS, the health status of the population were developed. Action
2000). Several experimental programs proved to be cost effective. plans were devised to meet these health goals. Most actions
A few large employers implemented fitness and health-teaching were preventive and aimed at reducing risks within specific
programs. These innovations resulted in an improvement in age groups (U.S. Public Health Service, 1979). For example,
health status and a reduction in illnesses and, thus, absenteeism. an immunization strategy targeted communicable childhood
Ultimately, they saved employers money by reducing sick pay diseases, hepatitis among health care workers, and influenza in
benefits and lowering health insurance claims (Aldona, 2001; older adults.
Task Force Community Preventive Services, 2007). In the 1980s, the efforts at health planning and emphasis on
Coupled with employer efforts, an awakening of consumer prevention stalled. A political and philosophic shift at the fed-
interest in health status and health care services occurred. eral level resulted in substantial funding cuts for the planning
Consumer groups became active in monitoring and question- efforts for public health and preventive health (Shonick, 1995).
ing standard medical practice, as well as espousing consumer Efforts to revive the emphasis on public health and preventive
responsibility for health-seeking behaviors. focus in the 1990s had little success.
Employees and labor unions drew public attention to the
link between occupational exposures and hazards and certain Emphasis on State Control and Administration of
illnesses and injuries. Their efforts helped the push toward laws Health Programs
intended to improve working conditions. Safety measures to In the 1980s, President Reagan was determined to limit the role
eliminate or reduce illness and injury received broad support of the federal government in health care. The Reagan adminis-
(Pickett & Hanlon, 1990; Robert Wood Johnson Foundation, tration oversaw severe cuts in federal funding for public health
2008; Sultz & Young, 2011). and developed a block grant system of state administration for
most remaining health and welfare programs (Shonick, 1995;
Comparison of Health Status Indicators Patel & Rushefsky, 2006).
Information about models of care in other developed countries These efforts were resisted by the states, which were caught
became more available to consumers, health care profession- in a bind between federally mandated service requirements
als, sociologists, and economists (see ChapterÂ€5). Instead of and shrinking federal funds (Congressional Budget Office,
concentrating on physical care, political activists, Â�economists, 1992; Harrington & Pellow, 2001). The Omnibus Budget
Reconciliation Act (OBRA) of 1981, which created block grants promotion and disease prevention, which is the very essence of
and state oversight, also reduced federal funding by 25% community health practice, the survival of some public health
(Kronenfeld, 1997). The states had to choose between elimi- agencies has become doubtful.
nating or reducing benefits and increasing their budgets to
continue the coverage at the current level (Patel & Rushefsky, Power Conflicts within the System
2006). ChapterÂ€4 provides a more detailed discussion of fund- Change is not always beneficial to all concerned; therefore, some
ing impacts on state budgets. Currently, the state-adminis- resistance and conflict can be expected. Cost increases, grow-
tered block grant system is still in effect, and funding remains ing consumer awareness, and competing philosophies about
a major concern. the nature of health care delivery have produced some changes
that have created conflict among various participants (provid-
Rising Number of Uninsured ers and consumers) as they struggle to gain or maintain power.
In the 1980s and 1990s, there was a steady rise in the number Funding and regulatory conflicts between federal and state or
of people without health insurance. Strict criteria for eligibil- local governments have been discussed earlier in this chapter.
ity in government insurance programs and the rising cost of Many other power-related conflicts exist.
private health insurance are the main causes (see ChapterÂ€4). Insurance companies, physicians, and state regulatory bod-
The uninsured are primarily poor and members of minority ies struggle over treatment and cost issues. Malpractice fre-
groups. Their uninsured status places them at greater risk of quently pits administration, physicians, nurses, other health
poor health. ChapterÂ€21 describes the impact of poverty and care workers, and lawyers against one another as they strug-
lack of health insurance on health status. gle over issues of cost, liability, and jurisdiction. As consumer
The nation continues to grapple with health coverage prob- groups attempt to gain a greater voice in the delivery and
lems and has enacted incremental legislation to improve access organization of health care services, many of those already
for certain groups. For example, the CHIP provides health involved in the decision-making process work to retard or
insurance for children whose parents have limited income but dilute the influence of consumer groups. In the health care
are not eligible for Medicaid. Other efforts include increasing industry, power struggles have intensified and can be expected
health insurance portability for workers who change employers to continue even as continued attempts are made to resolve
and expansion of health benefits for the nation's veterans and the budget crisis.
the new Affordable Care Act.
Treatment Decisions: Multiple Players and the Impact on
Physician Practice
PUBLIC AND PRIVATE SECTORS TODAY
Health insurance providers and managed care organizations
Evolution continues as the health care system reacts to changes have expanded their roles in both practice and cost areas,
and pressures from providers and consumers. Escalating costs, including determining treatment modalities, necessity of medi-
cost shifting, tensions between health professions, and a frag- cal supplies and diagnostic tools, and appropriate time frames
mented structure have all been instrumental in impeding or for treatment. Hospitals, in turn, pressed by ever-tightening
expanding access to services as well as dictating the level of budget restraints, have initiated additional curbs on physician
services available for selected groups within the population. practice (Rice & Kominski, 2007). Physicians have vigorously
Managed care organizations have prospered, with increased resisted outside influences in practice decisions, pointing to the
enrollment at the expense of more traditional types of service need for professional autonomy to ensure optimal client care.
programs. Nevertheless, insurance plans, managed care providers, and
hospitals have gradually assumed influence over practice deci-
Continuing Shift in Federal and State Relationships sions. Some physicians have reacted to managed care's attempts
Federal efforts to reduce services and responsibilities and to to impact practice by becoming financial partners in regional
shift duties to the states continue, although the states must physician-owned and physician-operated managed care orga-
meet federally established criteria for health-related pro- nizations or in physician–hospital care networks, a form of
grams. For example, there are federal minimum standards integrated system. Both of these operate in direct competi-
for air and water quality and Medicaid services. The states tion with other types of managed care arrangements (Sultz &
must meet federal standards, even if it means that the states Young, 2011). Physicians have also organized labor unions in an
incur additional expenses. State and federal officials continue attempt to counter unilateral decisions made by managed care
to pressure each other to take on a greater share of the health that impact their practices. There are currently five multistate
care burden. physician unions.
Federal retrenchment and the financial hardships at the state
and federal levels have led to a weakening of public health agen- Nursing Concerns
cies at all levels (Leviton, Rhodes, & Chang, 2011). State and Competing interests hamper nurses’ attempts toward achiev-
local health departments have suffered severe funding cuts, ing greater respect and autonomy. Direct reimbursement has
which have resulted in reductions in staff (including public created conflicts with physician groups. New legislation has
health nurses), reductions in worker benefits, stagnating or sta- increased third-party reimbursement for nurse practitioners
tionary salary, reductions in the amount and type of direct care and some other advanced practice nurses, especially in the
provided to at-risk groups, and imposition of fees for services Medicare and Medicaid programs. The AMA opposes direct
once provided without charge (Sultz & Young, 2011; Walker, reimbursement for nurses. Nurse staffing and supervision deci-
1992). The existing staff work under increasing stress and pres- sions have been undermined by the increased use of unlicensed
sure. It is ironic that at a time of increasing emphasis on health assistive personnel.
These conflicts can be expected to continue because as nurs- of specialized workers (U.S. Department of Labor, 2011b).
ing increases its voice , others are forced to share their power in Technological advances have led to increasingly more complex
the decision-making process. A nursing voice on a hospital or health care requirements. This has fueled the demand for spe-
home care board, for instance, means that someone else is dis- cialization. It takes special skills to operate an MRI or com-
placed or his or her influence is diluted by the addition of a new puted tomography (CT) scanner or to prepare and maintain
member. It is crucial that nurses increase their presence in the a heart–lung bypass machine. Add to this the myriad types of
policy-making arena to protect their practice environment and care and treatment options available, and it is easy to see how
influence delivery and service decisions (Garnica, 2009). specialization in health care has become so widespread. Nurses
As nurses’ wages increase, administrators must find ways and physicians have moved from general practice into specialty
to meet these salary concessions. Wage increases were histor- areas. Specialization is often viewed as more prestigious than
ically passed on to the consumer, but current budgetary con- general practice. Specialty imbalances and geographical imbal-
straints do not always allow this. However, even in the midst of ances still exist in the distribution of physicians (Sultz & Young,
a nursing shortage, nursing salaries have not increased as much 2011). Up to this point, specialization has not been problematic
as could be expected (Unruh & Fottler, 2008; Feldstein, 2012). for nursing. Federal estimates of future needs point to a con-
Administrators must make adjustments in budgets to accom- tinuing demand for graduate nurses prepared as nurse prac-
modate the increase in nursing salaries. Building or mainte- titioners and clinical specialists, including community health
nance projects, investments in new equipment, travel budgets, specialists. The National Council of State Boards of Nursing
administrators’ compensation packages, and wage or benefit (2009) predicts a continued shortage into the future, with esti-
increases for other health care professionals are all affected by mates of a shortage of half a Â�million nurses by 2025.
nursing salary increases. Whenever possible, administrators, Fragmentation remains a major feature of the U.S. health
especially hospital administrators, preferred sign-on bonuses, care system. Roemer and colleagues (1975) identified the fol-
recruitment of new graduates, and substitution of nurses with lowing as the most important problems associated with frag-
unlicensed assistive personnel over nursing salary increases. mented health care: poor access to care, gaps and inequities,
Nurses have become more politically active, speaking out inadequate prevention efforts, discontinuous and inappropri-
on the impact that cost cutting has on quality of care. The Joint ate care, poor responsiveness to consumer needs, inefficient use
Commission on Accreditation of Healthcare Organizations of scarce resources, ineffective planning and evaluation, esca-
(JCAHO; now known as the Joint Commission) reported that lating costs, inadequate quality controls, and fragmented poli-
24% of adverse events were related to low levels of nursing staff cies. Although some attempts have been made to address these
(JCAHO, 2005). Other studies showing adverse results of higher issues, they remain largely the same over 30â•›years later (Sultz &
nurse–client ratios are well publicized (Aiken, 2007; Buerhaus, Young, 2011).
Staiger & Auerbach, 2009; Rothberg etÂ€al., 2008; Schnelle etÂ€al., Subspecialization of professions aggravates the problem of
2008). The American Nurses Association (ANA) has developed fragmented care for individuals because specialists tend to con-
the National Database of Nursing Quality Indicators, a set of nurs- centrate on their specialties rather than take a holistic approach
ing-sensitive quality indicators for immediate use in collecting to care. Quite easily, one person can be seen by two or three
data that link staffing, skill mix, and patient outcomes (Montalvo, specialists without any coordination of his or her overall care.
2007). It is important that nurses use these indicators to demand For example, a nurse might have a patient who is taking medi-
that they become part of quality studies conducted by others. cation prescribed by two or three physicians. Without proper
coordination, medications might be counterproductive, or even
Shared Decision Making life-threatening drug interactions could occur. Multiple agency
Historically, physicians have assumed the major role in making involvement in a single person's care compounds the problems
decisions about client care and treatment. They have also had the caused by professional subspecialization. Consider some of the
most influence on policy decisions affecting health care (Feldstein, resources that might be needed to provide quality post-Â�hospital
2012; Sultz & Young, 2011). A large number of highly educated care to a patient who had suffered a stroke: the primary doc-
health care professionals now demand a greater share in the tor, a physician specialist, a nursing service, physical therapy
decision-making process. Physicians account for only 3.6% of all and other rehabilitative services, respite workers to relieve fam-
educated medical professionals (U.S. Department of Labor, 2011b, ily caregivers, Meals on Wheels, telephone monitoring, various
TableÂ€2). Although physicians have resisted any efforts at power assistive devices, home remodeling to accommodate physi-
sharing, other health care professionals have continued to gain a cal deficits, and senior daycare. Most communities still do not
voice in shaping health policy and services. President Clinton's coordinate their overseeing services for their citizens. Patients
Health Reform Task Force consulted nurse leaders and profes- or their families are often expected to coordinate these services.
sional nursing organizations. Nurses have also been involved at the Many patients fail to utilize the available resources because they
state level in planning boards for health care services, for exam- lack the skill and information necessary to plan for care.
ple, the Oregon Health Plan and MinnesotaCare. The Institute
of Medicine (IOM) (2011) has recommended an expanded role Quality-of-Care Concerns
for nurses in redesigning and improving the health care system. There is a real concern that overemphasis on cost containment
Health care professionals will continue to jockey for influence dur- has been detrimental to the delivery of health care services.
ing the terms of the current president and succeeding presidents. The question being asked is: Are cost-cutting decisions affect-
ing access and quality of care? The IOM estimates that between
Specialization and Fragmentation 44,000 and 98,000 people die each year as a result of medical
More than 43 million people are employed in the health errors (Geyman, 2002). An extensive review of health records
care industry, which has seen a rapid increase in the number across the country conducted by McGlynn and colleagues
(2003) indicated that 45% of patients do not receive the rec- The extent to which cost containment impacts the receipt of
ommended preventive care; 46% do not receive the recom- recommended care, the quality of care provided, and the access
mended acute care; and 44% do not receive the recommended to care is still under investigation. The federal government col-
chronic care. A review by Schoenbaum and colleagues (2011) lects quality data from Medicare and managed care organiza-
found a correlation between preventable mortality rates and tions. Some of the sources of these quality data are listed in
quality measures such as higher readmission rates and absence BoxÂ€3-9. At the present time, most states have some regulations
of prevention and education care for people with diabetes or with reporting criteria for both private source and Medicaid
asthma. The Commonwealth Fund reported that the United managed care plans.
States had more medically related errors and ranked last on Reporting of some data is voluntary; reporting of other
safe patient care compared with 16 other developed coun- data is mandatory and is tied to provider compensation. The
tries (Nolte & McKee, 2011). A number of legislative efforts coupling of payment to participation in data reporting has
have been made to allay concerns about the quality of health been expanding. For example, Medicare, Medicaid, and some
and ease of access to care for selected risk groups. BoxÂ€3-8 employer-provided health insurance plans will only insure
lists some of the most relevant legislation and some ongoing with managed care plans that participate in the evaluation
efforts as well. process.
BOXÂ€3-8â•…â•‡ RECENTLY ENACTED AND PROPOSED HEALTH REFORM MEASURES

Health Insurance Portability and Accountability Act Patient Safety Act—Federal Proposal
(HIPAA) of 1996—Federal Law • Requires all health care institutions to collect and provide to the pub-
• Limits insurance exclusions for preexisting conditions. lic information on staffing, skill mix, and patient outcomes; supported
• Requires insurers to renew coverage for consumers; may not drop by the American Nurses Association.
coverage on the basis of illness history.
• Allows portability of health insurance from job to job. Patient Care Mechanism—Federal Law
• Allows access to insurance coverage for small employers. • Balanced Budget Act of 1997—federal law allows states to care for
• Confidentiality provisions took effect in 2003; allow individuals more Medicaid patients via managed care plans.
control over records, require providers to safeguard records, and
guarantee the individual access to his or her personal records. Health Insurance Pools—State Law
Maternity Length of Stay—State Law • Thirty-five states have health insurance cooperatives. These pools
• Requires insurers to cover hospital maternity stays in accordance help small employers provide health care by pooling their money with
with medical criteria; most allow 24- to 48-hour hospital stay after an that of other small companies, which gives them greater flexibility to
uncomplicated delivery. negotiate lower prices.
Mandated Grievance Procedures—State Law CHIP—State Children's Health Insurance Program—

• Requires a quick review process when services are denied by man- Federal Law
aged care and other insurers. • Series of incremental access provisions that extended health care
• Covers denied access to specialists, failure to pay for medical services. coverage to low-income children and prenatal care and delivery to
• Reduces the ability of insurers to take punitive action against the pregnant women.
patient, the doctor, or other medical workers who provide information
to patients with respect to care alternatives. Medicare Prescription Drug, Improvement, and
Modernization Act of 2003
Any Willing Provider—State Law • Provides a prescription drug program. The program provides partial
• Requires health plans to admit any provider who accepts the plan's cost reimbursement for drugs based on income and limits set by
terms and payment rates. the act.
• Provides some prevention measures; for example, physical exami-
Other Specific Service Requirements—State Law
nations and screening for heart disease and diabetes for all new
• Limits same-day discharge for mastectomies.
Medicare enrollees.
• Prudent layperson decision reimbursement—insurers must pay for
• Requires changes to Medicare structures and payment systems start-
emergency department care if symptoms would lead a prudent lay-
ing in 2006 (additional funds for rural physicians and hospitals) and
person to seek care.
2010 (encouraged competition between privately managed Medicare
Mental Health Parity Act of 1996—Federal Law Advantage and Medicare. Medicare Advantage was provided $12 bil-
• Requires employers and health insurers to provide the same benefits lion to compete with Medicare. The Affordable Care Act will remove
for mental health (if they offer a mental health benefit) as they do for this subsidy.).
other types of health benefits; intended to prevent employers from For additional information, see TableÂ€4-2 (page 96).
limiting mental health benefits. Annual renewal requirement means
that the provisions can be discontinued at any time simply by not Patient Bill of Rights—Federal Proposal—Languished
renewing the legislation. Also does not mandate insurers or employ- in Congress from 1992 to 2004
ers to offer mental health benefits but merely dictates what they • Defines basic services and patient rights for consumers covered in
must do if these are offered. any type of health insurance plan.
(Continued)
BOX 3-8â•…â•‡ RECENTLY ENACTED AND PROPOSED HEALTH REFORM MEASURES—CONT'D
Universal Health Coverage—State Law nurses and physicians’ assistants, increased efficiency of the health
• Provides health care access to all residents: currently exists in care workforce, transitional care, home care, and home visitation and
Massachusetts, Vermont, Maine, and Oregon. school-based health centers.
• Expands grant funding for the education of health care professionals
Patient Protection and Affordable Care Act—2010* and ancillary health care workers, with emphasis on shortage areas
• Requires insurance provider to immediately expand coverage to such as geriatrics and primary care.
young adults under 26 under their parents’ health insurance plan • Establishes education loan repayment awards for health care profes-
(already implemented). sionals who promise to serve underserved populations and locations
• Expands coverage to an additional 32 million uninsured by 2019, pri- such as the National Health Service Corp, rural areas, prisons, and
marily through expanding Medicaid eligibility and establishing state Indian Health Clinics.
health insurance exchanges by 2014. • Establishes Accountable Care Organizations (ACOs) aimed to
• Requires the states to have an affordable insurance plan for preexist- improve the quality of services to Medicare patients and controls
ing conditions in adults and assures insurance coverage to all chil- costs by providing payment for all care provided before, during, and
dren with preexisting conditions. after a health care incident or in chronic illness situations. Could
• Provides “donut hole” rebates and incremental removal of the “donut be an option in place of fee-for-service and the current Medicare
hole” in Medicare Part D established by the Medicare Act of 2003. Advantage (managed care).
• Prohibits insurance plans from placing lifetime limits on the dollar • Establishes National Health Prevention and Promotion activities and
value of coverage. funding for research aimed to improve the health of communities
• Improves the health care workforce by establishing pilot programs through prevention and health promotion activities.
in the use of team-based care, expanded roles for advance practice
*This is a summary of some of the features of the Affordable Care Act. For more detailed explanations and to track health reform progress, use the
websites listed in Community Resources for Practice at the end of the chapter.
BOXÂ€3-9â•…â•‡ SOURCES FOR QUALITY DATA

HEDIS—Health Employer Data and Information Set Joint Commission (formerly known as Joint
(Developed by the National Committee on Quality Assurance [NCQA]) Commission on Accreditation of Health Care
• Accreditation service; voluntary for all managed care plans. Organizations)*
• Data on all types of insurance plans. Hospital data required as part of the accreditation process include
• Employers can use the data to help decide which health plan to offer quality outcome measures such as number of hospital deaths and read-
their employees. mission rates.
• HOS*—Medicare Health Outcomes Survey, part of HEDIS data. Medicare +
Choice is required to collect and review data on seniors every 2â•›years. Can Comprehensive Data Collection Programs—Voluntary
track health status over time if seniors stay in managed care. Pilot programs designed to improve health status of the frail older
adults and other high-risk groups by coordinating inpatient and out-
OASIS*—Standardized Outcome and Assessment patient services and collecting outcome measures.
Information Set for Home Care • PACE—Program for the All-Inclusive Care of the Elderly
A measure of patient functional, behavioral, social, and clinical status; • SHMOII—Social Health Maintenance Organization Model II
data are reported to state agencies for use in the nursing home certifi-
cation process. Centers for Medicare and Medicaid Services—https://
www.cms.gov/
FIM*—Functional Independence Measures • NHQI—17 quality measures on all Medicare-participating nursing
Data measures collected to incorporate into a larger patient assessment homes
tool; used to determine the amount of prospective payment by Medicare • HHAs—11 quality measures on home health agencies
to inpatient rehabilitative facilities. • NCQA—HEDIS reports
*Participation required for Medicare payment.
Quality-of-care requirements do not apply only to man- Detailed comparisons between managed and nonmanaged
aged care. Other health care providers are also required to make or fee-for-service care is a new area of investigation. So far, the
annual reports. For example, hospitals are required to pub- results have been mixed. Some studies of satisfaction show that
lish data on the number of hospital deaths and their readmis- enrollees in both plans are equally satisfied. Other studies show
sion rates. In keeping with ongoing concerns about the quality that managed care consumers are not as satisfied as are fee-for-
of health care in the United States, the AHRQ is required by service consumers (Pulcini & Hart, 2007b; Schur etÂ€al., 2004).
Congress to report annually on the nation's quality of health With respect to specific medical conditions, the results are sim-
care and disparities in care delivery. Harrington (2011) reports ilarly mixed. Garrett and Zucherman (2008) examined U.S.
that cost containment has been the overwhelming concern in counties that required all Medicaid patients to be enrollment
long-term care services during the past 20â•›years. Cost of ser- in managed care. They reported that adults in mandatory man-
vices, rather than quality of care, has dictated decision making. aged care had a lower number of emergency department visits,
but this was not offset by an increased use of ambulatory and Shorten Hospital Stays and Increase Home Health Care. The
preventive care. A comparison of Medicare patients in standard primary efforts at reducing hospital Medicare costs were federal
Medicare and Medicare managed care found managed care was actions. Prospective payment and diagnosis-related groups were
better at delivering preventive care such as immunizations and imposed on hospitals that cared for Medicare patients. These
smoking cessation. That same study found that customer sat- reforms were an attempt to encourage hospitals to curb costs
isfaction and ease of access was better in standard Medicare (see ChapterÂ€4).
(Landon etÂ€al, 2004). A study of patients with breast cancer The net effect of the federal reforms has been a reduction
found no difference in time to detection or patient outcome in the average length of hospital stay for Medicare patients and
when managed care and fee-for-service plans were compared an increased demand for home health care and other commu-
(Lee-Feldstein etÂ€al., 2000). Several studies found that HMO nity care services. The number of transfers to after-hospital care
patients were more likely to get mammograms compared with facilities has doubled. Home health care and other community
fee-for-service patients (American Association of Health Plans, agencies such as public health departments were and remain
2006; Roetzheim etÂ€al, 2008). Studies of managed mental health affected by the increased demand for community-related
care services for children and adults found that managed care services (Sultz & Young, 2011).
reduced the cost of services compared with fee-for-services pro- Managed or Coordinated Care Strategies. The purpose of
grams, but the quality of care has not been stringently addressed coordinated care strategies is to include a mechanism for
(Catalano etÂ€al., 2000; Frank and Garfield, 2007). Women in reviewing care before and during treatment to reduce costs and
mandatory Medicaid managed care were found to have 13% eliminate the use of unnecessary services. Coordinated or man-
fewer Papanicolaou tests and breast examinations than women aged care applies to other strategies aimed at controlling costs as
in fee-for-service programs (Garrett & Zucherman, 2008). The well as managed care organizations. Third-party payers usually
authors expressed concern that although managed care con- develop these strategies. Some of the current strategies include
trolled costs, prevention efforts had not improved. the requirement of prior approval for hospital admissions and
As part of a new effort to “pay for performance,” Medicare will for second opinions for surgery and other costly treatment
no longer pay hospitals for the treatment of preventable medical options, controls on the use of specialists, and case management
complications, including hospital-acquired infections, injuries of care provided to high-cost patients.
from falls, reactions to transfusions of the wrong blood type, air Economists are concerned that the cost savings associated
embolisms, bedsores developed in the hospital, and foreign objects with all types of managed care strategies are limited. They con-
left in patients during surgery. Medicare policy bars hospitals from tend that the savings benefits of managed care have now been
independently billing patients for the treatment of these mistakes. realized (Mechanic, 2008; Sultz and Young, 2011 ). Without
Comprehensive evaluations of quality issues are necessary. substantial new reform measures that limit access and services,
Consumers and employers need to be made aware of and to use the health care budget will increase and consume an ever-larger
comparison data in making decisions about health care plans share of the gross domestic product (Congressional Budget
and providers. Quality data are becoming more readily avail- Office, 2007; Feldstein, 2012; Patel & Rushefsky, 2006;).
able to the consumer via the Internet and print media. The Generic Medication Substitution, Drug Co-payments, and
Community Resources for Practice section at the end of the Pharmacy Choice Limitations. Insurance plans that pay pharma-
chapter provides a list of foundations with websites for con- cies directly for medications have specified that generic drugs
sumer use that can be accessed through the Evolve website. be used, whenever possible. Other plans simply put a cap on the
Nurses need to expand their involvement in quality care issues. amount reimbursed to the patient in an effort to encourage the
There are several ways nurses can assist with quality concerns: use of generic medications. There is also a widespread effort to
• Consumer education: provide information on health service educate consumers and health care professionals about the cost
and access rights savings associated with generic drugs.
• Legislation and regulation: ensure quality of care as an inte- Co-payments for drugs have increased from $2 to $10, $20,
gral part of health care delivery $30, or more. Patients are often expected to pay substantially
• Research: design, implement, and publish the results of qual- more if they want or need nongeneric drugs. Some insurance
ity-related research plans that provided a drug plan free to enrollees are now charg-
ing a monthly fee for the drug plan. Some plans require that
Strategies Employed to Address Problems patients with chronic conditions receive their medications by
Since the early 1970s, attempts have been made to address spe- mail from large processing centers under contract to the insur-
cific problems within the system. Efforts have been aimed at ance provider.
improving efficiency, coordinating planning, and controlling Reduce Waste of Equipment. Because of the emphasis on
costs. Some have been more successful than others. Following budget reduction, institutions have been more vigorous in their
is a brief discussion of the most important strategies. ChapterÂ€4 attempts to encourage the judicious use of disposable equip-
provides a more detailed discussion of selected cost-cutting ment. Some institutions have formalized their cost–benefit
strategies. reviews to make more fiscally sound decisions with regard to
equipment. Inventory reduction, which reduces stored supplies,
Decrease Costs cuts back on the amount of supplies on hand. Although this
Major efforts have been made to find solutions for the cost issue. practice is effective, supply shortages can arise if unexpected
Hospital expenses seemed a logical place to initiate reforms events occur to disrupt the supply line. Health facility man-
because hospitals accounted for approximately 50% of all personal agers are employing more rigorous review procedures in the
health care expenditures in 1980. By 2009, hospitals accounted for decision-making process concerned with new equipment and
only 30.5% of health care expenditures (CMS, 2011c, TableÂ€1). costly new technologies. These actions were first encouraged by
health planning legislation that attempted to reduce duplication Â�

nonphysician practitioners. Physician assistants may be more
of services. Now, because of tight budget restraints, administra- vulnerable to this risk because their practice is more dependent
tors are continuing the practice. on physician sponsorship.
Emphasize Managed Care Increase Accountability of Provider Services

Today, managed care is the largest provider of health care ser- The IOM (2011) found that the United States does not have an
vices in the country. Eighty-two percent of employees covered organized plan to compile health information that can be used
in employer health insurance plans are enrolled in managed to access health outcomes data and improve the accountability
care (Kaiser/HRET, 2011). Federal and state efforts at cost for health care outcomes. The IOM recommended the establish-
reduction have expanded managed care to vulnerable popu- ment of a core structure of indicators to be used to access data
lations covered by Medicaid and Medicare programs. In 2009, and improve the quality of health care in this country. In the
71.7% of the Medicaid population was enrolled in managed meantime, although currently disjointed, the oversight of ser-
care models (CMS, 2011b). Managed care is not as popular vices and costs is becoming tighter. Itemized bills are required
an option for older adults. In 2009, about 24% of Medicare and are carefully scrutinized by consumers and third-party pay-
enrollees used Medicare Advantage, the managed care option ers. Both government and private insurers have instituted mech-
(CMS, 2011a). That percentage may decrease in the near anisms to review patient service records for appropriateness of
future as the subsidies provided to Medicare Advantage are services and costs. Utilization review studies indicate that these
removed as mandated by the Affordable Care Act, forcing mechanisms are cost effective (Rice & Kominski, 2007: Sultz &
that plan to compete on an equal footing with the standard Young, 2011). Nurses are often employed as reviewers because
Medicare plan. Nevertheless, there is every indication that their expertise is an asset to the insurers.
managed care will continue to expand its reach in the health Government has increased its efforts to scrutinize billing
care services market to populations currently served by fee- costs to identify billing fraud and abuse. The CMS is at the
for-service providers. forefront of that effort. Recently, the CMS announced fraud
charges against 94 suspects accused of falsely billing $251 mil-
Increase Productivity of Health Care Professionals lion for services they did not provide to Medicare patients
One method to reduce costs is judicious use of skilled workers. (Weaver, 2010).
To that end, techniques that increase the efficiency of the skilled
workforce and the use of substitute personnel are common. Reverse Aborted Implementation of Health Care Planning
Increase Patient Ratios and Use of Unlicensed Assistive As previously discussed, health planning gradually evolved from
Personnel. Increased patient ratios and the use of unlicensed a voluntary into a mandatory process with stringent criteria, but
assistive personnel have been especially dramatic within the only operated as such for a short period. The program produced
hospital environment. Nurses report increasing workloads, modest successes in terms of cost containment by retarding the
redistribution of labor, and an ever-increasing reliance on rate of increase in specific health care costs and allowed greater
unskilled labor to reduce the number of registered nurses per local participation in the decision-making process.
unit (Unruh & Fottler, 2008). Evidence is surfacing to indicate
that these changes have had a serious impact on morale, patient Promote Continuity of Care, Case Management, Medical Home
care, and patient outcomes (Aiken, 2007: Carayon & Gurses, Model and Accountable Care Organizations
2008; Person etÂ€al., 2004). Although in some circumstances Ensuring that people get what they need to maintain or
restructuring of the work environment can both improve pro- improve their health status requires the creation of some
ductivity and maintain quality of service, this does not appear method of coordinating all necessary services. This is espe-
to be the case with the current hospital changes. cially important in a system notorious for fragmented care.
Use More Nurse Practitioners and Other Physician Extenders. The use of case managers has proved to be effective. Pilot
Nurse practitioners and physician assistants are considered studies sponsored by the USDHHS have shown that the use
effective in certain settings. For health managers, economics of case managers to coordinate services to older clients has
is the major motivator (Shi & Singh, 2011b). Nurse practitio- been beneficial. Clients received all necessary services, and the
ners cost less than physicians, their care is of similar quality, need for institutional care, the most costly service method,
and consumers are pleased with their service (Diers & Price, was delayed, which benefited the entire system. Community
2007; Pulcini & Hart, 2007a). Nurse practitioners are particu- nurses make excellent case managers because they are already
larly effective in managing chronic problems and increasing familiar with many community resources and the referral
patient compliance with mediation regimens, appointment process. Case management has been a responsibility of com-
schedules, and behavioral changes (Sultz & Young, 2011). The munity health nurses since the profession's inception. With
Medicare and Medicaid programs took the lead in expanded the increase of managed care Medicare and Medicaid enroll-
the use of nurse practitioners (see ChapterÂ€4). As emphasis ees, there will be an added demand for nurses to play case
shifts toward noninstitutional services, nurse practitioners management roles.
are expected to assume responsibility for the care of a large Recently, the concept of “medical homes” has been advanced
portion of older adults and persons with a medically stable as a method to improve and coordinate care. This model aims
chronic illness or disability. to make primary care physicians the patient care managers,
The trend toward expanded use of nurse practitioners rather than nurses or other health care professionals (Ginsberg
could be reversed by an oversupply of physicians. As the sup- etÂ€al, 2008). While highly publicized, there has been little prog-
ply of doctors increases, the risk exists that physician groups ress toward this practice model. Presumably physicians who
might attempt to reduce the supply or limit the practice of qualify as “medical homes” will reorient their practice toward
Â�
prevention, health education, and coordination of services additional cost savings. Piecemeal legislative corrections of
while receiving additional compensation for services. Sultz and health provider or health insurer decisions are cumbersome and
Young (2011) question whether primary care physicians can be unworkable. At a minimum, some expanded public oversight
the hub of “medical homes” because of the shortage of primary will be needed. Light (2008) argues that fundamental reform
care physicians and the lack of a strong primary core compo- and universal health care coverage are the keys to good-quality
nent in the current health care system. A variation on the “med- health care. He has identified nine benchmarks for fairness in a
ical home” concept entitled accountable care organizations, are health care system. They are as follows:
pilot projects to be funded by the new Affordable Care Act (see • Good public health and basics
BoxÂ€3-8 for an overview). • Democratic accountability and empowerment
• Universal access—coverage and participation
Increase Patient Cost Sharing • Equitable financing—by ability to pay
All insurance plans have raised consumer costs for health • Comprehensive and uniform benefits
plans—even HMOs, which have historically had less patient • Universal access—minimization of nonfinancial barriers
cost sharing compared with other plans. Cost sharing comes • Value for money—clinical efficacy
in the form of increasing premiums, adding or increasing co- • Fair and efficient costs
payments, and raising the deductible paid by consumers before • Patient autonomy and choice
the insurance plan pays anything. Increasing patient cost share Perhaps it is time to look again at proposals for national
reduces the employer's insurance cost and increases the profits health care systems. There are two types of national health care
for insurance companies and their shareholders (Harrington & systems: a single-payer system and an all-payer system. They are
Estes, 2008; Hollister & Estes, 2008). outlined in TableÂ€3-2 and discussed in the following sections.
Single-Payer System
A NATIONAL HEALTH CARE SYSTEM?
In a single-payer system, the government is the sole funder of
Reform efforts have had little impact on costs and have proved health care. All citizens are covered, and private health insur-
unsuccessful at reaching underserved populations. The ANA ance is unnecessary. The monies to finance care come from tax
strongly advocated a national health care plan with universal revenues. Centralized control of costs and utilization of ser-
coverage, health insurance coverage for everyone (ANA, 1992, vices are elements of such systems. Fixed fees are assigned for all
2005). The ANA supported universal access to care with com- health care services. Administration can be either contained at
munity-based primary care, illness prevention, and health pro- the federal level or allocated to the states.
motion initiatives. In 1993, the United States seemed prepared
to implement some type of national health care, but vigor- All-Payer System
ous opposition derailed the attempt (Navarro, 2008). Despite An all-payer system is one in which health care is financed by a
this failure, the health care system has seen significant changes number of sources, public and private. A wide variety of pro-
in payment structure and health care delivery in both private posals fall into this category. Each has its own structure, but
and public sectors. Managed care organizations of every type some common elements exist. Although all citizens would be
have proliferated. covered, control would be more decentralized. Public financing
Although cost saving was a primary concern in 1993, qual- would be from tax revenues; private financing, through insur-
ity of care is now becoming a focus. The large number of unin- ance and out-of-pocket payments. Theoretically, there would be
sured is a major concern. Legislative and regulatory efforts are a minimum standard of service offered to all citizens, and pro-
aimed at protecting consumers’ rights and improving access for viders would be free to add more. Costs and utilization of ser-
selected populations. Incremental change, rather than dramatic vice would be less centralized and more difficult to manage. The
change, is the current policy. The remaining question is whether ANA takes the position that an all-payer system is the one most
further significant cost savings can be achieved under the pres- likely to work for U.S. health care reform.
ent circumstances (Feldstein, 2012; Geyman, 2008; Mechanic, No health care system is without problems. Each new pro-
2008). Economists believe that most of the cost savings asso- posal has advantages and disadvantages. As the country searches
ciated with shifting populations into managed care have been for an alternative delivery system, it is imperative to examine
realized. The current question is: Can managed care provide and debate all plans, including the current model. Criticisms of
care to all and still be profitable? Some believe managed care each should not be taken at face value but investigated for valid-
Â�organizations will self-destruct when they cease to demonstrate ity and relevance.
TABLEÂ€3-2â•…â•‡ NATIONAL HEALTH CARE SYSTEM PROPOSALS

INSURER COVERAGE FINANCE PAYMENT
Single-payer system Government Universal Combination of taxes Fees set by government
(e.g., income and sales)
All-payer system Mix of insurers, government, Universal, but there may Combination of taxes and Fees can be set by
and private organizations be some differences in private monies (e.g., government for all or only
type of care employer insurance and for special groups
out-of-pocket payments)
Universal Coverage and State Efforts Singh, & Tsai, 2010). These competing segments are concerned
In the absence of any federal action, many states moved toward about how change will affect their interests. Any change has its
universal coverage. Three states—Massachusetts, Vermont, critics. Among the most vocal are those who have a vested inter-
and Oregon—have mandated universal health coverage. Other est in maintaining the status quo. In health care, the providers
states have passed laws authorizing state government to inves- have a lot at stake. Any change will have an impact on practice,
tigate the costs of universal care, to increase insurance coverage and some could reduce profits. The goal of each provider group
for selected vulnerable populations, or to mandate employer- is to minimize impact on its area of special interest. For exam-
provided health insurance. Massachusetts, with the earliest ple, the AMA opposes legislation expanding the scope of prac-
effort, has expanded coverage to formerly uninsured portions tice for nurse practitioners and direct reimbursement for their
of the population while experiencing higher than expected costs services (Feldstein, 2012). To that end, groups might engage in
(Commonwealth Fund, 2008). The progress of the states toward efforts to advance proposals with little or no impact on their
universal health care has been hampered by current state budget own operations and defeat or drastically alter those with more
crises and uncertainty about the Affordable Care Act. Oregon stringent controls.
decided to go forward with its own plan, but other states have Perhaps because they have the most to lose, the biggest play-
held back on coverage expansions as they try to determine the ers in the debate over health care reform have been the drug
fiscal costs of meeting the new federal legislation mandates and insurance companies, the hospital industry, HMO orga-
(Commonwealth Fund, 2009). nizations, and Health Professional political action commit-
tees (PACs). Each works to advance favorable proposals and to
Universal Coverage and Federal Efforts: The Patient defeat plans that have an impact on its own independence or
Protection and Affordable Care Act, 2010 profit. Insurance companies are especially concerned about the
The Affordable Care Act, some of which is summarized in single-payer system, although some physician groups and hos-
BoxÂ€3-8, is an ambitious attempt to expand health insurance cov- pitals are also opposed to this system.
erage to the 32 million currently uninsured. It will also attempt to A consortium of physicians, called Physicians for a National
improve health care quality and services while managing health Health Plan (2011), support universal coverage. The American
care costs. Because it mandates states expand coverage to more Medical Student Association (AMSA, 2010) and the ANA are
citizens through the Medicaid program and health insurance actively working to promote universal health care. Nursing and
exchanges, the Affordable Care Act is opposed by some states. public health have traditionally been more active in supporting
Those states challenged the law in court and the law was upheld consumer rights and universal access to health care. The ANA
by the U.S. Supreme Court. Most states (37) have acted or are supported Medicare and Medicaid long before those in other
in the process of acting to establish health insurance exchanges, disciplines did. Both the ANA and the American Public Health
especially those states which have already established extended Association have been active in support of a national health care
coverage programs. (National Conference of State Legislatures system. However, because no profession is completely altruistic,
[NCSL], 2011). Since it is an evolving issue, the current status of nursing, too, is concerned about protecting its interests.
health care reform can be tracked on several websites listed in the Several strategies exist to influence the political decision-
Resources section at the end of this chapter. making process: one is to contribute funds to support the elec-
tion of sympathetic politicians in an effort to influence policy
Integrated Delivery Systems: The Present Reality and regulation of health care. The health industry contributed
With or without health reform, consolidation of health care approximately $55 million to 2010 federal candidates. Those
delivery services into larger and larger health networks will con- funds came from a few organizations, including the ANA. The
tinue. These voluntary mergers of health facilities and provid- ANA shares represented 0.11% of the total (TableÂ€3-3). Lobbying
ers create networks that reduce the provider options available is another way to advance an agenda and is not as easy to track
to consumers. Some of the networks are controlled directly as are campaign contributions. As the debate on national health
by third-party payers. Sultz and Young (2011) have noted that care continues, pay particular attention to news accounts of lob-
managed care organizations continue to merge into managed bying activity. Look for each organization's budget for lobbying
care conglomerates. Five managed care companies now serve activities, and scan newspapers and television for organization-
over 103 million persons (Atlantic Information Services, 2010). sponsored advertisements about health care plans.
Consolidation and expansion is continuing, and it is expected Influencing the President, any health-related task force, and
that in the near future, a single network will either dominate Congress is an accepted part of the political process. Nurses
or monopolize a geographic area and assume responsibility need to become more astute in evaluating the impact of per-
for the health status of the regional population (Kreitzer, 2007; sonal interests on any organization's position on specific deliv-
Shi, Singh, & Tsai, 2010; Sultz & Young, 2011). If that happens, ery plans and on the information about those plans they supply
regulatory oversight will become inevitable to protect con- to the general public. Nurses need to become very active in the
sumer interests. If change occurs as predicted, the final struc- political process and to make their voices heard in spite of the
ture will resemble the managed competition model proposed risk of being excluded.
by President Clinton's Health Task Force, complete with gov-
ernmental oversight. CHALLENGES FOR THE FUTURE
Vested Interests The health care system is in a state of turbulent change. Public
There is an inevitable tension between various interest groups, health practitioners have long advocated universal access to
for example, purchasers, consumers, practitioners, health plans, health care. Cost concerns point toward retrenchment in fund-
and shareholders of for-profit corporations (Navarro, 2008; Shi, ing and service. At the same time, the concept of health as a
TABLEÂ€3-3â•…â•‡CAMPAIGN CONTRIBUTIONS BY HEALTH CARE ORGANIZATION AND INDUSTRY

POLITICAL ACTION COMMITTEES FOR 2008 FEDERAL CAMPAIGN
GROUP CONTRIBUTION ($)
Pharmaceutical/health products 11,116,923
Health Care Profession Political Action Committees 26,356,343
American Medical Association 11,444,400
American Nurses Association 582,911
Hospitals/hospital systems/nursing home organizations 7,101,109
Health services/health maintenance organizations 5,935,210
Total data from the Federal Election Commission; compiled by the Center for Responsive Politics. Retrieved September 14, 2011 from http://www.
opensecrets.org/pacs/sector.php?txt=H&cycle=2010, and pacs/industy.php/txt=H01&cycle=2010.
right has gained popularity. The latter two issues have engen- structure is evolving to meet that expectation. Major changes
dered concern about what direction to take. Supporters of the to the Medicare program in 2003, the addition of more unin-
right to health care want expanded services. Supporters of fund- sured children to CHIP in subsequent years, and the efforts of
ing reduction seem devoted to service cuts. Change in either the Affordable Care Act have continued that evolution. A philo-
direction is vigorously opposed by the other group. We could sophic shift toward a more community-directed health promo-
be headed either toward inertia or a stalemate or toward a time tion focus and away from an illness-oriented focus, as directed
of collective community in which we tackle the problem with by the new Affordable Care Act, would make that goal more
creativity and drive. The challenge is to find a way to cut or viable. To provide a higher quality of care, competing interests
maintain cost levels and to simultaneously ensure a minimum need to form a coalition, rather than concentrate on protecting
standard of health care for the entire population. The current vested interests.
KEY IDEAS
1. The U.S. health care system is a fragmented, Â�noncentralized 7. The crisis in federal, state, and local government budgets
arrangement consisting of multiple public and private providers. has severely decreased the ability of states and local govern-
2. The cost of health care is paid for by a similar system of ments to deliver public health services adequately.
multiple sources. 8. Cost-containment strategies have been only marginally
3. Community/public health nurses need to know how the successful, slowing the rate of increase rather than reducing
health care system is structured as well as how it operates the cost of care.
because this has a significant impact on nursing practice 9. Cost-containment measures and recognition of the impor-
and determines who has access to services and what types tance of community health care will continue to increase
of services are available. the demand for community health services, including com-
4. Although the United States has the most advanced medical munity health nursing.
technology, qualified personnel, and abundant resources in 10. Health care is at a crossroads. Incremental change is the
the world, it does not lead in health status compared with current model. Many players influence the decision-Â�making
other developed countries, and on some specific indicators process. Vested interests are intent on tailoring change to
(e.g., infant mortality), it compares poorly. their advantage.
5. Acute care, rather than disease prevention or health promo- 11. To improve the health status of the country's entire pop-
tion, has been the major focus of the health care delivery ulation, any decision about the evolving structure of our
system in the United States. health care system must ensure a reasonable standard of
6. Recognition of the importance of disease prevention as an care for all citizens.
effective means of improving health status is growing.
1. Develop your vision of the ideal health care system. List system. Explore his or her concerns about health care:
some of the characteristics that constitute such a system. how needs are being met, expectations of how the illness
What would be the goal or goals of your ideal system? will affect life in the future, and ideas on what (if any-
2. Think about how you would go about implementing thing) should be changed about the current method of
your ideal system. Consider some of the problems you care delivery.
are likely to encounter. Identify individuals, groups, 4. Investigate current health-related issues in your commu-
and organizations with a vested interest in the present nity. Arrange an interview, in person or by phone, with a
system. How might you expect them to react to your legislator who represents your community in the state legis-
proposal? lature or with a staff member. Explore health-related issues,
3. From your current practice, identify a chronically ill indi- find out his or her position, and lobby for your position on
vidual and explore his or her thoughts on the present the issue or issues.
5. Discover which agencies in your state are responsible for the a. How would you start to locate information that might
public health of citizens. Is there centralized or Â�decentralized be helpful to your study? Determine if resources for pre-
management of state responsibilities? Determine some key natal care are available, accessible, acceptable, adequate,
indicators of health. Compare your state's indicators with and effective.
those of the surrounding states. How does your state fare? b. What other health issues could have an impact on your
6. You are a community/public health nurse in the public problem? Are the surrounding areas having similar
health department of Coty, a town of approximately 25,000 problems, or is your town unique?
population on the outskirts of a major metropolitan city. c. What about the local providers of care? What would
Your health department provides primary obstetric care to their concerns be with an intervention plan? If they are
certain prenatal populations. You notice that among your opposed, how might you structure your plans to reduce
clients, the infant mortality rate is higher than the national opposition?
average. The director of public health has authorized you to d. What types of issues would be essential in constructing
explore the problem and design a plan that will reduce the an evaluation plan? Can you anticipate potential barri-
infant mortality rate in your area. ers to an effective evaluation plan?

Following is a list of foundations involved in health care issues. Milbank Memorial Fund: Interested in health care and health
Information about each organization is found on its website. statistics. Visit http://www.milbank.org/.
Carnegie Corporation of New York: Interested in education, National Conference of State Legislatures: Provides informa-
including health education at http://carnegie.org/. tion on state legislative actions. Track state efforts at health
Commonwealth Fund: Interested in health care issues, includ- reform at http://www.ncsl.org/.
ing access, insurance, and other policy concerns. Track infor- Robert Wood Johnson Foundation: Interested in ambulatory
mation on health reform at their Health Reform Resource care and health personnel. Visit http://www.rwjf.org/.
Center at http://www.commonwealthfund.org/. Rockefeller Foundation: Interested in health issues. Visit http://
Kaiser Family Foundation: Interested in health care issues, www.rockefellerfoundation.org/.
including access, insurance, and other policy concerns. You W. K. Kellogg Foundation: Interested in health delivery and
can track the progress of the Affordable Care Act at http:// education. Visit http://www.wkkf.org/.
www.kff.org/.
WEBSITE

• NCLEX Review Questions 3A: Federal Health Planning Efforts
• Care Plans
• Glossary
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CHAPTER
4
Financing of Health Care: Context for
Frances A. Maurer
FOCUS QUESTIONS
What sources provide funding for health care in the United States? What methods have been used to attempt cost containment
What has been the general pattern of expenditures for health care? in health care?
Are some groups at greater risk for diminished or no access to Has cost containment affected services? If so, in
health care services? what ways?
How have Medicare and Medicaid affected health care delivery How can nurses influence the costs and delivery of health
to the populations they serve? care services?
CHAPTER OUTLINES
Relevance of Health Care Financing to Community/Public Medicare
Health Nursing Practice Medicaid
Relative Magnitude of Health Spending in the United Trends in Reimbursement
States Prospective and Retrospective Reimbursement: Who Wins?
Private- and Public-Sector Shares of Health Expenses Managed Care, National Managed Care Companies, and
Priorities in Health Care Expenditures Integrated Health Systems
Cost Increases Affect the Entire Economy: You and Me Rationing of Health Care
Reasons for the Increase in Health Care Costs Impact of Malpractice Insurance and Defensive Medicine
Groups at Risk for Increased Costs and Fewer Services on Providers and Consumers
Health Care Financing Mechanisms Expanded Insurance Coverage and Effects of Health Care Reform
Self-Payment Reimbursement for Community/Public Health Nursing Services
Health Insurance The Nurse's Role in Health Care Financing
Insurance Portability Referring Clients for Benefits and Services
Health Care Assistance Advocating for Clients in Appeal Processes
Lack of Health Insurance Identifying Alternative Sources of Payment
Underinsurance and Associated Financial Risk Providing Documentation to Ensure Reimbursement
Level of Health Related to Medical Insurance Collecting Data to Evaluate the Impact of Reimbursement
Uninsured Children: A Special Concern (CHIP Program) Mechanisms
Publicly Funded Programs for Health Care Services Lobbying for Legislative and Administrative Changes
KEY TERMS
Centers for Medicare and Medicaid Free market economy Private insurance
Services (CMS) Gross domestic product (GDP) Prospective payment
Children's Health Insurance Program Health maintenance organizations (HMOs) Retrospective payment
(CHIP) Medicaid Risk groups
Consumer-directed high-deductible Medicare Self-insurance
health plans (HDHPs) Medicare Advantage Temporary Assistance for Needy
Co-payments Medicare + Choice Families (TANF)
Deductibles Patient Protection and Affordable Third-party payment
Diagnosis-related group (DRG) CareÂ€Act Uninsured
system Premium Universal coverage
86
CHAPTER 4â•… Financing of Health Care: Context for Community/Public Health Nursing 87
Today's nurses need to have a clear understanding of the finance related to the Â�specific medical condition for which the visits
mechanisms of the health care system in the United States. In are made. If, while on a home visit, a community health nurse
the past, such topics were not considered relevant to the prac- Â�discovers that other household members need or would ben-
tice of nursing and were also considered irrelevant to the plan- efit from Â�nursing care, these members might not be covered
ning and distribution of good nursing care. The expectation by the insurance Â�company, or, if they are covered, treatment of
was that people should be provided with the best and most the problem identified might not be considered a reimbursable
appropriate nursing care and medical treatments Â�regardless of service by the payer.
their ability to pay. Why should community health nurses care whether the
Although universal access to care is admirable, it has never needed services are paid for? Why not just provide the Â�service
been a reality in this country. Only time will tell if the new while in the home? Although occasionally this solution is
Patient Protection and Affordable Care Act of 2010 (Affordable Â�possible, more often, time constraints will not allow the nurse
Care Act) can achieve the goal of universal health care. Debate to do this. The nurse's employing agency is reimbursed only for
rages about potential rationing of health care, but health care is specific services provided to patients. Therefore, the agency will
already rationed by people's ability to pay. A person's financial set a nurse's patient load for the day on the basis of a Â�reasonable
status affects the quality and quantity of care she or he receives. time to perform those designated services. Nurses who Â�routinely
Current events have served to highlight that problem to health provide additional services to patients or care for other house-
care providers, the public at large, and individual consum- hold members might fall behind in the agency's caseload
ers. The new Affordable Care Act attempts to address many of Â�expectation. Nurses may not be covered in case of a malpractice
the issues presented in this chapter. Where it is relevant, that claim because the additional service was not first sanctioned
Â�information will be presented in ITALICS to highlight present, by the agency. Therefore, the community health nurse faces a
ongoing or expected changes. dilemma: how to reconcile the ideals of good Â�nursing care with
the Â�realities dictated by circumstances, the nurse's employer,
RELEVANCE OF HEALTH CARE FINANCING and the financial reimbursement system.
TOÂ€COMMUNITY/PUBLIC HEALTH
NURSINGÂ€PRACTICE RELATIVE MAGNITUDE OF HEALTH SPENDING
INÂ€THE UNITED STATES
Why is the financing of health care services important to the
community health nurse? Why not just continue providing Since 1965, national expenditures on health care have risen
appropriate care to a caseload or community and leave others steadily and are a serious concern. Yearly costs have risen from
to worry about financial costs and how to meet them? For one $12.7 billion in 1950 to $2.48 trillion in 2009 (Figure 4-1). Of
thing, nurses will find that nursing practice, to some extent, is even greater concern than escalating costs is the increase in
shaped by those financial constructs. If a community health health care expenditure as a portion of the national budget. The
nurse is providing home visits to a client newly diagnosed with share of health care costs in the gross domestic product (GDP)
diabetes, the number of home visits allowed is limited by the continues to increase in comparison with other Â�expenditures.
government agency or private insurance company that finances The GDP is a monetary measure of the production of a Â�country.
the visits. A nurse assigned to provide skilled nursing care in Health care currently outstrips the combined costs of both
the home to an individual (e.g., dressing changes) might find defense and education (Figure 4-2).
that the person requires other services such as nutritional The increase in the proportion of the GDP (17.6%) devoted
health teaching or medication monitoring. These services to health care means that individuals and families spend more
might not be covered by the payer, especially if they are not on health care and have less to spend on food, clothing, housing,
25 47000
Percentage of Gross Domestic Product
3500
20
3000
Billions of Dollars
15 2500
2000
10
1500
1000
5
500
0 0
A 1950 1960 1965* 1970 1980 1990 2000 2009 2020 B 1950 1960 1965* 1970 1980 1990 2000 2009 2020
*Medicare and Medicaid programs begin Projected costs

FIGUREÂ€4-1â•‡ Health care costs for selected years, 1950-2020. (Data from Centers for Medicare and
Medicaid Services, Office of the Actuary, and Office of National Estimates.)
88 CHAPTER 4â•… Financing of Health Care: Context for Community/Public Health Nursing
20
All health expenditures
Percentage of GDP (1950-2009)

15
Defense expenditures
10
Public education expenditures
0
1950 1955 1960 1965 1970 1980 1990 2000 2009*
*Education figure is 2008 data.
FIGUREÂ€4-2â•‡Health, education, and defense spending. GDP, Gross domestic product. (Data
from Augenblick, J. [2001]. The status of school financing today. Denver: Educational Commission of the
States; and Garamone, J. Historical context important when considering Â�budget requests. Retrieved April 2,
2008 from http://www.defenselink.mil/news/newsarticle.aspx?id=2966; U.S. Bureau of the Census. [2012].
Statistical abstract of the United States 2012: The national data book. TableÂ€503: National defense outlays
and veterans Â�benefits: 1960 to 2012. Washington, DC: U.S. Census Bureau; National Center for Educational
Statistics. [2011]. Gross Â�domestic product (GDP) in elementary and secondary schools as a percentage of
GDP 1969-70 to 2007-2008. Retrieved October 19, 2011 from http://nces.gov/edfin/tables/Â�t ab_gdp.asp; and
Centers for Medicare and Medicaid Services [2011]. National health expenditures Â�summary and GDP:
Calendar years 2009 to 1960. Retrieved October 19, 2011 from http://www.cms.gov/nationalhealthexpendi-
turesdata/02_nationalhealthaccounts.historical.asp.)
education, leisure, and other needs or interests. The personal 1970, the federal share had doubled. Since the change to block
cost of health care—what each American spends on health care grants, the federal share has been reduced and in 2009, the
services and products such as insurance premiums, medica- Â�federal government paid approximately 62.6% of Â�public-sector
tions, and physician and hospital services—has doubled every costs, while state and local governments paid 37.4% (U.S.
decade. The average yearly cost for every American was $8086 Census Bureau, 2012h).
in 2009 (Centers for Medicare and Medicaid Services [CMS], In 1965, the private sector accounted for 74% of all health
2011e). By the year 2020, it is estimated that health care costs care expenses. By 1975, after Medicare and Medicaid were well
will average $13,708.80 per year for each person in the country established, the private-sector share dropped to 57.5%. Today,
(CMS, 2011g). the private-sector share of expenditure is 51.4%. The pattern of
health expenditure is a reflection of age and social risk factors.
Private- and Public-Sector Shares of Health Expenses Health care services provided to risk groups cost more than care
Governments at all levels provided 48.6% of the total health provided to more healthy individuals. Risk groups are groups
care costs in 2009 (Figure 4-3). Two large programs, Medicare with a likelihood of accidents or illness because of low income
and Medicaid, account for 35.2% of the country's entire health or inability to easily access health care services. As social health
expenses (U.S. Census Bureau, 2012g). In 1965, before Medicare programs make access and care available to these risk groups
and Medicaid, the federal share of health care expenses was (e.g., older adults and the economically disadvantaged), these
roughly equal to the combined state and local contributions. By expenses escalate.
80
Priorities in Health Care Expenditures
By far, the largest amount of money is spent on personal health
Private
60 care and very little on public health. In Figure 4-4, expendi-
tures for 2009 are broken down by type and source of funding.
Percentage
40 Personal health care services accounted for all but 16% of the
Public entire health budget (U.S. Census Bureau, 2012g). Hospital care
20 is the most costly category, and physicians' and clinical services
are the second highest cost area.
0 Public health, research, and construction together account
1950 1970 1980 1990 2000 2009 for a mere 9% of the entire budget. Public health activities are
Selected Years subsidized wholly by the public sector. State and local govern-
FIGUREÂ€4-3â•‡ Public and private shares of health care costs. (Data ments bear the major costs of providing these services. Public
from Centers for Medicare and Medicaid Services.) health's share of funding has remained relatively stable since
Government administration and

net cost of health insurance (7%)
Other* (14%)
Hospital care (31%)
Nursing care facilities and

continuity care retirement
communities (6%)
Dental and other

professional services (7%)
Investments (6%)
(Includes research,
structures, and equipment)
Prescription drugs (10%)
Physician and
clinical services (20%)
*Includes public health spending,

other health/residential/personal
care, home health care, other
medical products
FIGUREÂ€4-4â•‡ Where U.S. health care dollars were spent in 2009. (Data from Centers for Medicare and
Medicaid Services, Office of the Actuary, National Health Statistics Group. TableÂ€1: National health expendi-
tures by type of expenditure and program: Calendar year 2009. Retrieved October 3, 2011 from http://www.
cms.hhs.gov/nationalhealthexpend/data/downloads/PieChartsSourcesExpenditure2009.pdf.)
the early 1970s. Government, especially the federal government, a significant role in cost increases. Between 1950 and 1990, there
bears the major responsibility for research. Most of these funds were several periods of heavy inflation. The net effect was a
are used or distributed by the National Institutes of Health. Â�dramatic increase in the cost of basic goods and services such as
The private-sector invests much of the construction funds for food, fuel, electricity, telephone, construction, labor, and insur-
Â�building projects. ance. As inflation increases prices, the health care industry's
costs for these goods and services are also increased, and these
Cost Increases Affect the Entire Economy: You and Me higher expenses are passed on to the consumer. Inflation helps
Health care expenditures are particularly significant in the explain increases in the overall monetary expenditure for health
Â�economy because they are very extensive. As health care expands care but does little to explain health care expenditure increases
its share of the country's GDP, other industries lose ground. in the share of the GDP. These are more closely related to other
For example, for every 1% increase in GDP of health care, factors:
there is a corresponding 1% loss in revenues to other indus- • Growth in the number of older adults in the population
tries. Eventually, everyone is affected by increases in health care • Use of advanced technology
costs. Government agencies must pay for increases in Â�services • Growth of specialties in medical care
that they are pledged to provide. Government expenses are • Reimbursement mechanisms and administrative costs
Â�ultimately the responsibility of the taxpayer. As federal and • Burden of uninsured and underinsured populations
state health care costs have escalated, the increased expense has Increased demand for services is primarily the result of
been passed on to individual taxpayers via income tax and other federal programs (Medicare and Medicaid) and an aging
Â�
taxes. Insurance companies pass on increases in expenses to Â�population. Before these programs were instituted, cost was
Â�employers. Employers, in turn, usually pass on the extra costs a rationing factor for the poor and older adults who were in
to their employees by increasing the employees' share of health need of health care. Medicare and Medicaid reduced the access
insurance contributions. Those without health insurance pay Â�barrier and created a greater demand for health care among
out of pocket, which refers to personal and direct payment for groups for which it was previously restricted. At the same time,
health care. No one escapes the consequences of increases in the the growth of the older adult population created an additional
cost of health care services. demand for services. Even without Medicare, the number of
older adults requiring health care services has grown, and, as
REASONS FOR THE INCREASE IN HEALTH more and more baby boomers reach old age, the need for health
CAREÂ€COSTS care services is expected to increase even more. By the year 2030,
older adults are expected to represent 20% of this country's
There are three basic factors responsible for the escalating costs population. In comparison, in 2010, 13% of the population, or
of health care. The first is inflation. As a generic factor, inflation 40.3 million persons, were 65â•›years of age or older (U.S. Census
affects the costs of all types of goods and services and has played Bureau, 2012j).
Technological advances in medicine have been enormous care in a timely manner for acute and chronic conditions and
and expensive. Development costs of new procedures, drugs, forgo or delay preventive care. The result of these behaviors is
and equipment are high, and new technologies generally increased severity of illnesses, more complications of illnesses,
require more skilled technicians and professional operators. and greater use of emergency rooms (Institute of Medicine
Advances in medical treatment have also created an increased [IOM], 2007; U.S. Department of Health and Human Services
demand for services because refinements frequently increase [USDHHS], 2011), actions that increase the eventual cost of
the number of patients who can be successfully treated. Sultz treatment. ChapterÂ€21 provides a more detailed discussion
and Young (2011) substantiated the impact of new technology of the impact of poverty and lack of health insurance on the
on rising health care costs. They suggested that better planning health status of individuals.
could reduce some of these costs and rescue utilization. More
Â�stringent research is needed to determine whether higher-cost HEALTH CARE FINANCING MECHANISMS
technologies are more beneficial and cost effective. Ginsburg
(2011) contends that technology's impact on cost is a mixed Currently, health care financing in the United States is very
bag. Some procedures cost more, whereas others reduce costs complex. Services are paid for by a variety of sources and meth-
over time. For example, computed tomography (CT) scans cost ods rather than by a single funding source (Figure 4-5). Health
more compared with radiographs, but they have reduced the insurance is a voluntary arrangement developed and Â�managed
need for exploratory surgery. by commercial insurance companies, Blue Cross and Blue
Shield, and managed care organizations. Employers provide
GROUPS AT RISK FOR INCREASED COSTS insurance for many of their workers. Health care for the poor
ANDÂ€FEWER SERVICES is provided for by local, state, and federal funding, primarily
through Medicaid. State and local health departments provide
To further complicate matters, as health care costs have some direct services, most of them concentrated in the area of
Â�escalated, government and private industries have made efforts preventive health services (well-baby clinics, family planning,
to contain expenditures. These efforts have resulted in actions immunizations). Senior citizens are usually covered under the
that have either limited access to health care or have reduced Medicare program, and some might also have additional insur-
available services to certain segments of the population. Three ance to supplement Medicare coverage. The federal government
specific groups have been particularly hard hit by escalating provides directly funded care to a variety of groups, including
costs and reductions in services: Older adults, children from military personnel and their families, armed services veterans,
low-income groups, and a growing population of medically and American Indians. Individuals might also pay for health
indigent individuals. The medically indigent are those who do care services directly.
not have health insurance coverage, do not qualify for govern- Insurance and government-funded programs are examples
ment health care assistance, and are unable to pay health care of third-party payment, in which a third party (i.e., someone
costs on their own. other than the recipient of care) directly pays for all or part of
In 2010, 46% of the aged were 75â•›years or older (U.S. Census the health care services provided. The third party might be a
Bureau, 2012j). Older adults, especially those who are frail, are private insurance company or government. Frequently, the
at increased risk for disability, chronic disease, and need for Â�client has no idea of the exact costs of the services provided and
expanded health care services. As discussed later in this chapter, sometimes never sees the bills.
the services they receive under Medicare are limited and require
co-payments. Self-Payment
Children in low-income families are another risk group. The Self-payment, or self-insurance, is a method by which a per-
percentage of children below the poverty level rose from 17.9% son or a family essentially assumes the financial cost of all
in 1980 to a high of 22% by 1993 (Lewit etÂ€al., 1997; U.S. Census medical services. This was the most common method of pur-
Bureau, 2002). During that same time, the social Â�service and chasing services before the 1930s. Currently, however, it is the
health care assistance programs designed to assist them were, in least Â�common method of payment, primarily because individu-
many instances, cut back. By 1993, a growing economy increased als are extremely wary of the financial burden posed by chronic
employment opportunities, and the state Children's Health
Insurance Program (CHIP) contributed to increased access to
health insurance and a decline in the number of children from Employers Individuals
low-income families. Currently, one of every five children (14.8
million) in the United States lives in poverty and one of every 10
children is uninsured (DeNavas-Walt, Proctor, & Smith, 2011;
U.S. Census Bureau, 2012a, 2012b). State govt. Private insurance
In 2010, approximately 50.4 million persons were medically
Federal govt.
indigent (DeNavas-Walt, Proctor, & Smith, 2011). Those in
this group are uninsured, with no health insurance, including
Local govt.
Â�government-sponsored medical insurance. They are the “work-
ing poor.” Their income makes them ineligible for government
assistance but is not sufficient for them to purchase their own
health care services or insurance. Health care goods and services Philanthropy
The uninsured and underinsured contribute to escalat-
ing health care costs because those individuals delay seeking FIGUREÂ€4-5â•‡ Funding sources for health care goods and services.
Medicare
Out-of-pocket ($502.3 billion)
TABLEÂ€4-1â•…â•‡TYPES OF INSURANCE
($299.3 billion) COVERAGE FOR INDIVIDUALS
ENROLLED (n)
12.2% TYPE MILLIONS %
20.2% Employment-based 169.2 55.3
Medicare 44.3 14.5
Medicaid 48.6 15.9
Medicaid
($373.9 billion) 15% Military* 12.8 4.2
Individual 30.1 9.8
Uninsured 49.9 16.3
*Includes TRICARE and CHAMPVA.
5.1% 32.2% Data from U.S. Bureau of the Census. (2010). Income, poverty, and
Other government
programs health insurance coverage in the United States: 2010. Current Population
3.5% Reports Â�P60-239. Washington, DC: U.S. Department of Commerce,
($126.8 billion)
Economics and Statistics Administration.
Other private ($88.4 billion) Private health 80

insurance
($801.2 billion) 70
FIGUREÂ€4-6â•‡ Funding sources for health care (2009) in billions of
60
dollars (total = $2.486 trillion). May not total to correct amount
due to rounding and selected reporting by the Centers for 50
Percentage
Medicare and Medicaid Services (CMS). The category “Other
private” includes industrial health services, nonpatient reve- 40
nues, and privately financed construction. (Data from Centers for 30
Medicare and Medicaid Services, Office of the Actuary, National Health
Statistics Group.) 20
10
or catastrophic illnesses. Today, self-payment costs are usually 0
Â�co-payments (a consumer share of the cost for a particular 1988 2000 2005 2011
Â�service) and deductibles (the amount a consumer must pay up FIGUREÂ€4-7â•‡ Percentages of employees with Â�employer-sponsored
front before insurance assumes any cost for services). Additional health insurance for selected years. (Data from Kaiser/HRET. [2007;
out-of-pocket costs are for services not provided by insurance 2011]. Employer Health Benefits Survey. Menlo Park, CA: Kaiser Family
Foundation.)
plans. Private out-of-pocket costs make up 12% of the total
Â�expenditures for health care (Figure 4-6). The Â�percentage of
self-payment expenditures have doubled since 1996 as managed Employers' costs of insurance have risen over the years as
care and other insurance providers increase the Â�co-payments Â� remium costs have increased. Employers paid on average $1767
p
and deductibles required by their policies. in premiums for a single employee in 1981 and $5429 in 2011
(Kaiser/HRET, 2011). Premiums increased 43% between 2007
Health Insurance and 2011. Rising costs have forced employers to reexamine the
Health insurance gradually replaced self-payment. Since 1970, cost of offering health insurance benefits. Hefty Â�insurance costs
it has been the most common means of paying medical costs. are directly related to decreases in the number of employer-
Private health insurance premiums and health Â� insurance offered plans during the same period.
Â�payments for health services accounted for $801.2 billion in Cost-containment strategies are becoming routine in
2009, or 32.2% of the total health care budget for that year employer-provided group health insurance plans as Â�employers
(CMS, 2011f). costs continue to escalate. General Motors (GM), for Â�example,
had $5.3 billion in health care costs in 2005 (Pennsylvania
Employer-Provided Health Insurance Department of Health, 2008). The Centers for Medicare and
The most common form of health insurance is Â�employer-provided Medicaid Services (CMS), the federal agency in charge of the two
insurance, in which employees and their families are covered programs in its name, reports that employer Â�cost-containment
through employers (TableÂ€4-1). Usually, the employer pays strategies include reimbursement for generic-only Â�prescriptions;
some or all of the cost of insurance for workers. Employer- increasing reliance on second Â�opinions for surgery; Â�provisions
provided health insurance is an expected (but not Â�universal) for preadmission testing to eliminate the greater costs incurred
benefit for employees. This type of coverage appears to be for these hospitalization services; and increased Â� reliance
Â�eroding (Figure 4-7). By 2011, more than 41% of workers on Â� outpatient surgery. Health maintenance organizations
were not covered (Kaiser/Health Research and Education Trust (HMOs), the most tightly Â� controlled health insurance and
[HRET], 2011). Employees of small companies are less likely to Â�service providers, and other managed care plans (preferred
have Â�employer-sponsored health insurance. Only 48% of firms provider organizations [PPOs], and point-of-service plans)
with nine or fewer employees offer health insurance plans, are offered to employees as an alternative or exclusive health
whereas almost all companies with 100 or more employees do plan. By 2011, almost 97% of employees in Â�employer-sponsored
so (Kaiser/HRET, 2011). plans were in managed care (Kaiser/HRET, 2011).
Recently, employers have started to offer consumer- health care. The average annual premium for an employee with
directed high-deductible health plans (HDHPs) as a means family coverage is $4129; deductibles average another $1521 for
to control their health insurance costs. These plans are called PPOs and $627 for hospital costs (Kaiser/HRET, 2011).
consumer directed plans because the health care consumer The current political debate centers on whether health
decides how to use the money in the account. There are two insurance coverage should be mandated for all firms with
Â�
types of HDHPs. One type is an HDHP with a health reimburse- employees. Most small business leaders are opposed to
ment option in which employees pay a high initial deductible employer-mandated health insurance, claiming the net effect
and the employee is reimbursed for portions of the health care would be a loss of jobs, increasing costs to consumers, and some
costs in excess of the deductible by a health insurance plan usually business Â�failures. Proponents argue that it is sound Â�business
provided by the employer. The second type of HDHP plan is a practice to provide coverage because it will attract a more stable
Â�
health Â�savings account. In this plan, an employer usually pays a workforce. There have been some moves in the direction of
certain amount into a health account, and the employee has the employer-mandated health insurance for workers, and several
option of Â�adding more. The employee usually picks the insurance states have passed Â�legislation requiring such benefits (Davis
plan or opts just to pay for health care costs from the health & Schoen, 2003; Krisberg, 2007). Massachusetts, for example,
savings account. has enacted expanded coverage for all citizens. Employers have
In HDHPs, the employee's deductible costs range from $1100 the option of providing health insurance or paying into a state
to $5800 per single employee and as much as $2300 to $11,600 insurance pool (Lee, 2007). Pennsylvania, California, Oregon,
for family coverage (Nathan, 2009). HDHPs are best suited for and Vermont have enacted similar plans (Health Care Financing
young healthy individuals and their families. Many employees, and Organization, 2007; Krisberg, 2007). The new Affordable
however, do not have an option because that may be the sole Care Act will require employers to provide health insurance to
plan offered by the employer. HDHPs accounted for 23% of employees or pay a fee to help finance subsidies for those Â�without
employer offered health plans in 2011 and their Â�popularity with access to affordable care. These fees will then be used to offset
employers is growing (Kaiser/HRET, 2011). the cost of coverage for persons who must purchase their health
Employers have also become more involved in their Â�benefits insurance privately through the state medical health insurance
programs, increasing self-funding of health benefits, using exchanges (Kaiser Family Foundation [KFF], 2009).
Â�noninsurance program administrators to monitor costs, and
requiring employees to shoulder more of the cost of health Other Health Insurance Options
insurance. Some employers have eliminated family Â�coverage There are several non–employer-related methods of purchasing
or have made the employee premiums so high that lower-wage health insurance. Medicare is a government insurance program
Â�employees Â�cannot afford family coverage. On average, Â�employees designed primarily for use by older Americans. Medicare will
are required to pay 18% of the premium cost for Â�individuals be addressed later in this chapter. In addition, individuals can
and 28% of the premium cost for a family plan (Figure 4-8). Â�purchase health insurance on their own.
The employee share of health premiums and cost sharing
(deductibles and per-episode costs) has increased as employers Privately Purchased Health Insurance
have reduced their contributions to health plans. This action by Approximately 9.8 million individuals have private insurance
employers places additional families at risk for poor access to and purchase their own health insurance (DeNavas-Walt etÂ€al.,
2011). Private purchase individuals do not have access to a
sponsored insurance program. They are more likely to purchase
11000
private health insurance if their income is adequate and they are
10000 regularly employed.
Most uninsured families have low incomes (Figure 4-9). For
9000 these families, cost is a deterrent to seeking health care. Unlike
with employer-provided health insurance, the premium cost
8000 (the price charged by the insurance carrier) is paid totally by
10,944
7000
the individual. Where not regulated by state laws, premiums for
an individual cost $5000 or more (Congressional Budget Office
6000 [CBO], 2008). Family coverage costs even more. For individ-
Dollars
uals from low-income and marginally middle-income groups,

5000 these premium costs are unaffordable. For example, Collins and
colleagues (2008) reported that 43% of people whose income
4000
was 200% or less of poverty level found it very difficult to find
3000 affordable health insurance.
4508 Compared with group insurers, private health insurers can
2000 4129 more easily discriminate on the basis of the characteristics of an
Employer
individual. Insurers charge higher premiums for persons Â�living
1000
in urban environments, smokers, older persons, and females
921 Employee
0 (compared with males in the same age group) and for those
Individual plan Family plan with preexisting conditions. Unless state laws prohibit it, insur-
FIGUREÂ€4-8â•‡ Average annual costs of employee/employer Â�premiums, ers can deny insurance coverage to individual applicants. Denial
2011. (Data from Kaiser/HRET. [2011]. Employee Health Benefits Survey, rates average approximately 33% of applicants in states with
2011. Menlo Park, CA: Kaiser Family Foundation.) no guaranteed coverage guidelines. In response to insurance
120 or allow medical savings accounts or tax-exempt premiums for

other groups such as the unemployed or the employed with no
100 employer health insurance plan.
8%
21.8% 15.4% Rutgers (2011) reported that the health portability act has
26.9%
reduced insurance providers' use of preexisting conditions to
Percent of Population
80
deny coverage. The act does not limit the amount an insurer
can charge. Substantial premium costs have undercut the intent
60 of the portability act. Many individuals simply cannot afford to
92% purchase coverage (Patel & Rushefsky, 2006).
84.6%
40 78.2%
73.1% Health Care Assistance
20 Health care is funded in a number of ways for people who can-
not afford to pay for services and do not have health insurance.
Health care assistance is another third-party payment mecha-
0
< $24,999 $25,000 - 49,999 $50,000 - 74,999 $75,000 or > nism in which payment is provided by a government program
Uninsured
(either federal or state) or private charity. The most famil-
Insured iar program of this type is Medicaid, which provides service
to approximately 47.4 million persons at a cost of $373.9 bil-
FIGUREÂ€4-9â•‡ Insurance status by household income. (Data from
DeNavas-Walt, C., Proctor, B. D., & Smith, J.C. [2011]. Income, poverty,
lion, or 15% of the entire health care budget (CMS, 2011f; U.S.
and health insurance coverage in the United States: 2010. U.S. Census Census Bureau, 2012d). Details of this program are discussed
Bureau, Current Populations Reports, P60-239. Washington, DC: U.S. later in the chapter. Both state and local health departments
Department of Commerce, Economics and Statistics Administration, provide a variety of health services. Most of these services are
U.S. Bureau of the Census.) aimed at poor populations, and most are prevention oriented,
although some direct services to ill persons might be available.
Funds to support these services are a mix of federal, state, and
Â�
selection practices, and in an effort to make privately purchased local monies (see ChapterÂ€29).
health coverage feasible for more individuals, approximately Private charity provides a variety of services to the needy.
half of the states have attempted reforms. These efforts include Nonprofit organizations usually target special health care needs
the following: or special risk groups. Philanthropic gifts to hospitals assist
• High-risk insurance pools for otherwise uninsurable individuals with payments for persons without insurance, and many health
• Establishment of an insurer of last resort, usually Blue Cross care providers offer some free care. Spontaneous fundraisers
or Blue Shield meet expensive special needs such as liver or heart transplanta-
• Guaranteed issuance of insurance to all who apply tion for certain individuals. It is difficult to quantify the actual
• Guaranteed renewal of insurance to all dollars provided by charitable organizations and events for
• Limits on deniability due to preexisting conditions direct health care services to individuals. Philanthropic activi-
• Premiums rating restrictions ties accounted for 0.8% of the total health budget in 2010, or
All states now operate high-risk pools for persons who approximately $19.8 billion (Giving USA, 2011). That amount
must self-insure due to the Pre-Existing Insurance Plan Â�created includes both direct care to individuals and contributions to
by the Affordable Care Act (Anderson, 2011). Risk pools are research and facilities development. It is safe to say that chari-
Â�temporary through 2014 when consumers will have access to table contributions make up a minuscule portion of the health
health Â� coverage through insurance exchanges. The Affordable care budget.
Care Act Â�lowers Â�premiums by 40% in 18 states where the high risk
pool is administered by the federal government. It bans Â�insurers Lack of Health Insurance
from Â� discriminating against persons with preexisting medical More than 50.4 million persons are not covered by health insur-
Â�conditions. Some states had risk pools and mandated premium ance or assistance of any kind and are unable to pay for health
restrictions prior to the Affordable Care Act. In the past, if an care services on their own (DeNavas-Walt etÂ€al., 2011). Others
insurance carrier decided a state's requirements caused too are without health insurance at some time or other during a
great an expense, it could choose not to operate in that state. calendar year. Most of the uninsured are “the working poor”—
In addition, a portion of the bill which takes effect in 2014 will workers attempting to provide a living for themselves and
Â�prohibit higher insurance rates for preexisting conditions. their dependents at low-paying jobs with few benefits. They
and their dependents make up an estimated 80% of the med-
Insurance Portability ically indigent (Hoffman, 2012). In 2010, 28 million workers
The Health Insurance Portability and Accountability Act were uninsured, most of whom (78%) were full-time workers
(HIPAA) passed by the federal government in 1996 has made (DeNavas-Walt etÂ€al., 2011). The remainder of the uninsured
limited efforts to improve access to health insurance for are individuals who are currently unemployed or uninsurable
Â�individuals. The law guarantees access to private insurance and others who fall outside the eligibility requirements for
for individuals who have just left a qualified group insurance Medicare or Medicaid (e.g., some of the homeless, some older
plan, requires the renewal of insurance coverage, and authorizes adults, and children).
Â�federally tax exempt medical savings accounts that can be used Many of the uninsured work in a service industry such as
to pay health insurance premiums for self-employed individuals. food or janitorial service. Those jobs require few skills and
These federal reforms did not address affordability of premiums Â�little education, offer fewer benefits, and are generally low
paying. Service-type jobs are increasing, which places more Â�

preventive Â�services Â�create or exacerbate health problems that
workers at risk. By 2010, there were 19.2 million service jobs persist Â�throughout life. Treatment of the chronic conditions
(U.S. Census Bureau, 2012i). Most of those employed in that result is far more costly than the services that could have
Â�service positions receive no health insurance benefits. When prevented such problems.
the uninsured need health care, they are limited in their The number of uninsured children has declined since
options. They must pay at the time of service or find a health the Children's Health Insurance Program (CHIP) was
care provider who is willing to defer payment. Many delay Â�established in 1997. The CHIP expands health insurance
seeking care, hoping their health conditions will improve on Â�coverage to uninsured children from low-income groups, who
their own. are not already covered by other types of assistance Â�programs
such as Medicaid. It is funded by federal grants to partici-
Underinsurance and Associated Financial Risk pating states, which design and administer the program. In
In addition to those with no medical insurance, there are 2009, the cost of the program was 11.1 billion dollars (CMS,
millions who are underinsured. These individuals have
Â� 2011f). Before 1997, approximately 25% of children were
Â�insurance plans that require large out-of-pocket expenses or not covered by any insurance program, including Medicaid.
limit Â�coverage of catastrophic illnesses. Workers who change Since the Â�inception of the CHIP, the Â�percentage of children
jobs and cannot afford insurance under the portability act are Â�without health Â�benefits has declined to 9.8% (DeNavas-Walt
at risk. Medicare enrollees are at risk because Medicare pays etÂ€al., 2011).
for less than 50% of their total health care costs. The number Problems with the CHIP program has included the
of underinsured is Â�difficult to measure. Estimates vary. Some Â�variability in income standards for eligible families and also
estimates indicate that 26% to 34% are underinsured. Those Â�variability in available health care services in the various states.
who are Â�underinsured risk less access to health care and poorer The Affordable Care Act will set standard criteria for services and
health because of their insurance status (Patel & Rushefsky, eligibility as Â�discussed in the Medicaid section later in this chap-
2006; IOM, 2007). Hoffman (2012) reported that the under- ter. For Â�additional information on the CHIP, see ChaptersÂ€21
insured are at financial risk in a crisis and that over half the and 27.
Â�bankruptcies in this Â�country are associated with medical bills or
debts or health problems. PUBLICLY FUNDED PROGRAMS FOR HEALTH
Level of Health Related to Medical Insurance CAREÂ€SERVICES
The medically indigent (uninsured) have greater health risks Medicare and Medicaid are the two programs that provide
(Geyman, 2008; Hoffman, 2012; Inglehart, 2002). These fami- a major portion of health care services to populations that
lies have a harder time acquiring the basic necessities of food, have been identified as having greater need (older adults)
clothing, shelter, and transportation, and their medical needs or having fewer resources (poor families) than the majority.
force them to make hard choices about exactly what services Specific costs and benefits change periodically. Rather than
they can afford. Studies show that the uninsured include a concentrating on current benefits, this discussion focuses on
larger Â�number of people in fair-to-poor health, with a greater exploring each Â�program's basic purpose, evolution, and ben-
incidence of chronic illness and early death (IOM, 2007). They eficiaries. A brief comparison of covered and excluded ser-
are less likely to seek care early, make fewer visits to physicians, vices for each program is given, and examples and costs are
and are less likely to be hospitalized than are insured indi- used to illustrate points under discussion. This information
viduals (Patel & Rushefsky, 2006; Hoffman, 2012). Because is important to community health nurses because many of
they delay care, their health problems are usually more severe their clients are covered by these programs. Nurses need to
when they do seek care (Sultz & Young, 2011). The unin- know what services clients can expect if they are enrolled in
sured Â�overuse Â�hospital Â�emergency departments because they these programs.
have no Â�personal health care provider (Kaiser Commission
on Medicaid and the Uninsured (KCM&U), 2009). The cost Medicare
of such care is assumed either by the hospital or by govern- Medicare was created in 1965. It was an attempt to ensure that
ment programs. Emergency department care is a more costly adequate medical care would be available to older adults and
form of service than care at clinics or physicians' offices. The some persons with chronic illnesses and that the price of such
American Hospital Association (AHA) reported that the services would not be so prohibitive that individuals would have
cost of uncompensated care in hospitals has doubled every to forgo basic care. It has significantly improved access to health
5â•›years. The estimated costs of uncompensated care (for hos- care services for eligible persons, and it has helped reduce the
pitals and other providers) is between $42.7 and $61 billion level of poverty among older adults.
dollars (Clemans-Cope, Garrett, & Buettgers, 2010; Families Medicare is federally funded and is financed by a tax on
USA, 2009). wages. Every citizen who is currently working provides a
Â�portion of her or his salary to the Medicare program. Employers
Uninsured Children: A Special Concern (CHIP Program) and Â�employees contribute an equal percentage of wages to
Although there are fewer uninsured children than unin- fund Medicare. The contribution levels for both employer and
sured adults in most states, they are an aggregate of special employee have risen, so that both pay 1.45% of the worker's
concern to health professionals. The cost of providing access salary into the Medicare Insurance Fund. Medicare's budget
and Â�treatment to children is low, and the long-term benefits increased from $4.7 billion in 1967 to $519 billion in 2010
to health care costs are high. Untreated illnesses and lack of (KFF, 2010b).
Medicare has evolved into an important source of income services that they use. Critics charge that co-payments, espe-
for health care providers. It furnishes more than 29% of total cially for hospital care, have escalated until they are a major
income to hospitals and 21.6% of all income to physicians (CMS, hardship for a large percentage of the covered population.
2011f). Physicians in certain medical specialties Â� commonly Medicare pays less than half of recipients' health care costs; In
exceed the 21% average Medicare income level. These include 2009, Medicare recipients paid 15% of their total household
thoracic surgeons, internists, and radiologists. income on medical expenses not covered by Medicare (KFF,
2011a), an especially difficult burden for those on limited,
Beneficiaries fixed incomes.
The primary beneficiaries of Medicare are older adults who con- Co-payments were instituted to save government money
tributed to the system during their working life or the spouses and to encourage judicious use of services. Numerous studies
of the contributors. In 1972, Congress extended coverage to per- Â�support co-payments as a method that tends to reduce usage.
sons under age 65â•›years with long-term disabilities or end-stage There is an inverse relationship between services used and the
renal disease. In 2010, there were 47.5 million persons receiv- rate of co-payment: a 20% or 25% co-payment significantly
ing Medicare benefits, 39.6 million of whom were seniors and reduces the use of services (Inglehart, 2002; Sipkoff, 2010). In
7.9 Â�million of whom were persons with disabilities (U.S. Census other words, as the personal cost declines, people seek more
Bureau, 2012f). health care, and as personal cost increases, people curtail the
use of services until it becomes an acute situation (Wallace
Benefits etÂ€al., 2008).
Medicare is divided into four parts: Part A is hospital Critics of cost sharing charge that it discourages people
Â�insurance, Part B is supplementary medical insurance, and from receiving necessary medical care or encourages them
part D Â�covers prescription drugs. All contributors are cov- to Â�postpone care until the condition becomes more severe or
ered by Part A. Part B and Part D are voluntary and are even life threatening. Although there are few data from con-
limited to those who choose to participate and pay a pre- trolled studies to support this argument, it is known that
mium deducted from their Social Security checks. Part C is people who are living on small amounts of money tend to be
Medicare managed care, called Medicare Advantage. There sicker when they seek care and require more extensive care as
are currently 11 million persons (23% of Medicare enrollees) a result (Collins etÂ€al., 2008; Geyman, 2008; KFF, 2010a). It
enrolled in Medicare Part C. Most Medicare recipients who would appear Â�logical to assume that the same condition holds
use Part A opt to participate in Part B coverage. Part D, which true with persons whose co-payment levels are relatively high
began in 2003, has a 60% participation rate (KFF, 2010b). with respect to their incomes. Data to support or deny this
The cost of premiums has steadily increased, and voluntary position would be extremely useful when planning changes to
contributions currently pay for only 25% of the total cost the system.
of Part B benefits; the rest is financed by the federal govern- Equity. A major concern with cost sharing is the question
ment. Benefits under Part A, Part B, and Part D are listed in of equity. Medicare is a program in which everyone, regard-
TableÂ€4-2. less of circumstances and finances, essentially pays the same
amount or cost for similar benefits. Therefore, greater cost
Criticisms burdens are placed on the poor because their out-of-pocket
Several major concerns have been raised about the program expenses reflect a larger proportion of their incomes than
structure. Most criticisms have to do with institutional bias, the costs of persons with larger incomes. This dispropor-
Â�service restrictions, and equity. tionate cost is illustrated in Figure 4-10. If three patients are
Institutional Bias: Change from Inpatient Care to Outpatient hospitalized for the same number of days for the same prob-
Care. The Medicare payment structure previously was heav- lem and receive the same Â� treatment, their costs (Medicare
ily weighted in favor of hospital care. More recently, as a result co-payments and deductibles) are essentially the same, but
of the need for cost-cutting measures, hospitals received per- the impact on their finances is not. As income goes up, the
mission to expand services provided by more cost-effective impact of health care expenses is less. The greatest burden is to
outpatient clinics. Outpatient clinics are less labor intensive, Mr. A who has the lowest income. Partially in response to
take up little space, and cost less to operate than inpatient ser- this concern, the Medicare program initiated a means-tested
vices. For example, outpatient clinics can operate with fewer premium for Part B in 2007. Premiums for people with incomes
employees, are not staffed 24 hours a day, and require less above $85,000 ($170,000 for a couple) cost more than premi-
high-technology equipment than inpatient units. The use of ums for those with incomes below that level (CMS, 2011d). The
hospital outpatient services grew by 160% between 1996 and new Affordable Care Act builds on that effort and includes both a
2006 (Sultz and Young, 2011), and growth is expected to con- premium and a payroll tax on earnings for higher income indi-
tinue. Between 1985 and 2005, hospital outpatient revenues viduals (KFF, 2010b).
increased 21% and 63% of all surgeries were done on an out-
patient basis (Gourevitch etÂ€al., 2008). Other types of outpa- Protection from Financial Hardship
tient services such as free-standing emergency care centers and Medicare does not protect the individual from financial desti-
preferred provider organizations are also expected to grow tution, which was the primary reason for the creation of the
(see ChapterÂ€3). program. Currently, the cost of co-payments and restrictions
Limited Access and Unequal Burden of Risk. Cost sharing is a on coverage make it very difficult for many persons who face a
requirement of the Medicare program. In addition to the Part major illness, particularly a long illness, to afford the health care
B payment, recipients must pay a portion of the expenses of the services they need.
TABLEÂ€4-2â•…â•‡MEDICARE BENEFITS
Medicare (Part A): Hospital Insurance—Covered Services for 2011
SERVICES BENEFIT MEDICARE PAYS YOU PAY
Hospitalization: Semiprivate room and board, First 60â•›days All but $1132 $1132
general nursing, and miscellaneous hospital 61st to 90th day All but $283/day $283/day
services and supplies (Medicare payments 91st day* and beyond All but $566/day $566/day
based on benefit periods) All costs
Skilled nursing facility care: Semiprivate room First 20â•›days 100% of approved amount Nothing
and board, general nursing, skilled nursing Additional 80â•›days All but $141.50/day $141.50/day
and rehabilitative services, and other Beyond 100â•›days Nothing All costs
services and supplies† (Medicare payments
based on benefit periods)
Home health care: Part-time or intermittent Unlimited as long as client 100% of approved amount; Nothing for services; 20% of
skilled care, home health aide services, meets Medicare medically 80% of approved amount for approved amount for durable
durable medical equipment and supplies, necessary conditions durable medical equipment medical equipment
and other services
Hospice care: Pain relief, symptom For as long as physician
All but limited costs for Limited costs sharing for
management, and support services for certifies need
outpatient drugs and outpatient drugs and inpatient
those with terminal illnesses inpatient respite care respite care
Blood Unlimited, if medically 80% of cost after first three For first three pints‡; 20% of
necessary pints per calendar year additional pints
Medicare (Part B): Hospital Insurance—Covered Services for 2011
SERVICES BENEFIT MEDICARE PAYS YOU PAY
Medical expenses: Physicians' services; Unlimited, if medically 80% of approved amount $162 deductible,§ plus 20% of
inpatient and outpatient medical and necessary (after $162 deductible); approved amount and limited
surgical services and supplies; physical, 50% of approved amount charges above approved amount ||
occupational, and speech therapy; for outpatient mental health plus 50% for outpatient mental
diagnostic tests; and durable medical services health services
equipment and other services
Clinical laboratory services: Blood tests, Unlimited, if medically Generally 100% of approved Nothing for services
biopsies, urinalyses, and more necessary amount
Home health care: Part-time or intermittent Unlimited for as long as 100% of approved amount; Nothing for services; 20% of
skilled care, home health aide services, client meets conditions for 80% of approved amount approved amount for durable
durable medical equipment and supplies, benefits for durable medical medical equipment
and other services equipment
Outpatient hospital treatment: Services for Unlimited, if medically Medicare payment to hospital Co-payment amount varies (after
the diagnosis or treatment of illness or necessary based on hospital cost after $162 deductible)
injury co-payment by recipient
Blood Unlimited, if medically 80% of approved amount First three pints plus 20% of
necessary (after $135 deductible and approved amount for additional
starting with fourth pint) pints (after $135 deductible¶);
Screening and Preventive Services: For As outlined in Medicare For the most part pays the Nothing for flu and pneumonia
example, aortic aneurysm, bone density, Handbook total approved amount and immunization and other
mammogram, Pap test and pelvic costs for pneumonia and flu preventive services, may incur
examinations, prostrate screening, certain immunizations a physician fee in process of
immunizations and yearly wellness doctor screening services.
visits All costs of shingles vaccine
Medicare Prescription Drug Coverage (Part D)
SERVICES BENEFIT INSURANCE CO-PAYMENT YOU PAY
Prescription drugs provided through Varied Varied Varied
privateÂ€insurance companies
*This 60-reserve-days benefit might be used only once in a lifetime.
†
Neither Medicare nor private Medigap insurance will pay for most nursing home care.
‡
Blood paid for or replaced under Part B Medicare during the calendar year does not have to be paid for or replaced under Part A.
§
Once client has had $162 of expenses for covered services in 2011, the Part B deductible does not apply to any further covered services received
for the rest of the year.
||
Federal law limits charges for physician services.
¶
Blood paid for or replaced under Part A Medicare during the calendar year does not have to be paid for or replaced under Part B.
2011 Part A monthly premium: None for most beneficiaries; persons who did not contribute during employment years might purchase by paying a premium.
2011 Part B monthly premiums: $115.60 (premium might be higher if you enroll late or have income over $85,000).
From Medicare and you. (2011). Washington, DC: U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.
16.66%
8.33%
5.55%
83.34% 91.67% 94.45%
Mr. A.: $15,000 Mr. B.: $30,000 Mr. C.: $45,000

FIGUREÂ€4-10â•‡ Percentage of income needed for health care for three individuals with different
incomes and similar health care needs. All three persons have $1500 out-of-pocket expenses in
deductibles and co-payments for Parts A and B Medicare benefits.
Those with chronic illnesses can easily have several hospital Services Not Covered
stays because of complications and deteriorating health status. Medicare has only recently covered prescription drugs for
While in the hospital, a person can expect to see the primary enrollees on a voluntary basis. A common misconception is that
physician and one or two specialists and to undergo radiog- Medicare includes long-term nursing home care. These benefits
raphy and other diagnostic examinations. With co-payments are severely restricted. Skilled nursing home care is limited to
and deductibles for covered services and no ceiling on potential 100â•›days per year with mandatory deductibles (see TableÂ€4-2).
expenses, it is easy to see that this person could quickly accrue a Nursing Home Care. Custodial nursing home care, the type of
bill of many thousands of dollars. Often, older adults are faced care required by most older adults who are nursing home resi-
with the prospect of “spending down” to qualify for another dents, is not covered by Medicare or by many private insurance
health coverage program—Medicaid. “Spending down” is the plans. The average annual cost of nursing home care per patient
process whereby a person must first exhaust most assets to pay varies by geographical region but now is estimated to be between
medical bills. When the person's assets are nearly gone, she or $74,239 and $82,113 (Alzheimer's Association, 2011), an
he will qualify for medical assistance care under Medicaid, the amount that can rapidly deplete personal savings. In fact, many
program that provides care to the economically disadvantaged. nursing home residents meet the income means test for
Medicaid coverage. Approximately 37% of the costs of nursing
Medigap Insurance home care are paid by the individual or private health insur-
To insure against devastating financial loss, most older persons ance, 20.3% by Medicaid, and 7.6% by Medicare or private
(approximately 54%) have some additional health care insur- insurance (CMS, 2011f).
ance from private companies (KFF, 2010b). “Medigap” policies
are intended to reimburse out-of-pocket costs for Medicare- Mrs. Jones had Alzheimer's disease and required custodial
covered services. In addition, some pay for services not covered nursing care for 2â•›years before her death. The cost of 2â•›years of
by Medicare. In 1990, Congress directed the National Association care was $95,000. The Jones family had to “spend down,” using
of Insurance Commissioners to standardize Medigap Â�policies $15,000 of their savings, before Medicaid paid for nursing care.
because of fraud, abusive sales tactics, and problems with
Â�benefit comparisons. Because of confusion, many older Â�persons As the incidence of chronic illnesses increases with age, the
had purchased two or more policies with duplicate benefits. probability of nursing home admission also increases. The life-
This group developed 10 standardized plans (Figure 4-11). Each time risk of needing institutional care is about 75% (CMS,
Medigap insurance provider must offer the basic policy (A) and 2011b). Two of every five older adults can expect to stay in an
may choose to offer any or all of the remaining plans (B through extended-care facility, either as an intermediate step between
L). These new insurance plans eased comparison of costs and hospital and home or at the end of life. This important and
benefits for older adults. common need, one of considerable concern for older individu-
The need for Medigap insurance places older adults from als, is not covered by Medicare. Other services and benefits that
low-income groups at the greatest financial risk. Although 54% are not covered are outlined in Box 4-1. The most Â�burdensome
of Medicare recipients carry extra coverage, 46% do not, usually of these are prescription gap coverage, deductibles, and
because they cannot afford coverage (KFF, 2010b). These people Â�co-payments, especially for older adults with chronic illnesses
might be eligible for Medicaid because of extremely low incomes. and Â�disabilities. In 2011, the Part A hospitalization deductible
Premiums for Medigap insurance are expensive, ranging from increased to $1132, and the monthly cost of Part B coverage
$1764 to $2412 or more per person per year (Moeller, 2011). With increased to $162, or $1944 per person per year.
increasing premium costs, more older adults can be expected to be Prescription Drugs. Until 2006, Medicare did not provide
unable to afford coverage. For example, an older couple living on prescription drug coverage except as part of the managed care
a fixed income of $20,000 per year would pay 17% to 24% of their program. Because only a small percentage of seniors Â�participated
total income in Medigap premiums alone. In addition, they would in managed care at that time, most paid for prescription drugs
pay the medical cost of Part B Medicare premiums and a 20% out of pocket. Currently, with the rising costs of drugs, about
co-payment on any medical services needed. If their income was 18% of out-of-pocket costs in health care are attributed to drug
$30,000 a Medigap policy would take up to 16% of their income. costs (CMS, 2011f). Because older adults consume a larger
Ten Standard Medigap Insurance Policies
Medigap Plans
How to read the chart:
If a check mark appears in a column of this chart, the Medigap policy covers 100% of the described benefit. If a row
lists a percentage, the policy covers that percentage of the described benefit. If a row is blank, the policy doesn’t cover
that benefit.
Medigap Plans
Medigap Benefits A B C D F* G K L M N
Medicare Part A Coinsurance and hospital costs up to an
additional 365 days after Medicare benefits are used up
Medicare Part B Coinsurance or Copayment 50% 75%
Blood (First 3 Pints) 50% 75%
Part A Hospice Care Coinsurance or Copayment 50% 75%
Skilled Nursing Facility Care Coinsurance 50% 75%
Medicare Part A Deductible 50% 75% 50%
Medicare Part B Deductible
Medicare Part B Excess Charges
Foreign Travel Emergency (Up to Plan Limits)
Data from Centers for Medicare and Medicaid Service (2011). Choosing a Medigap Policy: Out-of-Pocket Limit**
A guide to health insurance for people with medicare. Available at www.medicare.gov/
Publications/Pubs/pdf/02110.pdf. $4,640 $2,320
* Plan F also offers a high-deductible plan. If you choose this option, this means you
must pay for Medicare-covered costs up to the deductible amount of $2,000 in 2011
before your Medigap plan pays anything.
** After you meet your out-of-pocket yearly limit and your yearly Part B deductible
($162 in 2011), the Medigap plan pays 100% of covered services for the rest of the
calendar year.
*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for
some office visits and up to a $50 co-payment for emergency room visits that don’t result
in an inpatient admission.
FIGUREÂ€4-11â•‡ Ten standard Medigap insurance policies. (Data from Centers for Medicare and Medicaid
Services. [2011]. Choosing a Medigap policy: A guide to health insurance for people with Medicare. Baltimore,
MD: Author.)
BOXÂ€4-1â•…â•‡MEDICAL SERVICES NOT Mr. and Mrs. Smith have an annual income of $35,000.
COVERED OR LIMITED UNDER Both have chronic medical conditions. Mr. Smith has a
THE MEDICARE PROGRAM heart Â�condition that requires prescription drugs costing
• No coverage for long-term care (custodial care over an extended period $1988 per year. Mrs. Smith has Parkinson's disease and pays
in the home, a custodial nursing home, or a residential care facility) another $2540 a year for medication. The total cost of their
• Limited coverage for nursing home care (only for a skilled nursing Â�medications is $4528 per year. In addition, they pay $3888
home for limited periods) in Â�premiums for Medicare Part B coverage and $2700 per
• Part A and Part B deductible and co-payment obligations year in Medigap insurance. These medical expenses total
• Cosmetic surgery $11,116 per year, or approximately 31% of their annual
• Drug coverage income. Physician office visits, laboratory bills, and other
• No coverage for dental, eye, ear, and foot care, including eye- medical costs, excluding hospitalization, if necessary, would
glasses, hearing aids, and dentures be Â�additional expenses. It would be useful if the nurse or
• Limited coverage for home health care services; does not cover another health care Â�professional could help them explore the
unlimited nursing care or custodial care, Meals on Wheels or other possibility of obtaining Medicare Part D assistance for low-
food service programs, or homemaker services income individuals as well as Medicaid to help with Medicare
• No coverage for diabetic supplies, such as insulin and syringes, co-payments.
unless used with an insulin pump
number of prescription drugs, with no prescription insurance Older adults often do not comply with prescribed medi-
and rising drug costs, they are at special risk. Older adults live in cation therapy because the costs are more than their limited
families in which health expenditures, including prescription Â�budgets can handle.
drugs, account for 10% to 18% of total income (Selden &
Banthin, 2003; KFF, 2011a). About 35% of seniors report skip- Attempts at Program Change
ping doses or discontinuing medications because of costs Efforts to alter Medicare services, providers, and payment
(Kocurek, 2009; Nekhlyudov etÂ€al., 2011; Safran etÂ€al., 2002). mechanisms have been, and continue to be, made.
Early Efforts at Medicare Reform: Easing Consumer Cost 2003 Medicare Reform Act: Medicare Part D and Redesigning
Concerns for Prescription Drugs and Catastrophic Illness. In Medicare Managed Care
1988, Congress attempted to improve Medicare coverage by In 2003, Congress passed amendments to the Medicare program,
easing the cost burden on patients with chronic and cata- making substantial changes to covered services, including the
strophic Â�illnesses and Â�adding a prescription drug plan. This establishment of a prescription drug plan (see ChapterÂ€3, BoxÂ€8)
comprehensive reform package was repealed because of and reinventing Medicare managed care. The 2003 reforms did
opposition from senior groups concerned about the addi- not expand coverage in other areas of concern to seniors (e.g.,
tional costs. Congress did act to reduce the financial con- extended home health care or nursing home coverage).
cerns of married couples. In 1990, a separate amendment Medicare Part D: Prescription Drugs. Medicare Part D is
was passed providing some relief from catastrophic expenses. the prescription drug plan. Approximately 29 million are
Some joint financial assets held by a married couple were enrolled in Medicare Part D. Ten million of those are receiv-
protected. The Medicare and Medicaid programs would pro- ing help with drug costs and premiums through Part D
vide services for the partner who had the illness, and the Â�Low-income Subsidy (Hoadley etÂ€al., 2011a). The program is
healthier spouse was allowed to retain limited assets (the family funded through federal contributions and the premiums and
home and some income). Â�co-payments of the enrolled participants. The participants
Physician Reimbursement Mechanism. In 1997, Congress pay approximately 25% of program costs. In 2010, the cost of
considered a bill allowing physicians more flexibility in their Medicare Part D was 63.5 billion (U.S. Census Bureau, 2012e).
payment structures. Doctors who contracted directly with Seniors enrolled in the plan pay a base premium of $35.15 per
the patient and did not accept Medicare assignment would month or $421.80 per year.
not be subject to Medicare restrictions. They could charge A concern with Part D is the coverage gap or “donut hole.”
whatever they decided for their services, choosing between If a senior's drug costs exceed a certain amount, then the indi-
Medicare and client payments at will. Under the current system,
Â� vidual pays the full cost of medications between that amount
Â�however, physicians may not charge more than 15% above the and the end of the gap. In 2012, the gap starts at $2930 and
Medicare-approved price, even if they do not participate in ends at $4700 (out-of-pocket personal drug costs of $1570, in
the Medicare program. Physicians who treat Medicare patients addition to monthly premium costs). Gap coverage and the
must accept the Medicare-approved price, so many physicians large number of options in drug plans have created confusion
are dissatisfied with that level of compensation. The American among seniors. Many seniors are unaware of the coverage gap.
Medical Association (AMA) reported that 33% of primary Some Medicare Part D policies and those available through
care Â�physicians reported that they limited the number of new Medicare managed care cover the gap amount. These Â�policies
Medicare patients because of Medicare compensation levels are more expensive, approximately twice the cost of the base
(Rohack, 2010). plan ($945 to $1183 per year). Twenty percent of seniors
Â�participating in Medicare Part D reached the coverage gap in
Medicare Managed Care Plan 2009 (Hoadley etÂ€al, 2011b). There is a catastrophic amend-
Established in 1997, Medicare + Choice encouraged the use ment that allows for very small co-payments for medication
of managed care arrangements by persons with Medicare after an enrollee reaches the end of the coverage gap. This
Â�insurance. The providers received a predetermined fee and amendment is intended to offset the extreme costs of medica-
agreed to provide benefits at least equal to the current Medicare tions if a person has multiple drug needs.
package. Managed care organizations that participated in In an effort to reduce the burden of drug costs for both the
Medicare + Choice initially received incentive payments to nation and the individual the new Affordable Care Act has made
enroll seniors (Sultz & Young, 2011). changes to Medicare Part D including the following:
Benefits of Managed Care. Enrollment in a managed care • An additional increased premium for higher-income
organization meant that Medicare recipients did not have to beneficiaries
purchase Medigap insurance but had to accept the health Â�service • A rebate to enrollees of $250 per year for those who have reached
restrictions of their plan. Some seniors found this arrange- the coverage gap
ment beneficial because they did not have to struggle with the • A 50% discount on brand name drugs and 14% discount on
paperwork for Medicare and/or Medigap and because Medigap generic drugs (the discounts are made possible through agree-
Â�insurance was costly for many. ments with drug manufacturers for brand name drugs and a
Declining Enrollment in Managed Care. Medicare + Choice government subsidy for generic drugs)
was not popular with Medicare participants. Peak enroll- • A gradual limitation on the enrollees costs in the coverage
ment was approximately 6.3 million people (15% of eligible gap. In 2020, enrollees' costs will be limited to 25% of medica-
Â�participants) (Sultz & Young, 2011). After the initial period, tion costs.
the Â� number of participants and providers declined. The The overall costs of these program changes will not be known
decline in the Â�number of health care providers was the result for some time. The changes may be revenue neutral (no addi-
of Â�government funding cuts that reduced payments. The tional cost burden) if the manufacturers discounts and additional
decline of participants was either voluntary because of dis- premiums to higher-income enrollees meet the added costs. The
satisfaction or involuntary because of provider discontinu- program still has many options for Medicare Part D insurance
ance of Â�service. Between 1998 and 2003, 2.3 million enrollees coverage, which is confusing to many seniors. The states and the
was Â�terminated from Medicare + Choice when their Â�providers Centers for Medicare and Medicaid Services (CMS) have set up
withdrew from the program (KFF, 2003). Only half of the online plan comparisons to help with Â�decisions about insurance
affected participants were able to find coverage with another choices. Those are only available to enrollees who use computer
managed care plan. systems, and many older adults do not.
Medicare Part C: Medicare Advantage. The Medicare Advantage and young children from these disadvantaged groups but has
managed care program, established in 2003, replaced Medicare + been less successful in caring for poor older adults, those with
Choice. Seniors pay a fee to the selected managed care Â�disabilities, and adults and children who are not covered under
Â�program. In addition, they may have out-of-pocket costs and the programs for pregnant women and for children. Medicaid
co-payments. Some enrollees purchase additional insurance
Â� provides benefits to approximately 45% of those below the
to cover these medical expenses and those not covered by their Â�poverty level (KCM&U, 2010).
managed care program. In 2010, 23% of seniors were enrolled Individual states administer the program. Medicaid is
in Medicare Advantage (KFF, 2010b). financed by income tax revenues at the federal level and by
To encourage managed care plans to participate in Medicare general tax revenues at the state level, with some contributions
Advantage, Congress offered financial incentives to those plans. from local municipalities. Overall, the federal government pays
In 2005, that incentive was $800 per enrollee or 11% more than approximately 50% of the Medicaid budget, but the specific
the cost of similar benefits in Medicare (KFF, 2008). In effect, allotment for each state varies from 50% to 76%, depending
Congress created a competition with the original Medicare pro- on criteria set by the federal government. States with limited
gram and provided cost incentives to managed care plans that Â�economic resources receive a greater share from the federal
participated. In 2010, the Medicaid Advantage program got Â�government. For example, Mississippi receives the full 76%
14% more than standard Medicare providers (Reinhard, 2012). federal share, whereas Alaska receives 67.6% federal funding.
The new Affordable Care Act removes the extra subsidies paid to Since the recent recession, the federal government has boosted
Medicare Advantage plans at a cost savings of $136 billion over the percentage of funding for each state, but this is a temporary
10â•›years. measure that requires ongoing congressional approval.
Medicare Advantage was promoted as easier to navigate than Like Medicare costs, Medicaid costs have risen dramatically
Medicare and as a plan that could save seniors money. Initial (Figure 4-12). In 1968, the program cost approximately $3.45
research does not support that claim.Â€Biles and colleagues Â�billion in both federal and state contributions; in 2009, costs were
(2008) found that seniors in good health did save on out-of- $373.9 billion. By the year 2020, Medicaid costs are expected to
pocket health expenses (premiums for Part B, D, Medigap be $908.1 billion (CMS, 2011e). Medicaid expenditures impose
insurance, and deductibles) when they enrolled in Medicare an increasing burden on state budgets. In fact, expenses have
Advantage. They also reported that 22% of Medicare Advantage often outpaced the rate of growth in state revenues, which has
plans cost seniors in poor health more than the out-of-pocket created a major concern for state administrators.
costs of health care premiums (including Medigap insurance)
and deductibles.
Several problems with Medicare Advantage have emerged. 950
There are a large number of participating managed care orga-
900
nizations (443), each of which offers a variety of insurance plan
choices with different premium costs (KFF, 2011c). This has 850
created confusion, similar to that encountered when Medigap 800
insurance was first offered. Medicare recipients are locked into
750
a managed care plan for a full year, which makes it impossi-
ble for seniors to change plans if they encounter any problems 700
with their plan selection. Insurance agents marketing managed 650
care plans to seniors have used deceptive practices to enroll
consumers and have misrepresented benefits available in those 600
plans. Thirty-nine states have reported abuses, and 71% of all
Billions of Dollars
550
Medicare Advantage plans have been penalized for market-
500
ing abuses through 2009 (Government Accountability Office
[GAO], 2009; Kennelly, 2008). Ongoing evaluation of the exist- 450
ing program is needed. Perhaps there will be additional changes 400
to the program as problems become manifest.
At the present time, Medicare remains a program with Â�limited 350
coverage, and it is a program with increasing cost Â�liabilities for 300
the consumer and government. The current Â�concern is whether
250
Medicare can address the needs of persons with chronic illnesses
in a more comprehensive fashion and, if so, at what cost to the 200
individual and the nation. The new Affordable Care Act has 150
taken steps to control costs and increase the quality of Â�services.
Only time will tell if this effort is successful. 100
50
Medicaid
0
Medicaid, created in correlation with Medicare in 1965, is a 1968 1970 1980 1990 1996 2000 2009 2020
grant program designed to provide medical assistance to those (projected)
from low-income groups. It is funded by both federal and state FIGUREÂ€4-12â•‡ Medicaid costs for selected years, 1968-2009, in
governments. Medicaid has done a moderately competent job billions of dollars. (Data from Centers for Medicare and Medicaid
of providing care to limited segments of pregnant women Services.)
Beneficiaries welfare, known as Temporary Assistance for Needy Families

The number of persons that Medicaid serves has varied. In (TANF) (formerly Aid to Families with Dependent Children
1983, the number of persons receiving benefits was approxi- [AFDC]). However, not all low-income families Â�qualify for
mately 21.5 million, the same number as in 1979. Because the TANF and Medicaid. See ChapterÂ€21 for a more detailed
number of persons in low-income groups grew by approx- Â�discussion of TANF, poverty, and the relations of Â�poverty to
imately 10 million during that same period, the net effect health status.
was that approximately 55% fewer poor were covered by In addition to beneficiaries mandated by the federal gov-
the Â�program (Sorkin, 1986). During recessions, the number ernment, states may extend care to other groups, for whom
of people eligible for Medicaid usually increases. In 2009, care may or may not be funded by federal matching funds.
Medicaid enrolled 61.8 million people in the program (U.S. Many states offer optional programs. Thirty-three states
Census Bureau, 2012c). Past and current studies indicate that cover “medically needy” families, but income and asset
many more people who are not enrolled in the program are ceilings vary (KFF, 2010c). Some families might find that
also in need (Berk & Schur, 2001; General Accounting Office their incomes are too high rendering them unable to qual-
[GAO], 1996; IOM, 2007; KCM&U, 2011). ify initially, but extensive
Â� medical expenditures will reduce
their assets to qualifying Â�levels. Seventeen states chose not
Mandated and Optional Recipients to extend coverage to “Â�medically needy” families through
The states are required by the federal government to provide optional programs.
services to certain groups and have the option of providing ben- From time to time, the federal government mandates cover-
efits to others (Box 4-2). The states have some control over the age for certain at-risk populations. These additional coverage
number of state residents covered under federally mandated mandates were the result of increased concern over the uneven
programs. The states can establish most of the eligibility criteria coverage criteria for pregnant women and children. Medicaid
such as income and asset ceilings as well as other criteria. Most coverage was extended in all states, first to pregnant women
states provide Medicaid coverage for families with children on and to children younger than 5â•›years in two-parent homes that
BOXÂ€4-2â•…â•‡MEDICAID BENEFICIARIES AND SERVICES*

Medicaid Recipients Major Benefits under Medicaid
Federally Mandated Recipients Federally Required
• All persons in federal aid programs, including Supplemental Security • Inpatient and outpatient hospital care
Income (SSI) and Temporary Assistance for Needy Families (TANF)* • Physician services
• Pregnant women and children under 6â•›years of age with a family • Diagnostic services (laboratory tests, radiography)
income below 133% of the poverty level • Skilled nursing facility services for persons 21â•›years or older
• Infants born to Medicaid-eligible pregnant women • Home health care for persons eligible for skilled nursing
• Recipients of adoption assistance and foster care who are under Title services
IV-E of the Social Security Act • Nurse–midwife services
• Certain low income people with Medicare • Federally qualified health center and rural health services
• Selected financially devastated persons • Pediatric and family nurse practitioner services
• Early and periodic screening, diagnosis, and treatment (EPSDT) for
Federally Optional Recipients people under 21â•›years of age
• Infants up to age one and pregnant women not covered under manda- • Transportation services
tory rules with incomes below 185% of federal poverty level
• Optionally targeted children from low-income families State-Determined Optional Services
• Children under 21 who meet income and resource requirements for • Clinic services
TANF but otherwise not eligible • Prescription drugs
• Uninsured women from low-income groups who are screened for and • Dental care, eyeglasses, prosthetic devices and durable medical
diagnosed with breast cancer equipment
• Certain older adults, those with visual impairment, or adults with • Rehabilitation and physical therapy
Â�disabilities who do not qualify for income assistance (welfare) • Case management
• Certain persons with tuberculosis (financial limit), for tuberculosis • Inpatient psychiatric services for individuals under age 21
drugs and ambulatory care only • Respiratory care services for ventilator-dependent individuals
• Recipients of state supplemental income payments • Intermediate care facilities for individuals with mental retardation
• Individuals from low-income groups living in waived home and (ICF-MR)
Â�community-based settings who would be eligible if institutionalized • Nursing facility services for people under 21â•›years of age
(e.g., those with mental disorders) • Hospice services
• Institutionalized individuals eligible under special income levels • Home and community-based care to certain persons with chronic
(amount set by each state) impairments
*Before August 1996, TANF was called Aid to Families with Dependent Children (AFDC).
Note: Covered services are provided to those groups with federally required coverage. Mandated services to optional groups are less
comprehensive.
Data from Centers for Medicare and Medicaid Services. (2011). Medicaid eligibility. Retrieved October 17, 2011 from http://www.cms.gov/Medicaid
Eligibility/03_MandatoryEligibilityGroups.asp#TopOfPage and 05_OptionalEligibility; and Kaiser Commission on Medicaid and the Uninsured. (2012).
Medicaid a primer: 2010. Menlo Park, CA: Author. Retrieved October 19, 2011 from http://www.kff.org.
met TANF and AFDC income eligibility standards. Gradually, been even greater if the federal government had not boosted its
Â�benefits were extended to the following: contribution because of the dire conditions of state budgets in
• All pregnant women, and children younger than 6â•›years, at or the current recession.
below 133% of the federal poverty level Despite the temporary federal boost, states must con-
• Families that meet the TANF requirements tend with federal actions that have effectively reduced the
• All children aged 6 through 19â•›years in families with income expected federal share of the Medicaid budget in most times.
below the poverty level In 1981, as part of the Reagan administration's Omnibus
• Caretakers, relatives, or legal guardians who take care of Budget Reconciliation Act, federal Medicaid grants to the
Â�children under age 18 (age 19, if still in school) states were reduced 11.5%. In return, states were allowed more
• Selected Supplemental Security Income (SSI) recipients administrative discretion but also had to comply with new
• Beneficiaries whose incomes are so limited they cannot Â�service directives
Â� that increased state Medicaid costs (Patel &
afford Medicare insurance premiums and co-payments Rushefsky, 2006). The federal Medicaid contribution is recal-
• Individuals and couples living in medical institutions with culated annually, so the states risk a reduction of federal funds
monthly incomes up to 300% above SSI standards (CMS, each year.
2005; Dotson, 2002; GAO, 1995; KCM&U, 2010). Unequal Distribution of Services to Beneficiaries. A Â�relatively
The result has been an expansion of the Medicaid program small group of people account for most of the costs in the
to certain populations that meet the federal poverty level crite- Medicaid program. The average annual Medicaid costs are
rion. This has reduced some of the uneven application of the four to seven times higher for older adults and those with dis-
various state TANF standards for Medicaid eligibility. abilities than for children and their parents. Older adults and
Cost savings were the reason for extending coverage. those with visual impairment or other disabilities—21% of the
Providing for prenatal and pediatric care to these Â�populations beneficiaries—use 63% of the Medicaid budget (U.S. Census
cost significantly less than providing treatment for Â�problems Bureau, 2012c; Figure 4-13). Medicaid pays for more than half
that would have resulted without care. Still, the program expan- of Â�nursing home patient-days (Day, 2011). Faced with expand-
sions were limited. Women who are not pregnant are not ing numbers of older adults and other participants with disabil-
Â�covered and are, therefore, still required to meet their states' ities, the program has become less able to serve the very people
established criteria. for whom Medicaid was originally intended.
Medicaid does not cover all people with limited incomes. In Variable Program Qualifications among the States. Eligibility
general, the following needy groups are excluded: single persons standards for Medicaid are primarily state Â�determined. Each
and childless couples who are not older adults or have disabili- state has its own ceiling on income and allowable personal assets
ties; most two-parent families; families with a parent who works based on a percentage of the federal poverty level (e.g., 100% of
at a low-paying job unless the income is very low as determined the poverty level, 50%, and so on). If the federal
Â� poverty level
by state TANF criteria; legal aliens who entered the United States for a family of four is $21,113 (in 2010), a state with a ceiling
on or after August 22, 1996 (are barred for 5â•›years) (CMS, 2005; of 50% of the poverty level will provide Â�benefits to a family if
CMS, 2011c; Hoffman etÂ€al., 2001). the family's income is $11,056 or less per year; if their income
is $11,300, they are ineligible in that state. However, the same
Benefits family might very well be covered in other states with higher
Medicaid benefits vary greatly, depending on how they are set ceilings. Figure 4-14 shows how one family might be affected by
up by the states. The states must provide federally mandated different state ceilings. It is estimated that Medicaid benefits do
minimum services but are at liberty to provide other services. not reach 33% to 50% of the Â�population below the poverty level
Approximately 50% of Medicaid budgets are spent to provide because of variations in state eligibility rules.
federally mandated programs. Optional services account for
most of the remainder of budget expenses. Federal Â�minimums
60
and selected state optional benefits are listed in Box 4-2.
Community health nurses need to become familiar with the 47.8%
50
benefits extended to participants in their states of residence.
Percentage of Total
40
Criticisms
The most important concerns with the program are related to 30
increasing costs, unequal distribution of services, the impact of 22%
cost-cutting measures on beneficiaries, and the wide variation 20
14.8%
in benefits and recipients covered. 7.1%
Program Cost Increases. Both the states and the federal 10
Â�government have reasons for concern. Since 2002, the total
0
Medicaid budget has risen 44% (CMS, 2011a). Increases in Disabled
Children Adults Aged
program costs have occurred at both federal and state levels.
Cost per $2935 $2912 $14724 $14843
Medicaid costs represent a greater share of state budgets than of recipient
the federal budget. In addition, state Medicaid costs have risen
FIGUREÂ€4-13â•‡ Medicaid cost of serving older adults and those
at three to five times the rate of increases in state revenues. The with disabilities compared with cost of serving children and
percentage of state and local budgets consumed by Medicaid other adults. (Data from Centers for Medicare and Medicaid Services.
costs were 21.2% in 2009, or $103.4 billion (Georgetown [2010]. Health Care Financing Review (Statistical Supplement). Baltimore,
University Health Policy Institute, 2011). State costs would have MD: Author.)
20000
18000
16000
Annual Family Income in Dollars
14000
12000
Family of Four Income: $11,300
10000
8000
6000
4000
2000
0
State A State B State C State D State E State F State G
(20% or (30% or (40% or (50% or (60% or (70% or (80% or
Below) Below) Below) Below) Below) Below) Below)
Poverty Level Percentage that Is Criterion for Medicaid Eligibility

Interpretation
Not eligible Eligible
State A State D
State B State E
State C State F
State G
FIGUREÂ€4-14â•‡ Income as a percentage of the poverty level as a criterion for Medicaid eligibility in
selected states. In states A, B, and C, the hypothetical family is not eligible; in states D, E, F, and
G, the family is eligible.
In addition to federally covered required services and service of Medicaid income ceiling restricts the number of persons
recipients, there is wide variation in the state offered optional who can qualify for the program (Rowland, 2008). Follow-up
services and covered recipients. Benefits are uneven and not studies of dropped populations indicate that when services are
comparable among the states. Refer to Box 4-2 for optional terminated, there is a general worsening of health status, less
Â�coverage of groups and benefits. Â�satisfaction with health care, and increased inability to obtain
In an effort to address this variability in Medicaid criteria and other sources of care compared with persons not terminated
services, the new Affordable Care Act has established a standard from programs (Cohen etÂ€al., 1996; GAO, 1996; Long etÂ€al.,
income eligibility requirement for all persons. That standard will 2008). The long-term effects of restricting access can be costly
be all those under age 65â•›years and below 133% of the poverty because people become sicker and require more intense treat-
level. There will no longer be state optional categories or exclusions. ment by the time they obtain care.
The law will gradually start enrolling eligible individuals and is Another method of cost containment is the addition of cost
expected to cover an estimated 16 more million people by 2019 sharing or co-payments. Although co-payments and Â�deductibles
(KCM&U, 2010). The increase in new enrollees is expected to in this program do not approach the costs in other co-payment
increase demand for clinicians to care for them. Those in high- programs (e.g., Medicare), they generally tend to have the same
est demand will be primary care physicians and nurse practitio- effect. People who can least afford it pay the most in terms of
ners. Part of the new health legislation provides for an increase in relative cost. It is important for community health nurses to
reimbursement for primary care services as well as new funding understand the economic burdens health care can impose and
for training of primary care providers. the impact cost can have on an individual's ability to access and
Federal and State Cost-Containment Effects on Beneficiaries. utilize health care services.
Cost cutting within the Medicaid program has resulted in Controlling the amount paid for a service by establishing set
dropping some needy individuals or some necessary services fees for services is another means of cost containment. Set fee
to them. For example, barring noncitizens from benefits for schedules have resulted in an effort by some providers to limit
5â•›years from the date of immigration has reduced the number service to Medicaid populations. For example, some physicians
of eligible recipients. Starting in 2001 and continuing, the states refuse to treat Medicaid patients or place a limit on the number
have experienced budget deficits that necessitated making cuts of such patients they will accept in their practices (Dovey etÂ€al.,
in Medicaid reimbursement or tightening eligibility require- 2003; Gifford etÂ€al, 2011; Hunt & Knickman, 2005). The willing-
ments. For example, Missouri dropped 89,000 individuals, ness of physicians to accept Medicaid patients is tied to the level
and Tennessee had to cut recipients in TennCare (a Medicaid of payment received: lowering the fee any further will reduce
Â�managed care program) (Gardner etÂ€al., 2007). The lowering access for a larger number of patients from low-income groups.
The most widely used method of cost containment is to limit TRENDS IN REIMBURSEMENT
the choices or dictate the providers of service by using man-
aged care plans. The result of limited choice is that Medicaid Cost concerns have stimulated changes in the reimbursement
recipients can be told which providers and services to use and structure and delivery of services. These changes are expected to
can be denied service if they do not comply with these restric- continue and evolve in the future as efforts at cost containment
tions. This may place a burden on patients in terms of time and intensify. Reimbursement mechanisms have significant impli-
Â�transportation problems. cations for community nursing because they affect the types of
services nurses can provide and have a direct influence on the
Medicaid Managed Care scope of independent practice.
Since 1993, the federal government has allowed states to expand
managed care to Medicaid populations and all 50 states use Prospective and Retrospective Reimbursement:
managed care programs for their Medicaid benefits patients WhoÂ€Wins?
(Pulcini & Hart, 2012; Rowland, 2008). Approximately 70% The two payment systems for health care services are retrospec-
of all beneficiaries are enrolled in managed care plans (Klees, tive and prospective payments. With retrospective payment,
Wolfe, & Curtis, 2010). Some states see managed care as a means service is provided and then payment is after the fact. AÂ€patient
of expanding Medicaid services to populations not historically goes to her or his physician for a sore throat, is seen and treated,
covered by benefits (KCM&U, 2011). For example, 1.1 million and then is billed for the service. Retrospective payment is
in Florida and 500,000 in Tennessee are now covered. Other a cost-based reimbursement system. Retrospective payment
states such as Oregon, Rhode Island, Maryland, Massachusetts, essentially allows individuals and institutions to recover all costs
and Oklahoma have also experimented with expanded coverage of care. Retrospective payment provides no incentive for effi-
to targeted populations. cient management of health care services. Alternative services
Garrett and Zuckerman (2008) studied the effect of that might be as effective and cost less need not be Â�considered.
Â�managed care on Medicaid recipients and found that man- With retrospective payment, the patient or third-party payer
aged care Â� lowered the number of emergency department assumes all the risk of higher costs. The hospital, physician, or
Â�visits, some visits to health care providers, and the rates of other Â�providers of service bear no financial risks.
use of Â� preventive services. Gifford and colleagues (2011) Prospective payment compensates the provider on a
have reported that many states find their enrollees have dif- Â�case-by-case basis for health services. The facility or provider
ficulty accessing Â�specialty and surgeon services. The authors can expect only a predetermined amount, regardless of the
note these same difficulties are experienced by Medicaid fee- amount of time, energy, and service involved in providing
for-service enrollees and is probably the result of low rates of care to a Â�particular case or patient. Such a payment structure
provider reimbursement. Some states have found both a cost encourages efficiency; there is an incentive to use effective and
savings and improved quality of care when using managed cost-efficient alternatives.
care to provide care to medically complex patients such as Prospective payment is a method of placing limits on the
persons with disabilities
Â� or human immunodeficiency virus/ increasing costs of medical services and encouraging efficient
acquired immunodeficiency syndrome (HIV/AIDS) (Klees, management techniques. Any provider who reduces the cost of
Wolfe, & Curtis, 2010). supplying service below the reimbursement price cuts operating
losses and/or makes a profit. As an extra incentive, the Â�provider
Current Concerns Regarding the Medicaid is allowed to keep all money the provider is paid, even if the
Program costs for that service are less than the reimbursement sched-
Efforts at Medicaid cost containment has led to sporadic cov- ule. Prospective payment has become the most popular form of
erage and services based on state economic situations. In payment system.
Â�fiscally good years, the states expand coverage. In fiscally dif- The diagnosis-related group (DRG) system is a major
ficult years, the states cut coverage and services to needy popu- Â�prospective payment system initiated by the federal Medicare
lations, although there is an increased pool of people in need program. It consists of a predetermined fee structure for
of those services. For example, in the fiscal year 2009, 22 states Â�services provided by hospitals for a list of over 468 Â�diagnoses
reduced reimbursement payments to providers such as hospi- (Apold, 2012). The length of stay and costs reimbursed for
tals and nursing homes; 5 states limited enrollment; 23 states each diagnosis are preset. For example, a patient who is admit-
increased premiums for enrollees at the top of the income ted with a stroke and no complications would be expected to
eligible; 3 states raised co-payment rates; and 7 states cut or stay in the hospital several days and then be transferred to a
restricted benefits (Smith etÂ€al., 2008). The net result is that rehabilitation facility. If the hospital can treat and discharge
vulnerable populations see-saw back and forth between health the patient earlier than the prescribed length of stay, the hospi-
coverage and no coverage. tal makes more profit. If the hospital needs to keep the patient
The federal government is anxious to reduce its share of longer, the hospital makes less profit. There are procedures for
Medicaid costs and has proposed changes to the funding mech- waivers and appeals if the patient required extra services and
anism. These changes include outright reduction in funding to hospital days.
the states and a reorganization of Medicaid into a federal block The DRG system has been expanded to other service
grant program (Patel & Rushefsky, 2006; O'Brien, 2008). These areas by the federal government. Physicians, ambulatory
efforts, if successful, will limit enrollment and reduce services to clinics, dentists, and nursing homes are some of the service
additional vulnerable groups. State governors are leery of such providers who are affected. As long as the interest in reduc-
efforts, fearing the result would be additional burdens on state ing the cost of service persists, expansion of the DRG system
Medicaid budgets. is a real possibility.
Managed care can also be viewed as a type of prospective

Â� estimated $116 to $180 billion in health care services (Patel &
Â� ayment system. HMO, PPO, and POS providers care for an indi-
p Rushefsky, 1999). During that same period, employers saved
vidual for a predetermined premium or price (see ChapterÂ€3). approximately 11% in premium costs. Since that time, the
Because these types of service provision have proven to be cost cost savings for managed care have slowed or been eliminated
effective in delivery of care, their popularity continues to increase. Â�altogether (KFF, 2010d).
Most employers include managed care plans in their health plan Quality of care has been a continuing concern in the man-
offerings. Federal and most state employees have these options. aged care market. Initially, managed care afforded limited
Some employers have limited employees exclusively to managed access to specialists or services, as a cost saving strategy. At the
care plans. The Medicare and Medicaid programs are increasing Â�present time, due to consumer pressure and state legislation,
their reliance on Â�managed care systems. access to services and specialists is much improved. There is
some information available on quality standards via state and
Managed Care, National Managed Care Companies, federal quality measures; however, few comparison studies that
andÂ€Integrated Health Systems look at quality results in managed care, as compared with other
A number of trends have been identified in the managed care Â�service providers, are available. The emphasis on evidence-
market. There is a movement toward allowing consumers more based Â�practice should provide additional research to help health
choices in service decisions. More and more people are enrolled care professionals and the consumer understand the impact of
in managed care; at the same time, the number of managed care Â�managed care on the quality of health care.
organizations is diminishing. Concerns about access and quality Managed care providers are more insulated from malpractice
of care have led to a growing effort to study these issues in the than are other types of health care providers. There have been
managed care environment. several unsuccessful efforts at the federal level to pass Â�legislation
allowing malpractice suits against managed care organizations.
Consumer Choice As a reaction to the lack of federal legislation and other quality
Consumer choice is dictating a trend away from HMOs, a more issues, 47 states have enacted legislation Â�regulating some practices
restrictive model, and toward PPOs and POSs, more permis- in managed care organizations (Patel & Rushefsky, 2006). For
sive models (Kaiser/HRET, 2011). With permissive models, example, the state of Maryland mandates that Â�pregnant women
patients have greater choice. They may designate a primary cannot be discharged from hospitals on the day of delivery and
care Â�physician. They are also allowed more flexibility in seeking that patients cannot be charged for emergency department visits
Â�out-of-network providers and services. that “any prudent layperson” would consider necessary.
Consolidation: Empires and Integrated Systems Rationing of Health Care

The movement is toward bigger and larger managed care orga- Not everyone in the United States has access to health care ser-
nizations. Most of the larger companies are for-profit and have vices. Cost-containment measures that increase out-of-pocket
continued to grow through consolidation of smaller Â�managed expenses and make health insurance unattainable for some have
care organizations. Sultz and Young (2011) refer to this trend the effect of rationing health care. Those who cannot afford care,
as a move toward managed care empires. Some experts pre- or are not included in the specialized health/welfare Â�programs,
dict that in the next 5â•›years, consolidation will reduce the do without.
number to only three to five large national companies. Others
Â�contest that claim.Â€Mechanic (2008) asserted that managed Care and Cost in a Free Market Environment
care Â�organizations that restrict Â�consumer choices and physician The U.S. economic system is biased toward a strong capitalistic or
autonomy would decline. He believed managed care will con- free market economy. This means that in general, Â�business has tra-
tinue to evolve into forms that address costs, practice rationing ditionally been allowed to operate independently, without much
of services, and reduce restrictions on consumer choices but at governmental interference. That same inclination has been fol-
the same time require greater financial contributions and cost lowed in the system or market providing health care Â�services. The
sharing by the health care consumer. private sector plays a substantial role in the Â�delivery of health care,
Integrated systems are also a growing trend. Integrated systems and private providers are free to set the price for health care services.
are large organizations that own or control a complete range of In a free market, not everyone can purchase services. As the
health care facilities and provide service to a large population of prices of services go up, the number of consumers who can
consumers, for example, Kaiser Permanente and the Department Â�participate or purchase health care goes down. In a free Â�market
of Veterans Affairs. Their goal is to provide all health care ser- economy, the price of a product determines how much will be
vices required by their enrollees. Services include inpatient and produced (supply) and consumed (demand). In the health care
outpatient care; prescription drugs; ambulatory services; home system, products include all types of care (either services or
health care; case management; physical therapy; diagnostic and goods) such as physician office visits, nursing care, dental care,
Â�laboratory services; and rehabilitative and custodial care facilities. medications, diagnostic tests, and prosthetics.
Integrated systems save money by controlling the type of Figure 4-15 shows how price influences both the production
services provided to their enrollees. The aim is to employ case (supply) and the consumption (demand) of a specific good (in
management to oversee comprehensive medical services and this case, Pill A). Note that a pharmaceutical company is willing
save money without sacrificing quality of care. to make (supply) many more of Pill A if they can charge a price
of 70 cents per pill. The consumer is more willing or able to
Quality versus Cost: A Concern afford Pill A (demand) if the price is 10 cents per pill. A price in
Managed care was successful in reducing costs of care in the middle is where the consumer and manufacturer compro-
selected areas. Between 1990 and 1996, managed care saved an mise, dictating both price (40 cents per pill) and supply.
Impact of Malpractice Insurance and Defensive

70
Medicine on Providers and Consumers
60 De There is ongoing concern that the cost of malpractice insur-
ma
nd ance might affect consumer services and costs. Periodically, in
Cost of Each Pill
50 lin response to a malpractice insurance crisis, the U.S. Congress

e
(Cents)
considers legislation to limit malpractice claims. There is little

40 Equilibrium
e price and supply evidence to suggest that malpractice insurance premiums are
in
l yl excessive and seriously affect the cost of providing care in this
30 pp
Su country (Ginsburg, 2011).
20 Even though malpractice insurance premium costs increase
and decrease in a rhythmic cycle, the overall cost of physician
10 coverage has increased over time and some companies have
10 20 30 40 50 60 70 discontinued offering malpractice insurance. In 2007, the
median malpractice premium was $12,500 with general prac-
Quantity of Pills in Thousands titioners (GPs) paying about one third less and specialists such
FIGUREÂ€4-15â•‡ How price influences supply and demand of pill as neurologist and obstetricians paying substantially more
A. The supply line shows that as the price of an item increases, (Terry, 2008). Highly specialized physicians may pay as much
production and, therefore, the amount of goods produced as $150,000 per year in malpractice insurance. Premiums
increase. When the price is high, the producer is willing to make
larger quantities, and as the price falls, the producer makes
costs vary by Â� geographical region and area. For example,
fewer pills. The demand line demonstrates how price affects Â�premiums are higher in the eastern and suburban areas and
the consumer's demand for pill A. The higher the price, the less lower in the Â�western, southern, and rural areas of the United
is the demand. When the free market operates effectively, com- States. A few physicians have responded to malpractice costs
petition forces a balance between the amount supplied and the by going bare (doing without insurance). Terry (2008) reports
amount demanded. The price of goods produced at that point approximately 4% of primary care physicians do not carry
is called the equilibrium price, 40 cents per pill in this case. If
malpractice insurance.
the price were higher, the producer would be willing to supply
a greater quantity, but the consumer would not be willing (or Not all states will allow physicians to practice without
would be unable) to purchase that quantity, and there would be Â�malpractice insurance. Some states, for example, Massachusetts,
an oversupply. If the cost were lower, the consumer would be Kansas, and Wisconsin require a minimal level of Â�coverage.
willing to buy a greater quantity, but the producer would not be Others, for example, Pennsylvania require more extensive
willing (or able) to produce the quantity in demand at that price, coverage. Some doctors have altered their practices to cut
Â�
and there would be a shortage. insurance costs. They have discontinued riskier procedures,
Â�eliminated emergency department visits, stopped hospital prac-
tice, moved to states with insurance caps, or become Â�salaried
Health Care as a Right or Privilege hospital employees. One concern is that consumers may have
If one believes that health care is a privilege based on ability to limited access to physicians in areas of higher premiums.
pay, then there is no problem with providing care via the free AÂ€study during one crisis (GAO, 2003) found no widespread
market system. Those who can afford services receive them, access problems.
and those who cannot do without. Despite its free market Hospitals have been experiencing an increase in their
leaning, the U.S. government believes that some measure of Â�customary insurance premiums. Lakawalla & Seabury (2008)
care should be considered the right of its citizens. Government Â�suggested that malpractice insurance premiums represent a
has, therefore, assumed the responsibility for financing health minute percentage of overall hospital expenses. In New York,
care for selected aggregates of the population—namely, older for example, hospitals malpractice insurance represents 3% of
adults and those from the lowest-income groups. Government fixed costs (Benson, 2011).
has, in effect, become the guarantor of last resort for specific There is concern that patient access to physicians and Â�hospital
risk groups. services might be limited because of a malpractice Â�crisis. The
Under these conditions, a true market economy for health GAO report (2003) studied nine states affected by one crisis.
care does not exist, and, some would argue, with good rea- The report found no widespread access problems at this time.
son. The increasing concern regarding the U.S. health care It reported some reduction in access for emergency surgery
system is the lack of access for many for whom government and infant deliveries predominantly in rural areas. These access
is not a guarantor of last resort. The new Affordable Care Act problems were sporadic and correlated with the difficulty of
is an attempt to expand health insurance coverage to more of recruiting and keeping physicians in those areas.
the population. Another concern is that hospitals and doctors may Â�practice
ChapterÂ€3 provides a more detailed discussion of the issues defensive medicine. Defensive medicine means that providers
surrounding lack of access and universal coverage. The American employ certain strategies solely to reduce their risk of being
Nurses Association (ANA) supports development of a system sued. Several studies (CBO, 1992a; GAO, 2003) have suggested
of universal coverage, or health care for all (ANA, 2007, 1991; that the costs of defensive medicine are highly exaggerated. It
Trossman, 2003). Whatever your personal position on this issue, found that most testing and procedures are done to reduce the
it is useful to explore the extent of access and Â�services and their uncertainty of medical diagnosis, and these would continue
impact on the health status of risk groups. You will be in a better with or without the risk of lawsuits.
position to evaluate the impact of specific remedies as they are The impact of current malpractice insurance and Â�defensive
considered and debated. medicine costs on total health care costs is small. In past
Â�
malpractice crises, studies showed a limited impact on the Â�
primary, secondary, and tertiary prevention. Currently, trends
health care budget. The CBO (1992a, 1992b) reported that are Â�heavily weighted toward expanded reimbursement for sec-
Â�malpractice premiums make up only 1% of the total health ondary and tertiary community nursing services. Although
care budget. More recently, the CBO (2009) estimated that most nurses will still be employed in hospital settings, the
Â�liability costs represent approximately 2% of the total health number of nurses involved in providing care for those with
care Â�budget. According to the latest estimate by Mello and illnesses and disabilities in the community will increase. The
Kachalia (2010), the cost of malpractice is limited to 2.4% (55.6 overriding reason for these expanding opportunities is cost.
Â�billion) of health care costs. Most of that is connected with The strategies for cost containment already mentioned, cou-
defensive medicine, and only an amount of $10 billion (18%) pled with a Â�number of other factors, are responsible for the
was found to be the result of malpractice premiums or settle- growth in community-based services. Some of these other
ments. Nevertheless, efforts at tort reform are being Â�continued. Â�factors are as follows:
If successful tort reform will not have a major impact in reduc- • The DRG system has resulted in a reduction in the average
ing health care costs. According to the CBO (2009) estimate, length of hospital stay. Patients are discharged earlier and
the attempted reforms would have lowered insurance costs more frequently require nursing service in the home (Rice &
somewhat, resulting in a slight reduction in national health Komenski, 2007; Sultz & Young, 2011).
care costs (0.2%). • The financial cost of institutional care is greater than the cost
of providing support services in the home and community.
Expanded Insurance Coverage and Effects of As a result, government and insurance payers are expanding
HealthÂ€Care Reform their coverage of community support services as a substitute
Gradually, in the past 40â•›years, the health care system in the for or as a means of delaying institutional care (Harrington,
United States has moved to expand health benefits and health 2012; Kitchener etÂ€al., 2005).
insurance to targeted groups: women and children, older • With the aging of the U.S. population, it is probable that
adults, those with disabilities, and low-income families that there will be a larger population of older adults with chronic
are above the poverty level. Medicaid has expanded to low- illnesses requiring care, which thus expands the market for
income Â�populations it had previously excluded. Medicare has community services (Harrington, 2012).
expanded its categories of persons with disabilities. The states, • The search for less costly labor substitutes will enhance
through Medicaid and other programs, have acted to include the use of nursing services to provide additional care in
more lower-wage workers and their families in health insur- the Â�community (Brewer, 2005; Sochalski, 2002; Sultz &
ance Â�programs. The federal government has moved to protect Young, 2011).
workers from lack of insurance due to employment changes or • Care provided by nurses in independent practice settings
Â�preexisting health problems. demonstrates high levels of quality and patient satisfaction
The Affordable Care Act will continue to facilitate incremen- (O'Grady & Ford, 2012; Price, 2012).
tal changes as insurance coverage is extended to more Â�people The last factor on the list above has generated some con-
and health benefits are expanded. Managed care will play a flict. Traditionally, physicians and the AMA have resisted direct
preeminent role in these changes. The states will address the third-party payment for nursing services (Price, 2012). In addi-
problems of low-income workers by expanding the Medicaid tion, there has been resistance from private and public third-
program, requiring employers to provide coverage, and expand- party payers, although Medicare now provides reimbursement
ing the high-risk pools to lower insurance costs. The federal for nurse practitioners and clinical nurse specialists.
government has passed a prescription drug benefit, Medicare D, The ANA supports nurses receiving reimbursement for
for senior citizens. It has been suggested that Medicare can be care by third-party insurers. Restriction on reimbursement
adjusted to allow workers without insurance and early retirees has resulted in restricted practice areas for nursing as long
to buy into that plan or Medicaid. as Â�consumers must personally bear the cost of such services.
As people and benefits are added, we can expect to see greater Allowing third-party reimbursement for independent nursing
restrictions on individual choices to cut costs. For example, services will dramatically increase the demand for such Â�services.
Â�prescription drugs will be limited to generics, and managed care Most states have passed legislation authorizing Â�independent
might become the only employer-provided health insurance practice and reimbursement to nurse practitioners from Â�private
option. These changes will be accompanied by greater cost shar- and commercial insurers. Many states have placed limitations on
ing for health care services. Co-payments and deductibles will independent practice such as physician supervision or restric-
rise as government and employers seek to limit their shares of tions on prescriptive privileges, although it has been authorized
health care costs. Medicare and private health insurance could (Fairman etÂ€al., 2011; O'Grady & Ford, 2012). As cost-cutting
change from a defined benefit to a defined contribution plan. measures become more prevalent, the possibility of expanding
Government or the employer will contribute a fixed amount practice and direct reimbursement is higher.
into the consumer's account. It will be up to the consumer to The federal and state governments have played a major role in
decide how to spend it (Park etÂ€al., 2003; Pulcini & Hart, 2012). expanding third-party reimbursement for nurses, especially in
If health care costs are greater than the amount deposited, the government-financed health programs (O'Grady & Ford, 2012).
additional costs will be borne by the consumer. Federal employee insurance plans are authorized to make direct
payments to nurse practitioners and clinical nurse special-
Reimbursement for Community/Public Health Nursing ists. The federal government supports community health cen-
Services ters that receive direct payment for nursing services. Currently,
In the near future, the role of nursing in community settings there are more than 1200 such centers, 250 of which are nurse-
can be expected to expand in all three areas of prevention: managed health centers (Hanson-Turton etÂ€al., 2010; National
Association of Health Centers, 2011). Health Â�center projects The information that a nurse supplies to clients can reduce or
aim at increasing independent nursing practice in the commu- eliminate some of the financial burdens imposed by illness, as
nity. Community health centers act as a safety net, Â�providing well as secure access for primary care, health promotion, and
services to geriatric populations and to rural and urban under- health protection (e.g., immunizations).
served populations. These centers serve more than 24 million
persons each year, 66% of whom are below the Â�poverty level. Advocating for Clients in Appeal Processes
Funding is expanded under the new Affordable Care Act, with Clients might apply for help and find that they have been
$100 million to existing centers and an additional $600 million denied service. Although most agencies should take time to
for new centers (KFF, 2011b). inform clients of their options, many clients might be confused
about their rights of appeal and the reason for denial. There are
THE NURSE'S ROLE IN HEALTH CARE FINANCING a number of ways nurses can advocate for their clients in the
appeal process.
Nurses are not accustomed to considering themselves part First, ascertain the reason for denial of the claim. Frequently,
of the decision-making process involved in financing and inadequate information was supplied to the agencies. If this is
Â�reimbursement for health care services. Nursing practice has the case, helping the client to complete the application Â�correctly
only relatively recently begun to emphasize this aspect of might be all the action needed. Other ways nurses can be
Â�delivering care. Nurses generally become aware of the impact Â�advocates include exploring the appeals method, personally
of finances through their own personal or professional expe- contacting personnel within the agency to verify information
riences. In community health practice, it is more likely that or provide additional data, and enlisting the services of other
nurses are aware of the financial concerns related to delivery of experts who might assist the client in the process.
care because of the longer period of involvement with clients
and the emphasis on the psychosocial and family issues related Identifying Alternative Sources of Payment
to care. Various sources of services are available, especially within
Nurses can initiate or facilitate care for clients in the urban communities. If one program or agency has denied
Â�community setting in a number of ways. Only a few are Â�discussed benefits to the client, other sources should be sought. As a
here. Once nurses become sensitive to the link between finances nurse becomes proficient in identifying possible resources,
and the acquisition of services, they will be able to devise she or he will become more expert at locating other potential
Â�additional strategies. service resources.
Referring Clients for Benefits and Services Providing Documentation to Ensure Reimbursement
Client referral is the simplest of nursing actions and one that Agencies and programs have become increasingly insistent on
can provide great benefit and financial relief to clients. Often, adequate documentation of services. Programs continually
it is just a matter of matching clients to existing programs for monitor claims for benefits to ensure that they meet selected
which they qualify. However, to do so, nurses will need base- standards. When documentation is not in a format acceptable
line data on their local community services (i.e., local, state, to the agency, there is a risk that nursing services will not be
and federal benefit programs) and on the insurance coverage of covered. Even if the provided nursing services are considered
respective clients. This does not mean that nurses must become reimbursable by the program, nurses should document in a
experts in program criteria, application processes, and benefit way that makes clear to the agency that the specified service has
packages, but they should become aware of existing programs, been provided.
the types of clients who are generally served by those programs, Inadequate or incomplete documentation of provided
and the names and phone numbers of the initial contact p Â� ersons services has implications for both employers and clients.
for such programs. Agencies must provide correct paperwork to recoup their
Some of the major state and federal benefit programs costs for services. Similarly, a nurse's client might incur unex-
have been discussed in this chapter, along with some general pected Â�out-of-pocket expenses because the client has to pay
Â�criteria for eligibility. This information will allow you to screen for Â�covered services that should have been reimbursed by the
Â�potential program-client matches. Remember that the selection insurance company. Complete and accurate nursing records
criteria change from time to time, so your actions should not be reduce these risks.
directed toward narrowly applying selection criteria. Your role
is to identify potential client–program matches, interpreting Collecting Data to Evaluate the Impact of
Â�eligibility criteria broadly and leaving the reimbursing agency Reimbursement Mechanisms
to conduct a more stringent investigation. As noted earlier, there are consequences of the reimburse-
There are many community programs and resources that ment structure. Some of these are intended; others are unin-
have not been listed or examined in this chapter. Each com- tentional. Health care professionals are concerned that there
munity health nurse will, in the course of practice, devise her might be additional unintended consequences of the DRG
or his own community resources list and become familiar system. The DRG system encourages hospitals to reduce a
with the services
Â� that such resources can provide. It takes 3 to patient's length of stay. Longer stays are not profitable for hos-
6â•›months for a community health nurse to devise a basic list pitals. Health care professionals are concerned that patients are
of Â�community resources that includes both widely known pro- being Â�discharged in a sicker state and in need of more skilled
grams and those that are unique to the individual community. community Â�services than was previously the case. There is an
As the community health nurse becomes more proficient in her ongoing debate with respect to whether early discharge trans-
or his practice, the list of references and resources will grow. lates into poorer outcomes.
Community nurses who provide care to older adults and resent or support their views on health care needs. Thus,
other patients after hospital discharge are an invaluable source nurses can be an effective force in putting health care issues
of data to assist with risk assessment of early discharges. As on the public agenda.
this and other reimbursement mechanisms change and Â�service It is imperative that nurses become involved in the decision-
Â�practices are altered, nurses have a unique opportunity to making processes related to delivery of health care services and
Â�collect data regarding the implications of such mechanisms reimbursement, as nursing practice is affected by such issues.
and practices for health and health care delivery practice in Moreover, community health nurses and other public health
the community. professionals have always demonstrated concern for the social
implications of health care delivery, particularly the issues of
Lobbying for Legislative and Administrative Changes equity and accessibility of care.
One of the most effective ways to affect health care delivery and As a member of the nursing profession, you can support your
reimbursement is through political action, an avenue on which representative organization's position on health care issues. You
the nursing profession continues to concentrate more attention. might want to become active in nursing organizations and help
One in every 10 women voters is a registered nurse; thus, set the agenda of health concerns addressed by your Â�profession.
the potential for political influence is enormous. Nurses can The ANA developed a policy statement, Nursing's Agenda for
Â�influence legislation in several ways. As individuals, they can Health Care Reform (ANA, 2008). The Â�policy statement addresses
become more involved in the process by identifying their the appropriate use of managed care and the Â�nursing commu-
state and federal representatives and contacting them on nity's role in shaping managed care. The Â�support of every nurse
important health issues. Nurses can become active in their will be crucial to nursing's success at using the political process
affiliated party or in campaigns for individuals who rep- to address health goals.
KEY IDEAS
1. The practice of nursing in community and hospital settings 7. Medicare and Medicaid costs are a growing problem in gov-
can be limited or directed by the cost of delivering health ernment budgets, and these programs provide only limited
care services. health care services to certain populations. Medicaid pro-
2. Nurses need to know about the financing system of health vides health care services to less than 50% of the population
care to understand its impact on individual clients and their below the poverty level.
health status. 8. Poverty is linked to poor health, limited access to health
3. Health care in the United States is costly and is rationed by care services, and delay in seeking such services. Cost-
people's ability to pay. containment measures that result in less access are not
4. Certain groups are at greater risk of limited access to health cost productive. Acute and delayed care is ultimately more
care services because of cost. The three groups at greatest costly than preventive services and immediate treatment.
risk are older adults, the medically indigent, and children 9. Managed care has become the most common form of
from low-income families. health care delivery to both public- and private-sector
5. Health care is financed by a variety of options Â�(i.e., self- health care markets.
payment, health insurance, and health assistance programs). 10. Health care costs, universal access to care, and the quality of
Medicare is a government-operated health insurance pro- health care are ongoing, often competing concerns in health
gram. Medicaid and CHIP are government-operated health care delivery in the United States.
assistance programs. 11. The Patient Protection and Affordable Care Act of 2010 is
6. Employers have attempted to curb their costs by Â� placing designed to increase health care access to a greater propor-
restrictions on the types of services covered under their health tion of this country's citizens, while increasing the quality
insurance plans, by limiting their employees' plan options, by of health care and the ease of health care delivery.
negotiating with health care providers for reduced fees, and by
increasing the employees' share of health insurance premiums.
1. Develop your ideas for the “ideal” method to finance health Discover how much and what kinds of their medical bills
care delivery in the United States. How similar to or dif- Medicare pays. Ask if they would be willing to talk to you
ferent from the present system for financing health care is about their out-of-pocket expenses for medical care, includ-
your method? ing deductibles and co-payments under Medicare. Consider
2. Identify the groups that are affected by the way health care how these expenses might affect their ability to purchase
is delivered and paid for in this country. How might each of other necessities such as food, shelter, and clothing and how
these vested interests be affected by your “ideal” method of much is left to purchase incidentals and leisure treats.
financing health care? For those who would be affected by 4. Find out your state's cap for Medicaid eligibility for a fam-
the change (if any), consider how you might present your ily of three. What percentage of the current poverty level is
position to convince them to support your proposal. your state's eligibility cap—30%, 50%, 70%, or some other
3. Interview some senior citizens. What kind of experiences percentage? Plan a 1-month budget for a family of three for
have they had with health care services? Do they have any minimally adequate food, clothing, and safe shelter. Include
chronic conditions that require sustained medical care? the costs of a telephone, electricity, and fuel. Compare your
state's Medicaid cap for this fictional family with your 5. Review your current health insurance status. If you have
monthly budget. Is the capped income more or less than coverage, who provides this coverage? If your health care is
your expected monthly costs? If less, consider what you employer provided, what are your premiums, and what is the
might be willing to forgo paying for or purchasing. What if cost to your employer? Are there limits to your benefits? If so,
you had additional expenses, including medical costs? How what kind? Do you have a co-payment and/or deductible? If
would you restructure your budget to meet these unexpected so, how much are they? Does your insurance plan provide a
expenses? Is this achievable? catastrophic health benefit?
WEBSITE
STUDY AIDS
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NY: M. E. Sharpe. Mal carriers is good news to physicians. Medical American Nurses Association. (2007). Access to
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(6th ed.; pp. 162-168). St. Louis: Saunders. States. TableÂ€155. Washington, DC: Author. policy: Crisis and reform in the U.S. health care
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Jones & Bartlett. Washington, DC: Author. (7th ed.). Sudbury, MA: Jones & Bartlett.
CHAPTER
5
Global Health
Helen R. Kohler and Frances A. Maurer
FOCUS QUESTIONS
What is the concept of global health? What epidemiological transition is occurring?
Why are health disparities an important global concern? What features distinguish health care delivery systems?
How do intergovernmental and nongovernmental Which criteria are used to compare the effectiveness of health
organizations work to address health issues in the world? care delivery systems?
Which countries have higher rates of deaths from malnutrition What types of concerns are common to all forms of health care
and infectious diseases? delivery systems?
Which countries are more concerned about chronic How can nurses participate in the global health effort?
health conditions?
CHAPTER OUTLINE
Health: A Global Issue Health Care Systems in Developed Countries
Health Disparities among Countries Health Care Systems in Developing Countries
International Health Organizations Issues in Health Care Delivery Systems
Intergovernmental Organizations New and Emerging Health Issues
Voluntary Organizations Old and New Emerging Infectious Diseases
Health and Disease Worldwide Environment
Major Global Health Problems Tobacco Use
Problems Common to Developing Countries Terrorism, War, and Natural Disasters
Problems Common to Developed Countries Mental Illness
Health Care Delivery Systems Role of Nursing in International Health
KEY TERMS
Alma-Ata conference Globalization of health United Nations Children's Fund
Beveridge model Health disparities (UNICEF)
Bismarck model Health for All U.S. Agency for International
Centers for Disease Control and Intergovernmental organizations Development (USAID)
Prevention (CDC) Millennium Development Goals Voluntary organizations
Emerging infectious diseases Pan American Health Organization World Bank
Epidemiological transition (PAHO) World Health Organization (WHO)
Global Health Council (GHC)
HEALTH: A GLOBAL ISSUE

region, and people everywhere are in constant electronic commu-
It is a small world. Even though the population of the world will nication. “The explosion of cell phones in the developing world,
soon be 7 billion people (United Nations Population Fund, 2011) particularly in Africa” (where the majority of the Â�people have
distributed throughout more than 200 countries Â�worldwide, we access to a phone), has made expansion of new strategies for
are increasingly becoming a global community. Any Â�commodity or better health possible (Bristol, 2009). “Twitter, Facebook and
condition is only a plane flight away from any other Â�geographical smartphone apps have become the latest tools in the Â�public
113
114 CHAPTER 5â•… Global Health
health and disaster preparedness fields.” Information and However, Â�developed countries cannot guarantee their citizens
warnings about the March 16, 2011, earthquake and tsunami Â�protection from external disease sources. More than two Â�million
in Japan “were tweeted and texted as they occurred” (Tucker, Â�people Â�cross-national boundaries daily. It takes only a single
2011). Geographical information systems (GIS) are used to map Â�traveler with an undetected illness to expose many people, and
disease outbreaks and available health facilities to identify Â�sometimes many countries, outside his or her native land.
vulnerable populations most in need of preventive and curative
services (University of North Carolina, 2007; Yeoman, 2010). HEALTH DISPARITIES AMONG COUNTRIES
More people travel, travel is more rapid, and the boundaries
between nations are more fluid, and so we need to think of health, The health status of populations is greatly influenced by income
illness, and disease from a global perspective. Highly infectious level and therefore varies widely among countries, as shown by
diseases can circle the world rapidly, as the recent severe acute the health status indicators in TableÂ€5-1. Developed countries are
respiratory syndrome (SARS) epidemic and the H1N1 influenza richer and more economically stable. These countries can provide,
(“flu”) epidemic illustrate (see ChaptersÂ€7 and 8). It is almost in addition to other things, a better standard of health and health
impossible to isolate a contagious disease within the country of care for their citizens. Developed countries include Australia, the
origin. Other countries also face the risk of exposure. No nation United Kingdom, Germany, and the United States, among others.
can afford to become complacent. For example, the continued Underdeveloped or developing countries are poorer, often econom-
spread of human immunodeficiency virus/acquired immuno- ically unstable, and have less ability to provide health care for their
deficiency syndrome (HIV/AIDS) worldwide was partially the citizens. Social disruptions and wars also affect health in negative
result of complacency. Some countries were slow to recognize ways. Some examples of developing countries include Ethiopia, the
the threat of HIV/AIDS, others denied that the threat existed, Honduras, Vietnam, Malawi, and Rwanda. In very poor couÂ�ntries
and still others thought geographical distance from the initial such as Malawi and Rwanda, approximately 75% of the Â�population
epidemic protected them from the threat. was living on less than $1 a day in 2007 (World Health Organization
Countries with highly sophisticated medical systems are not [WHO], 2010a). Somewhere in between are middle-income coun-
immune to external health risks. They cannot isolate them- tries. These are countries that are progressing along the develop-
selves from exposure risks. Developed countries are more ment spectrum but have not achieved the same standard of living as
equipped to provide highly specialized care than are poorer that of developed countries. Brazil, China, Mexico, and Turkey are
developing countries. The former have more sophisticated examples of middle-income countries. These countries tend to pro-
resources to treat diseases and possess more stringent surveil- vide a standard of health care that is higher than that of poor coun-
lance and protection
Â� measures to reduce the risk of disease. tries but lower than that of developed countries.
TABLEÂ€5-1â•…â•‡INTERNATIONAL COMPARISON OF HEALTH INDICATORS FOR SELECTED

COUNTRIES: 2008
INDICATORS
LIFE EXPECTANCY INFANT MORTALITY RATE GROSS NATIONAL INCOME
COUNTRY AT BIRTH PER 1000 LIVE BIRTHS PER CAPITA (IN DOLLARS)
Low-Income Economies
Haiti 62 54 1180
Kenya 54 81 1580
Nepal 63 41 1120
Pakistan 63 72 2700
Sierra Leone 49 123 750
Uganda 53 84 1140
Middle-Income Economies
Brazil 73 18 10,070
China 74 18 6020
Costa Rica 78 10 10,950
Indonesia 67 31 3830
Jamaica 72 26 7360
Mexico 76 15 14,270
Thailand 70 13 5990
High-Income Economies
Australia 82 4 34,040
France 81 3 34,400
Germany 80 4 35,940
Japan 83 3 35,220
Sweden 81 2 38,180
United States 78 7 46,970
Data from World Health Organization (WHO). (2010). World health statistics 2010. Geneva: Author.
CHAPTER 5â•… Global Health 115
The health of the population in developing countries is The Declaration of Alma-Ata serves as a blueprint based on
Â�
dramatically impacted by poverty. Poorer countries have higher which countries can plan improvements to health services and
rates of death, disease, and disability. Children in develop- health status for their citizens (much as the Healthy People 2020
ing countries suffer from malnutrition and premature death. goals serve as a roadmap for improving the health of the U.S.
Infectious diseases such as malaria, meningitis, and cholera, population). The World Health Assembly expects these efforts
almost nonexistent in developed countries, are rampant in some to be a partnership among the country's leaders, health infra-
poorer nations. Life expectancy in these countries is shorter. For structure (organizations), communities, individual citizens,
example, the life expectancy in Japan is 83â•›years; in the United and, to some degree, other countries.
States, 78â•›years; in China, 74â•›years; and in Zimbabwe, experienc- At the United Nations (UN) Millennium Summit in New York
ing social unrest and high HIV/AIDS prevalence, just 42â•›years City in September 2000 (22â•›years after the Alma-Ata Â�conference),
(WHO, 2010f). the largest gathering of world leaders in history, represent-
Health disparities, the unequal levels of health among ing 189 nations, adopted the UN Millennium Declaration.
nations, are an ongoing concern of health care professionals The global representatives present committed themselves to
and world leaders. At the Alma-Ata conference, a Joint World giving a very high priority to elimination of worldwide pov-
Health Organization /United Nations Children's Fund (WHO/ erty by 2015 (WHO, 2004). The eight specific Millennium
UNICEF) International Conference on Primary Health Care Development Goals contained in the Declaration are the
held in 1978 in Alma-Ata, USSR (now Almaty, Kazakhstan) and following (Jacobsen, 2008, p.283; Uys, 2006):
attended by representatives of 143 nations, the WHO renewed 1. Eradicate extreme poverty and hunger
its goal of Health for All everywhere. This was a commitment to 2. Achieve universal primary education
the social justice of eliminating health disparities (WHO, 1998, 3. Promote gender equality and empower women
2000). As defined at the Alma-Ata conference, primary health 4. Reduce child mortality
care should encompass the following (WHO, 1978): 5. Improve maternal health
• Education about health problems and the means to prevent 6. Combat HIV/AIDS, malaria, and other diseases
or control them (country specific) 7. Ensure environmental sustainability
• Improved food supply and adequate nutrition for the 8. Develop a global partnership for development
population The governments of the 22 wealthiest donor nations in the
• Safe water and sanitation world agreed to commit 0.7% of their gross domestic prod-
• Maternal and child health care uct (GDP) by the year 2015 toward the accomplishment of the
• Immunization against infectious diseases Millennium Development Goals. FigureÂ€5-1 shows the extent to
• Prevention and control of endemic diseases which these nations have met their commitments 5â•›years after the
• Adequate treatment of common diseases and injuries summit meeting (UN Millennium Project, 2006; Organization
• Adequate and appropriate drug supplies for Economic Co-operation and Development [OECD], 2010).
Sweden
Luxembourg
Norway
Denmark
Netherlands
Ireland
Belgium
Spain
Finland
Austria
United Kingdom
Switzerland
France
Germany
Canada
Australia
New Zealand
0.70 UN Target
Portugal
Italy
Greece 0.48 Avg. Country Effort
Japan
United States
0 0.2 0.4 0.6 0.8 1

As a Percentage of Gross National Income
FIGUREÂ€5-1â•‡Government Aid to Official Development Assistance as a percentage of gross
national income 2008. (Data from Organization for Economic Co-operation and Development [OECD].
[2010]. OECD FactBook 2010. Paris, France: Author.)
The Pan American Health Organization (PAHO) and its col- how the worldwide recession which began in 2008 will affect the
laborators in the Disease Control Priorities Project published attainment of these goals.
the “Top 10 Best Buys” of health interventions for developing
countries (Eberwine-Villagran, 2007). “Best buys” are interven- INTERNATIONAL HEALTH ORGANIZATIONS
tions for which the money, time, and effort invested have a sub-
stantial effect on health and reduce health disparities in poorer Attempts to improve the level of health worldwide are a mul-
countries. Some are relatively simple, whereas others require tiorganizational effort. Both intergovernmental and voluntary
serious national or international commitment. The 10 interven- agencies focus on global health problems.
tions are listed in BoxÂ€5-1.
It must be remembered that to be more than empty slogans, Intergovernmental Organizations
the Alma-Ata Declaration of Health for All, the UN Millennium Intergovernmental organizations are agencies in which
Development Goals for reducing global poverty, and the des- Â�official representatives of various countries’ governments work
ignated Top 10 Health Interventions of the Disease Control together to improve health status. The agency can involve many
Priorities Project require political will and commitment plus countries (multilateral agencies) or just two countries (bilateral
predictable and sustained funding. agencies). The most well-known is the WHO.
The concept of globalization of health recognizes that barri-
ers between countries are blurring, that health issues cannot be World Health Organization
isolated within one country, that large health disparities among The World Health Organization (WHO) is a multilateral
countries are ultimately harmful to everyone, and that health agency involving approximately 193 countries. It was founded to
for the world's population should be the goal of every coun- be “the world's health advocate” more than 50â•›years ago (WHO,
try. The WHO has made the elimination of health disparities 1998). Although it is associated with the UN, it has its own bud-
its primary goal (Wagstaff, 2002). Although some progress has get and decision-making processes. Policy decisions and direc-
been made, much remains to be done. Even though the global tion are decided by delegates of the member nations at their
strategy of Health for All was endorsed by 143 countries at annual World Health Assembly held in Geneva, Switzerland.
Alma-Ata in 1978, it remains a statement of aspiration, not a The WHO is funded by fees and voluntary contributions from
reality (Novelli, 2005). With respect to meeting the Millennium member countries.
goals, much remains to be done by 2015. Former UN secretary- The WHO provides both technical support and health care
general Kofi Annan observed that there is still time for achieve- services to member nations, with an emphasis on poorer coun-
ment, but only “if we break with business as usual” and exert tries. It directs and coordinates international health projects,
the sustained action required (Uys, 2006). It is yet to be seen collaborates with other organizations and agencies in health
care programs, and monitors and reports on worldwide dis-
ease conditions, much like the Centers for Disease Control and
BOXÂ€5-1â•…â•‡TOP TEN BEST BUYS OF HEALTH Prevention (CDC) does for the United States.
INTERVENTIONS The WHO is leading the effort to establish international stan-
dards for medications and vaccines. One standard will ensure that
â•‡1. Vaccinate children against major childhood killers, including mea- the quality and dosage of medications are safe and at therapeutic
sles, polio, tetanus, whooping cough, and diphtheria.
levels. It also operates thousands of individual country projects,
â•‡2. Monitor children's health (using the Integrated Management of
usually in conjunction with the country's health ministry, the gov-
Childhood Illness strategy) to prevent and treat childhood dis-
ernmental body responsible for health care. Countries receive help
eases such as pneumonia, diarrhea, and malaria.
â•‡3. Levy taxes on tobacco products to increase their cost by at least with health planning—for example, distribution or establishment of
one third in order to discourage smoking and reduce smoking- health care services. The WHO helps run immunization programs,
related diseases. build health care infrastructure, and improve sanitation levels.
â•‡4. Mount a coordinated attack on the human immunodeficiency
virus (HIV) epidemic that includes promoting 100% condom use Pan American Health Organization
in at-risk populations; treating other sexually transmitted infec- The Pan American Health Organization (PAHO), established
tions; providing antiretroviral treatment, especially for pregnant in 1902 as an independent public health organization, now
women; and offering voluntary HIV testing and counseling. functions as a quasi-independent branch of the WHO. Part of
â•‡5. Provide children and pregnant women with essential nutrients, the PAHO's budget comes from the WHO and from other UN
including vitamin A, iron, and iodine, to prevent maternal anemia, agencies. The PAHO serves as a regional office of the WHO,
infant deaths, and long-term health problems. limited to the Americas, or the western hemisphere. There are
â•‡6. Provide insecticide-treated bed nets in malaria-endemic areas to 25 member countries.
reduce malaria rates The primary mission of the PAHO is to strengthen interna-
â•‡7. Enforce traffic regulations and install speed bumps at dangerous tional and local health systems to improve the health and liv-
intersections to reduce traffic-related injuries. ing standards of the population of the Americas. It provides
â•‡8. Treat patients with tuberculosis with directly observed short- expertise on disease and environmental management, sup-
course therapy to cure infected people and prevent new infections. ports research and scholarship efforts, and monitors diseases.
â•‡9. Teach mothers and birth attendants to keep newborn babies The organization has a major emphasis in Latin America, an
warm and clean to reduce illness and death. area of great need. The PAHO has worked hard to provide
10. Promote the use of aspirin and other inexpensive drugs to treat
childhood immunization and other methods of care to reduce
and prevent heart attack and stroke.
infant mortality. For example, the celebration of the ninth
From Eberwine-Villagran, D. (2007). Best buys for public health. Annual Vaccination Week in the Americas (April 23-30, 2011)
Perspectives in Health, 11(1), 2-9. brought the total number of individuals immunized against
Â�
vaccine-preventable diseases to over 323 million (PAHO, 2011). experts in the field are dispatched to the country in need, where
Several other WHO regions initiated vaccination weeks during they consult with the country's health care professionals and
that time, moving toward a global disease prevention effort. provide equipment and health resources as needed to develop a
comprehensive plan for disease control or elimination.
United Nations Children's Fund
The United Nations Children's Fund (UNICEF) (formerly the Voluntary Organizations
United Nations International Children's Emergency Fund) con- A wide variety of nongovernmental voluntary organizations
centrates its efforts in the area of maternal and child health. It assist in the effort to improve worldwide health. These volun-
is currently working in 190 countries (UNICEF, 2011a). It is an tary organizations are frequently referred to as nongovernmental
agency of the UN, from which it receives funding. In the past, organizations (NGOs). NGOs are not affiliated with a particular
UNICEF has concentrated on the control of specific commu- government, although some might work in conjunction with
nicable diseases. Although still maintaining that focus, it has a governmental agency on a specific project. Most developed
expanded into the area of primary prevention. More recent countries have nongovernmental organizations that operate in
efforts are geared toward ensuring fresh water and safe food health-related activities in developing countries.
supplies and providing health education for mothers, educa- In the United States, some religious groups operate health-
tion for girls, and immunization programs aimed at reducing related assistance programs for underdeveloped countries.
or eliminating vaccine-susceptible communicable diseases. Protestant denominations and the Catholic Church oper-
ate missions that serve selected countries (e.g., countries in
World Bank Africa, Asia, and South America). The Church Rural Overseas
The World Bank was established in 1944 to fight poverty by Project, which began as an organization sending food relief to
helping people to help themselves and their environments. post–World War II (WWII) Europe, now provides worldwide
It provides resources and shares knowledge through partner- emergency aid, long-term self-help projects, and assistance to
ships in the public and private sectors. Examples are provid- refugees from war-torn or famine-plagued countries.
ing low-interest loans and grants to developing countries for Some examples of religiously affiliated health aid organiza-
improvements in education, health, agriculture, and natural tions are Lutheran World Relief, Seventh Day Adventist World
resource management. Service, American Friends Service Committee, and Catholic
The World Bank is “not a bank in the common sense,” since it Relief Services. These groups operate hospitals and clinics as well
is composed of “two unique development institutions owned by as schools. Some groups provide health-related education in an
187 member countries.” It has over 100 offices worldwide, and is effort to increase the number of local health care professionals
headquartered in Washington, DC (World Bank, 2011). available to communities. Church organizations provide both
permanent and temporary staff for these endeavors. Catholic
Agency for International Development nuns and priests, Protestant pastors, and other religiously affili-
The U.S. Agency for International Development (USAID) is an ated personnel spend years or even their whole careers in mission
arm of the U.S. State Department. The USAID provides expertise work. Some health care professionals volunteer a year of service
and funding to countries that need economic development. The or do periodic work—for example, 1â•›month per year for special
USAID is an example of a bilateral agency in which one donor, projects. Some examples of these activities are the following:
in this case the United States, works with one recipient coun- • Surgical visits for the repair of cleft lip and palates
try. Other governments provide similar services to developing • Immunization projects such as measles vaccination
countries. Most of the USAID activities that are publicized are • Water supply projects such as digging wells for a village
related to agricultural and infrastructure development. In the or community
course of these activities, sanitation and water supplies, essen- • Home and other construction projects such as building a
tial elements for increasing the level of health in populations, clinic facility in a community with no previous structure, or
are also improved. In 2007, the USAID was also assisting many constructing or repairing a school building
countries with activities to combat avian flu, mostly by provid-
ing grants and technical assistance (USAID, 2007). In 2009, it
Tanya Jensen, an operating room nurse at Cleveland General
procured 42 million poultry avian flu vaccine doses for distri-
Hospital, is an active member of her church. One Sunday, Pastor
bution by the Indonesian Ministry of Health. The USAID also
Rifkin, a missionary working in Peru, spoke to the assembly
provides millions of bed nets for malaria prevention and hos-
about his church work. Tanya approached the pastor to ask him
pital equipment worth millions of dollars for the world's poor-
more about the medical problems he had encountered in that
est regions (USAID, 2009b). Its continuing work in Afghanistan
country. Pastor Rifkin mentioned that he and other missionar-
will be discussed in the section on War and Terrorism below.
ies had located 30 children in need of correction of cleft lip and
Centers for Disease Control and Prevention palate. Tanya volunteered to be a member of the surgical team
that the pastor was trying to organize. Four months later, Pastor
The Centers for Disease Control and Prevention (CDC), an
Rifkin called Tanya to say that he had been successful in locat-
agency of the U.S. Department of Health and Human Services
ing a surgeon volunteer, and a mobile hospital surgery unit was
(USHHS), provides expertise in controlling and preventing dis-
temporarily donated by another church group. Tanya agreed to
ease. Based in Atlanta, Georgia, it directs ongoing health-related
help. Two months later, Tanya spent 2â•›weeks in Peru. She and the
programs through the International Health Program Office. The
rest of the surgical team operated and provided postoperative
agency is also available for consultation during emergencies such
care for 52 children. The list of candidates grew as word about
as the 2003 SARS outbreak, the H1N1 flu pandemic of 2009, the
the project spread. Tanya found her time in Peru so rewarding
cholera epidemic in Haiti in 2010, and the Echerichia coli (E. coli)
that she volunteered to do another trip the following year.
outbreak in Germany in 2011. In instances of disease outbreaks,
Global Health Council preventive measures have been in wide use in developed Â�countries
The Global Health Council (GHC) is “the world's largest mem- for over a century. For this reason, people in developed coun-
bership alliance dedicated to saving lives by improving health tries have a better level of health, live longer, and eventually suf-
throughout the world.” Its mission is to provide information fer and die from chronic illnesses. The most frequent diseases in
and resources needed for successful work toward global health developed countries are heart disease, stroke, and cancer (WHO,
improvement. It serves and represents thousands of public 2011k). Because these illnesses result in shorter morbidity and
health professionals from more than 103 countries on six conti- quicker mortality in regions with scarce resources, 80% of deaths
nents (Global Health Council, 2011b). caused by them in 2008 were in low- and middle-income coun-
tries. Globally, noncommunicable diseases now account for nearly
Other Service Agencies two thirds of all deaths (United Nations News Centre, 2011).
Many organizations are involved in health service to develop- In the twentieth century, the general trend was toward
ing countries. Some of these are foundations, privately funded increasing life expectancy. That trend was diminished by the
philanthropic organizations, or other types of service agencies. HIV/AIDS pandemic. Some areas, for example, India and parts
A selection of these organizations is listed in BoxÂ€5-2. There are of Africa, were more affected by the pandemic than others. HIV/
many more voluntary organizations engaged in improving the AIDS has produced more devastation in poor countries with
status of health worldwide. few economic resources and inferior health care infrastructures
to fight the disease. TableÂ€5-1 illustrates the relationship between
HEALTH AND DISEASE WORLDWIDE health and economic status. Countries with relatively low stan-
dards of living have high infant mortality rates and a shorter life
There is wide disparity in health status among nations. As a span; for example, Sierra Leone had an infant mortality rate of
general rule, health status is inversely related to wealth. The 165 per 1000 live births and a life expectancy of 38â•›years at the
poorer the country, the more likely its citizens are to experi- end of its civil war. As a country's economic prospects improve,
ence preventable diseases and early death. Excessive deaths infant mortality rates fall, and life expectancy increases. For
from communicable and vaccine preventable diseases are still example, Japan has an infant mortality rate of 3 per 1000 live
occurring in developing countries. However, the epidemiolog- births and a life expectancy of 83â•›years (WHO, 2010f).
ical transition of chronic diseases (many of them preventable)
replacing deaths from infectious diseases worldwide is well Major Global Health Problems
underway. Only the poorest countries still have infectious dis- Worldwide health problems can be divided into two catego-
eases among their 10 leading causes of death (WHO, 2011k). ries. First are the easily preventable conditions and treatable
There are 150 million people worldwide who now have type infectious diseases. These are the types of problems still com-
2 diabetes, and that number is projected to double by 2025 mon to developing countries. For the most part, these con-
(Eiss and Glass, 2011). Unhealthy diet and lifestyle leading to ditions are easy to fix with adequate numbers of health care
obesity is fast becoming a common cause of global ill health. personnel, improvements in sanitation, and sufficient fund-
Many infectious diseases are easily controlled or prevented by ing. Other problems are more long-term ones. Chronic con-
sanitation efforts and immunization programs. These types of ditions are more frequent in developed countries, where the
BOXÂ€5-2â•…â•‡SAMPLE SERVICE ORGANIZATIONS

The Carter Center: Established in 1982 by former U.S. president Jimmy access to resources needed for healthy, productive lives. Its work takes
Carter and his wife Rosalynn, in partnership with Emory University, the place in more than 100 countries, ranging widely from polio eradica-
Center works to improve people's lives in more than 70 countries. Its tion efforts (along with Rotary International) to helping small farmers
many accomplishments are in the areas of human rights, economic improve their crops.
opportunity, disease prevention (especially guinea worm disease), men-
tal health care, and increased farm production. Rotary International: Established in 1905 in Chicago, Rotary
International is the oldest volunteer service organization in the
Doctors Without Borders (Médecins sans Frontières [MSF]): world. With 1.2 million business and professional leaders as mem-
Created by doctors and journalists in France in 1971, MSF has more than bers in 34,000 clubs worldwide, it has taken on polio eradication
22,000 health workers from 19 industrialized nations working in 60Â€coun- as a sustained commitment, with recent help from the Bill and
tries around the world. It is a neutral organization which provides aid to Melinda Gates Foundation. Rotarians provide a wide range of
people threatened by war, epidemics, malnutrition, natural disasters, and humanitarian services which help to build goodwill and peace in
other humanitarian crises. In 1999, MSF received the Nobel Peace Prize. the world.
It works in regions where other organizations fear to go.
Shriners International: This international fraternity has 325,000
The Ford Foundation: This grant-funding, private foundation supports members in 193 temples (chapters) spread across the United States,
national and international projects focusing on democratic values, eco- Canada, Mexico, the Philippines, Puerto Rico, and Panama. They sup-
nomic development, education, the arts, and human rights. port 22 Shriners Hospitals for Children. Regardless of ability to pay,
children under 18 who have orthopedic conditions, burns, spinal cord
The Bill and Melinda Gates Foundation: As a major funder of global injuries, cleft lip and palate, and certain other conditions are eligible
health programs, the organization is focused on helping all people
Â� gain for care.
Data retrieved May 30, 2011, from http://www.doctorswithoutborders.org/aboutus/?ref=home-sidebar-left, http://www.gatesfoundation.org/
about/Pages/foundation-fact-sheet.aspx, and http://www.shrinershq.org/ShrinersHQ/; July 4, 2011, from http:.//www.cartercenter.org/about/
accomplishments/index.html, http://www.en.wikipedia.org/wiki/Ford_Foundation, and http://www.rotary.org/en/aboutus/pages/ridefault.aspx.
easily preventable and treatable conditions have, for the most among children and less productivity and income among adults.
part, been eliminated or controlled. Chronic conditions, Malnourished children whose mothers have little or no education
which usually affect people as they age, are more complex to are at greatest risk of stunting of growth. “In Nigeria, nearly one-
treat and require more economic resources, especially now half, and in India, nearly 60 percent of the children whose mothers
that the obesity epidemic has spread to the poorest regions of had no education were stunted” (Population Reference Bureau,
the world as well. 2008a). Political unrest, intermittent warfare, and an increasing
population contribute to the problem of stunted growth.
Problems Common to Developing Countries Substantial worldwide effort has led to a number of inter-
Unsafe water is a leading contributor to illness and death in ventions, which have been somewhat successful in reducing
developing countries, where nearly one billion people (14% of malnutrition and starvation. Immediate food delivery to war-
the world population) do not have safe water supplies. “Four ravaged and famine-impacted countries provides only short-
percent of the global disease burden could be prevented if water term help. Long-term activities, which are the major focus of
supplies, sanitation and hygiene improved.” Two million deaths worldwide efforts, include helping countries and their peoples
each year from diarrheal disease are caused by these deficits. with the following:
“More than 50 countries still report cholera to the WHO.” The • Improvement of seed and farming techniques to produce
use of human wastewater for agricultural purposes in some better pest resistance and higher crop yield
countries also presents serious health risks (WHO, 2011m). This • Food fortification projects to provide high-calorie foods with
section highlights some of the major health problems in poor adequate vitamins and minerals (big bang for small food supply)
and developing countries. These include malnutrition related • Food supplements for the most vulnerable in the population
conditions, vector-borne diseases, and infectious diseases. The (i.e., infants, young children, and nursing mothers)
causes of death of children younger than 5â•›years of age, shown • Education related to nutritional guidance, and family plan-
in FigureÂ€5-2, are found mainly in developing countries, where ning to space childbirth
they are highly correlated with malnutrition and the mothers’ • The usual sanitation efforts aimed at providing clean water,
lack of education (WHO, 2005, 2010a). clean wells, and control of human and animal waste
The other end of the malnutrition spectrum is obesity. This is
Malnutrition and Obesity becoming a more obvious public health problem. In developing
A contributing cause to about one third of deaths in children countries, well over 100 million people risk chronic illnesses and
worldwide is undernutrition. The global recession which began premature death from diabetes, cardiovascular disease, hyperten-
in 2008 has increased the current risk of child malnutrition sion, and stroke. “Aware that obesity is predominantly a ‘social
because of falling incomes and rising food prices. Although and environmental’ disease, WHO is helping to develop strategies
between 1990 and 2005, there was a global decline in the num- that will make healthy choices easier to make” (WHO, 2011a).
ber of underweight children less than 5â•›years of age (from 25%
to 18%), the progress has not steadily continued. Prevalence Diarrheal Diseases
of undernutrition is increasing in some countries, and stunted Perhaps the most heartbreaking problem is death from diarrhea
growth affects many millions of children (WHO, 2010f). because it is easily controllable. Diarrhea continues to be the
Stunting of growth, manifested as height for age below nor- second leading cause of death from infectious diseases among
mal standards, results from long periods of malnutrition. children under age 5 (WHO, 2005). Diarrhea has many causes,
Damage caused by malnutrition during fetal development and most of which are associated with poor sanitation and con-
the first two years of life may be irreversible. It is associated with taminated water supplies. Cholera is one example of an illness
lower intelligence quotient (IQ) scores and difficulties in school that causes severe diarrhea. Diarrheal disease is exacerbated by
Under-5 causes of death Neonatal causes of death

Acute respiratory
infections (pneumonia) Other Neonatal
19% neonatal tetanus
2% 2%
Neonatal
Malaria causes Severe
8% Preterm infections
36%
birth 10%
Measles 10%
4%
Congenital
Diarrheal anomalies
diseases 3% Birth asphyxia
Diarrheal
(post-neonatal) 8%
diseases
17% HIV/AIDS Injuries 1%
3%
Others, including 3%
noncommunicable
diseases
10%
FIGUREÂ€5-2â•‡ Causes of death of children under 5 years of age, 2006. (Modified from United Nations
Children's Fund. (2007). The state of the world's children 2008. New York: Author.
poverty, lack of knowledge about the importance of personal TABLEÂ€5-2â•…â•‡HUMAN IMMUNODEFICIENCY

hygiene and community sanitation, and lack of medical sup- VIRUS (HIV) PREVALENCE %
plies and personnel. Reductions in mortality are the result of
AMONG ADULTS 15 TO
simple measures, including the following:
49Â€YEARS OF AGE IN
• Oral rehydration therapy to replace fluids and electrolytes
SELECTED COUNTRIES: 2007
(WHO/UNICEF oral rehydration salts)
• Encouraging women to breast-feed, whenever possible COUNTRY PREVALENCE %
• Improvements in sanitation and water supplies Swaziland 26.1
• Immunizations for vaccine-preventable illnesses that produce Botswana 23.9
diarrhea (e.g., measles and cholera) South Africa 18.1
The WHO has actively discouraged bottle-feeding because Zimbabwe 15.3
mothers in poor countries incorrectly use prepared formula. Mozambique 12.5
Canned formula is expensive, so mothers dilute the formula Malawi 11.9
with water; as a result, infants do not receive adequate nutri- Tanzania â•›6.2
tion. The HIV/AIDS epidemic has complicated WHO's policy Uganda â•›5.4
against bottle-feeding. Mothers with HIV infection who are Nigeria â•›3.1
not receiving antiretroviral (ARV) therapy are advised not to Ethiopia â•›2.1
breast-feed their children. If the mother is on ARV, the WHO/ Jamaica â•›1.6
UNICEF/Joint United Nations Program recommends exclu- Thailand â•›1.4
sive breast-feeding for the first 6â•›months of the infant's life. United States â•›0.6
This should be followed by breast-feeding along with replace- Brazil â•›0.6
Switzerland â•›0.6
ment foods (UNICEF, 2011b). Breast-feeding should stop once
Canada â•›0.4
a nutritionally adequate diet is available.
Greece â•›0.2
Human Immunodeficiency Virus/Acquired Immunodeficiency Pakistan â•›0.1
Poland â•›0.1
Syndrome
The AIDS epidemic was first reported in 1981, and 30â•›years later, Data from World Health Organization (WHO). (2010). World health
in 2011, there are more than 33 million people living with HIV/ statistics 2010. Geneva: Author.
AIDS worldwide, with at least 2 million of them being children
under 15â•›years of age. In 2009, cases of new infections were esti- improvement in the procurement, storage, and administration
mated to be 2.6 million, and AIDS deaths were recorded at 1.8 of blood; and advocacy efforts aimed at women and men who
million (WHO, 2009b). There has been “a 16-fold increase in are at risk because they have multiple sexual partners.
the number of people receiving antiretroviral therapy between Early prevention work tended to focus on Western World
2003 and 2010,” although about 9 million eligible people are theories of individual behavioral change. The field has moved
still not receiving it (WHO, 2011f). AIDS no longer appears on toward broader attention on social groups and communities of
the list of 10 leading causes of death in high-income countries, hard-to-reach populations. This move required acknowledg-
where antiretroviral drugs are readily available (WHO, 2011k). ment that target audiences will not adopt behaviors that are not
Global coverage of services for prevention of mother-to-child within their cultural norm (McKee etÂ€al., 2004).
transmission of HIV exceeded 50% in 2009 (WHO, 2011l). It is
expected that there will be much more widespread availability
Health care workers in India were faced with a growing epi-
of AIDS medications as a result of the upcoming price conces-
demic of HIV/AIDS. The WHO projected that without effec-
sions for 70 of the world's poorest countries. The lower prices
tive interventions, 25 million people would be living with
were negotiated with eight Indian pharmaceutical companies
AIDS by the year 2010. To combat the problem, health care
by British and American foreign aid organizations (McNeil,
workers evaluated populations at risk. They found that in
2011). Effective treatment is crucial for the social and eco-
80% of cases, sexually transmitted diseases (STDs) were the
nomic restoration of self-worth needed for patients to combat
result of infections acquired through sex work, either by the
the HIV/AIDS stigma (Campbell etÂ€al., 2011). TableÂ€5-2 shows
female sex worker or by her male patron. Condom use among
the prevalence of HIV in different parts of the world.
sex workers was very low. Health care teams developed an
AIDS has disrupted the lives of many families, leaving their
intervention, through female sex workers, to provide health
children with few adult supports. By the end of 2007, there were
teaching on disease spread and also provided a ready supply
at least 15 million “AIDS orphans” worldwide, with 12 mil-
of condoms. They found that the use of peers for education
lion of them in sub-Saharan Africa. AIDS orphans are children
improved the female sex worker's willingness to listen. The
under 18 who have lost one or both parents to AIDS (Orphans
sex workers reported an 89% increase in the use of condoms
Against AIDS, 2011). Sometimes, whole families are ravaged by
and a reduction in the proportion of unprotected sexual con-
the disease, depriving children of their parents, grandparents,
tacts from 67% to 25% (Nagelkerke etÂ€al., 2002).
and other relatives and leaving them to scavenge for food and
shelter to survive on their own.
International efforts have concentrated on primary preven- Many workplaces in Kenya are integrating activities toward
tion. A few examples of primary prevention efforts are educa- combating HIV, especially peer education programs, into their
tion about the cause and spread of HIV; advocacy of the use of daily operations. Employers have found that it is easier and
condoms and other protective measures during sexual activity; cheaper to educate and/or treat employees than to train another
person for the job vacated by someone who died from AIDS other antimalarials that have different modes of action. During
(Taravella, 2005). In 60 schools of the North East Province of pregnancy, both maternal anemia and placental disease
Kenya, peer health educators are being trained for leading “chill are treated preventively with sulfadoxine-pyrimethamine.
clubs” to promote HIV/AIDS awareness and teach preventive Instituting these practices has resulted in far fewer inpatient
strategies against the infection (United Nations Programme on cases and deaths from malaria in countries that can employ
HIV/AIDS [UNAIDS], 2011). these prevention and treatment strategies. There is still no
Voluntary counseling and testing (VCT) is a major strategy effective vaccine for malaria, although several are in develop-
of the HIV prevention and treatment programs in the commu- ment. A current clinical trial using an upgrade to a vaccine pro-
nity. With the help of trained counselors, people learn how to duced a 35% reduction in illness and a 49% reduction for up to
reduce their risk of infection. They can also learn about their 6â•›months in severe childhood malaria (CDC, 2011b).
HIV status and enroll for treatment, if necessary. A limited
number of mobile VCT services exist, and they are helpful in Tuberculosis
getting more people tested (Kresge, 2006). A recent innovation Tuberculosis (TB) is the second leading infectious disease cause
in mobile VCT services is “moonlight voluntary counseling and of death in adults worldwide (only HIV/AIDS exceeds it). The
testing,” in which HIV/AIDS counselors in remote areas of East largest numbers of new cases occur in the WHO South-East Asia
Africa bring a tent at night to areas where alcohol and drugs Region (WHO, 2010f). New smear-positive cases worldwide in
are sold and thus do VCT work in a more confidential setting 2008 were estimated to be 9.4 million, and over 1.8 million TB
(because of the stigma) than those used in daytime VCT work deaths occurred that year. Because people are often co-infected
(UNAIDS, 2011). with TB and HIV/AIDS, “tuberculosis case rates have more than
HIV has defeated efforts at vaccine development for almost tripled, and deaths have quadrupled over the past 15â•›years in
30â•›years. Failure of two promising vaccine candidates over the African countries with the highest rates of HIV infection.” The
last 10â•›years raised concerns about whether a vaccine could ever full scope of the problem is not clear because of inadequate sur-
be developed against the many existing subtypes of HIV. But in veillance data and diagnostic facilities in that part of the world
2009, a large clinical trial in Thailand showed that even though (Center for Global Health Policy, 2010).
protection afforded by the new vaccine candidate was only TB, by itself, is easily treated with medication, although effec-
31.2%, it brought hope for future prevention of HIV infection tive drug therapy is not always available to people in developing
(Berkley, 2010; UNAIDS, 2009). countries. New drug-resistant strains of the TB-causing organ-
In the meantime, in the summer of 2011, news about two ism (Mycobacterium tuberculosis) are complicating the treat-
landmark preexposure prophylaxis studies in Africa was pub- ment regimen for TB. Most of these strains arose as a result of
lished in the popular literature as well as in public health reports. incomplete treatment or poorly supervised treatment. For this
A new combination drug, Truvada, lowered the risk of infection reason, in the countries with the highest rates, a short course of
by at least 63% in the treatment populations. “Such treatment- directly observed therapy (DOTS), in which medical supervi-
as-prevention strategies may curb the AIDS epidemic by block- sion, drug therapy, and laboratory surveillance are combined to
ing the spread of HIV before it can do more harm” (New Hope combat the disease, has become the standard treatment for TB.
Against HIV, 2011). Individuals receiving DOTS are supervised as they take their
medication for the entire treatment period, which can be from
Malaria 6â•›months to 2â•›years. DOTS produces a remission rate of up to
Malaria is the most important vector-transmitted disease in the 95%. Globally, nearly all patients with TB under care are being
world. It is spread by the bite of the plasmodium infected female treated using DOTS (WHO, 2009d).
Anopheles mosquito. It is endemic to most of Asia, Africa, and As noted above, co-infection with HIV and M. Â�tuberculosis is
Latin America. In 2009, it caused at least 225 million cases and especially prevalent in Africa, and often results in death from TB.
781,000 deaths worldwide, with over 90% of deaths occurring Co-infection complicates the treatment of each illness because
in Africa among children under 5â•›years of age. Nearly half of the each expedites the progression of the other. A significant con-
global population is at risk for the illness (Centers for Disease tributor to new disease in countries with scarce resources
Control and Prevention [CDC], 2011a). for health care services is the ongoing transmission between
A number of global partnerships for malaria eradication patients with HIV and those with TB who congregate in clinic
have been established during the past 10â•›years. These include the waiting areas (Center for Global Health Policy, 2010). The reser-
Roll Back Malaria control program; the Global Fund to Fight voirs of both multidrug-resistant TB (MDR-TB) and extensively
AIDS, Tuberculosis, and Malaria; the World Bank program; drug-resistant TB (XDR-TB, which is resistant to almost all TB
and the U.S. President's Malaria Initiative. The UN Millennium drugs) are steadily expanding. Globally, the WHO Â�estimates
Development Goals discussed earlier also target malaria that a half million new MDR cases occurred in 2007, with 85%
Currently, the most recommended interventions for malaria of these in 27 specific countries (WHO, 2010f). Medicines for
control are being expanded in sub-Saharan Africa. Use of bed patients with MDR-TB are 50 to 200 times more expensive
nets treated with insecticide has been shown to reduce child compared with standard drugs, and “one case of XDR-TB can
mortality and could save as many as 5.5 lives per 1000 children cost $600,000 or more to treat,” with death as likely an outcome
sleeping under the nets. Spraying the interior walls of houses as cure (Center for Global Health Policy, 2010).
with insecticide reduces malaria, especially when done through- The Bacille Calmette-Guerin (BCG) vaccine, the only TB
out communities. Different sprays should be employed if vec- vaccine, offers limited protection for children and is not pro-
tor resistance occurs. Clinical management of malaria involves tective against pulmonary TB in adults. Efforts to develop a
outsmarting parasite resistance to first-line treatment such as more effective vaccine are underway in the United States and
chloroquine and using the new artemisinin derivatives with Europe by two nonprofit organizations supported by charities
such as the Bill and Melinda Gates Foundation. They are hopeful • Provides supportive funding to improve the availability of
that “the first new TB vaccine could be ready for use by 2016” effective treatments in developing countries
(Cookson, 2010). • Works toward wider immunization coverage for vaccine-
susceptible illnesses
• Trains health care workers in primary care, first-level settings
Vaccine-Preventable Diseases and Integrated Management of to effectively manage illness in infants and young children
Childhood Illness (e.g., malnutrition, dehydration, and breathing problems)
In the poorest countries of the world, nearly 11 million children
Â� Properly trained community health workers (CHWs)
under 5â•›years of age die every year from easily preventable can make a phenomenal difference in the health status of
and treatable illnesses such as diarrhea, lower respiratory tract their communities, especially with respect to “the traditional
Â�infections, measles, and malaria. Malnutrition contributes to scourges—childhood diarrhea, pneumonia, neonatal deaths,
half of these deaths. Most of these children die at home, and at malaria, leprosy, maternal tetanus, tuberculosis,” which then
least 40% of those that died never received any treatment at a tend to virtually disappear. The model for such programs is
health facility (UNICEF, 2009). in the Jamkhed region of India, where the world-famous
The WHO Expanded Program of Immunization (EPI) was Â�physician couple Mabelle and Rajanikant Arole has overseen
the first global effort to immunize children against vaccine-Â� the training of health care workers in 300 villages. The CHWs
preventable diseases. The resulting increase in vaccination are the front line for preventive care, and they can treat 80% of
delivery was further improved with the formation of the Global their community's health care needs. They work as volunteers,
Alliance for Vaccines and Immunizations (GAVI), a public– mostly 1 per village of about 1000 people (Arole & Arole, 2003;
private enterprise to boost child vaccination rates. Despite Rosenberg, 2008).
these efforts, the same preventable illnesses have continued to
kill thousands of children annually. In recent years, the WHO At an annual Global Health Council meeting, Dr. Mabelle
and the UNICEF developed the Integrated Management of Arole served as interpreter for a CHW from a rural village
Childhood Illness (IMCI) program. It has been adopted into the in India to present a paper about her work. This woman
health systems of over 80 countries, with the main areas of focus was in the first CHW class in that village. She described the
on “improving health worker skills, improving health systems, increased competence, confidence, and recognition experi-
and improving family and community practices.” All of these enced by the CHWs because of their knowledge and service
efforts have resulted in 78% fewer deaths from measles world- to their village population. She and the other local CHWs
wide between 2000 and 2008. However, measles is still a lead- soon found someone to teach them to read and write. Next,
ing cause of death among children, with most of the 164,000 with the help of a small “micro-loan,” they bought a sew-
deaths from measles occurring globally in 2008 in the under-5 ing machine to make clothing and other items for sale.
age group (WHO, 2009c). FigureÂ€5-3 shows preparations for Eventually, they were able to start a textile industry. They
vaccine administration at a rural health care facility. made all of the tote bags for the hundreds of Global Health
The IMCI program provides the following services: Council meeting attendees that year. The CHW ended her
• Teaches health care professionals to screen for all of the poten- presentation saying proudly, “And no baby has died in my
tial problems at the same time and to recommend referral to village for 10 years!”
first-level care facilities for children with serious illnesses
• Educates parents and child care workers to be alert for initial
signs of illness and teaches appropriate measures to care for Other Serious Health Concerns
the child with illness There are many more serious health issues in the develop-
ing world. Many are, however, preventable or easily treated.
Expanding primary health care services in developing nations
can have a substantial impact on these problems. Some of the
more serious concerns are described below.
• Maternal mortality: Approximately 1000 women died from
complications of pregnancy and childbirth every day in 2008,
resulting in about 365,000 deaths. A woman in a developing
country is 36 times more likely to die from Â�pregnancy-related
causes than a woman in a developed country. Maternal
Â�mortality is the health indicator that shows the widest gaps
between rich and poor (WHO, 2011e). It has been suggested
that the only way to lessen the human wastage from maternal
mortality is to educate and thus empower girls and women
(Crisp, 2010). FigureÂ€5-4 shows the largely preventable causes
of maternal death worldwide.
In addition to lack of obstetrical care, several cultural
practices found mainly in populations with low literacy rates
FIGUREÂ€5-3â•‡Effective primary health care services should be
contribute to the loss of mothers. Child marriages, in which girls
available at very simple local health facilities. Here a bach-
elor's-level nursing student in Kenya checks immunization as young as 5 years are married off mostly to older men, can
records (kept by the mothers) of children brought to a rural easily result in a 14-year-old mother, still ill and bleeding, caring
clinic. (Copyright Helen Kohler.) for her newborn baby and her 2-year-old toddler. Although the
Causes of maternal effective, and its use is spreading throughout the world.
death worldwide However, its cost and the poor health infrastructure in devel-
oping countries may still keep it from being readily available
(WHO, 2011d).
20% 24% • Human trafficking: This worldwide problem of modern
slavery, or debt bondage, involves people being forced to
8% work for others in brothels (sex trafficking), businesses,
private homes, armies, and so on. Especially in poor coun-
8% 15%
tries, victims may be lured from their homes by promises of
12%
a better life, or they may be sold into slavery by their own
13%
family. Globally, there may be as many as 800,000 adults
and children working in involuntary and often brutal
Severe bleeding 24% service to others (Sabella, 2011).
Infection 15%
Unsafe abortion 13% Receding Health Problems
Eclampsia 12%
Obstructed labor 8%
Global efforts have been successful in combating some of the
Other direct causes 8% world's health problems. Most of these problems have been
Indirect causes 20% reduced or eliminated through vaccination or vector control.
FIGUREÂ€5-4â•‡Causes of maternal death worldwide. (Data from Smallpox, polio, guinea worm disease, and river blindness are
World Health Organization Department of Essential Technologies. examples of receding health problems.
[2009]. Essential surgical care makes a difference. Geneva: Author.) The eradication of smallpox was the first success story.
Vaccination provides effective protection against smallpox.
A vigorous global effort to eradicate smallpox started in 1967.
practice of child marriage is now illegal in India, “it still thrives” That year, more than 10 million cases, with a 20% fatality rate,
in certain pockets of the country (Gorney, 2011). occurred across 43 countries. The successful WHO eradication
• Female genital mutilation: Female genital mutilation (FGM) strategy had two simple components. First, vaccinate at least
or female cutting (FC), a harmful practice found mainly in 80% of the population. Second, detect cases as quickly as pos-
central and northern Africa, is condemned by the WHO. In sible, isolate them in their homes, and vaccinate a large circle
this surgical procedure in girls who are very young, varying of friends and neighbors living around the infected houses.
amounts of the external genitalia are removed, usually by a The last known case of smallpox occurred in Somalia in 1977
traditional “circumcisor”. Often, this procedure is performed (Henderson, 2010).
in unsanitary conditions, which can result in infections and Significant progress has been made toward the eradication
even death. The results of infibulation, the most severe form of polio with an effective vaccine. During 1988, 350,000 chil-
of cutting/removal/sewing up, leaves the woman at risk for dren in more than 125 endemic countries were paralyzed. The
obstetrical and gynecological problems throughout her life incidence of polio has decreased by 99% since 1988, when the
(Population Reference Bureau, 2008b). Global Polio Eradication Initiative (GEPI) was launched. In
• Reproductive health: Women in developing countries have 2010, only 1291 cases were reported worldwide. The global erad-
more pregnancies during their lifetimes than those in the ication Â�initiative is a joint effort of Rotary International (which
developed world. Abortion is often used as a birth con- has contributed volunteer vaccinators and nearly $1 billion),
trol method. Approximately 21.6 million unsafe abortions the CDC, the UNICEF, and the WHO. The Gates Foundation
occurred in 2008 worldwide, nearly all in developing coun- has recently joined forces in what is hoped to be the final push
tries. Unsafe abortions account for almost 13% of all mater- toward the eradication of polio.
nal deaths (WHO, 2011i). It is unlikely that the aborting of Although polio has been confined, outbreaks still occur. Polio
female fetuses in some countries contributes much to these vaccination is an ongoing effort. In 2002, more than 500 mil-
statistics, since the practice occurs more in wealthy and lion children in 93 countries were immunized. In 2003, a seri-
Â�better-educated families that can afford the ultrasound scan ous lapse in vaccination programs and the resultant outbreak
for identifying the sex of a fetus. In India, it is estimated that of polio in Nigeria led the Global Polio Eradication Initiative
up to six million female fetuses were aborted during the past to spend $10 million dollars to vaccinate 15 million children in
10 years (Bosely, 2011). Nigeria and the neighboring Ghana, Niger, Togo, and Benin. In
• Refugees from famine and war: Large displacements of 2009, 10-country synchronized vaccination campaigns were car-
populations are the result of war, civil unrest, and famine. ried out in a push to break the resurfaced transmission of the wild
Refugees risk death, infectious diseases, and ongoing mal- polio virus (WPV) in some areas of Africa. Nigeria immunized
nutrition. The United Nations High Commissioner for more than 29 million children in the high-risk northern states.
Refugees (UNHCR) is at work in 120 countries striving to Unfortunately, some new outbreaks occurred in 2011. To achieve
safeguard the rights and well-being of more than 36 million the goal of stopping WPV transmission by the end of 2012, gov-
refugees. More than 50% are in Asia, and 20% are in Africa ernments will need to react promptly with increased resources
(UNHCR, 2011). and political commitment (CDC, 2011e ; WHO, 2010a).
• Viral hepatitis B: An estimated two billion people worldwide The reduction of guinea worm disease is another success
are infected with hepatitis B virus (HBV), and more than story, with eradication almost complete. Guinea worm infesta-
350 million of them have chronic liver infections which put tion is painful and crippling, leaving the affected person unable
them at high risk of death. The hepatitis B vaccine is highly to work and make a living, especially when the long worms are
emerging from the person's body. In 1986, 3.5 million people TABLEÂ€5-3â•…â•‡COMPARISON OF TOP
in 20 tropical countries had guinea worm disease. By the mid- 10Â€CAUSES OF DEATH FOR
dle of 2011, there have been fewer than 1800 cases, mostly in
LOW-INCOME AND HIGH-
Southern Sudan, where ongoing conflict has obstructed work in
INCOME COUNTRIES, 2008
some affected villages (Carter Center, 2011).
Guinea worm disease is a vector-borne illness. It is transmitted LOW-INCOME HIGH-INCOME
by the infected larvae of fleas, which reside in stagnant and unfil- â•‡1. Lower respiratory â•‡1. Ischemic heart disease
tered water. Ensuring clean water eliminates the problem. Efforts infections
at eradication are aimed at improving the water supply and teach- â•‡2. Diarrhea â•‡2. Stroke and other
ing villagers how to protect themselves from infestations. The cerebrovascular disease
Carter Center, in partnership with the CDC and the WHO, is still â•‡3. HIV/AIDS â•‡3. Tracheal, bronchial, lung
leading the work in the last four countries reporting the disease— cancers
Ghana, Ethiopia, Mali, and Sudan (Farabaugh, 2009). â•‡4. Ischemic heart disease â•‡4. Alzheimer disease and other
Currently, river blindness (onchocerciasis) affects approximately dementias
37 million people, about 500,000 of whom are visually impaired â•‡5. Malaria â•‡5. Lower respiratory infections
and 270,000 of whom are blinded. The condition is concentrated â•‡6. Stroke and other â•‡6. Chronic obstructive pulmonary
in sub-Saharan Africa and is also found in a few areas of Latin cerebrovascular disease disease
America and Yemen. It is a parasitic disease transmitted by the â•‡7. Tuberculosis â•‡7. Colon and rectal cancers
bite of black flies, which breed in rivers. River Â�blindness is Â�easily â•‡8. Prematurity and low birth â•‡8. Diabetes mellitus
weight
treated and prevented with ivermectin (Mectizan). Since 1987,
â•‡9. Birth asphyxia and birth â•‡9. Hypertensive heart disease
a significant portion of the medication has been Â�distributed by
trauma
Merck & Co., free of charge, to endemic countries. Eradication 10. Neonatal infections 10. Breast cancer
is a two-step process: (1) control or eradication of the Â�vector,
and (2) provision of medical prophylaxis and treatment to From World Health Organization (WHO). (2011). The top 10 causes of
Â�at-risk Â�populations. Recently, elimination of onchocerciasis with death. Retrieved July 3, 2011, from http://www.who.int/mediacentre/
factsheets/fs310/en/index.html.
Â�ivermectin treatment was achieved in a study conducted in Mali
and Senegal. In the study populations, only a few people in those
countries remained infected after 15 to 17 years of widespread the entire population lives to an advanced age, free of disease
treatment (CDC, 2010a, 2010b; WHO, 2009a). and disability” (WHO, 2011h).
Problems Common to Developed Countries

HEALTH CARE DELIVERY SYSTEMS
People in developed countries enjoy a better standard of living
than those in developing countries, but even in developed coun- Health care delivery systems are generally based on the
tries, there are some health disparities linked to income level. Â�principles of capitalism or social welfare. In the capitalistic or
Poverty is a persistent causal link to poor health, even in more entrepreneurial model, the overriding principle is minimal
affluent countries. People in poverty in the developed world are, government involvement and reliance on private-sector pro-
for the most part, better off than their counterparts in poorer viders for health care services (see ChapterÂ€3). In the welfare
countries. However, they still experience a lower standard of models, governmental direction and regulation is expected.
living and poorer health status than their more affluent neigh- The degree of government responsibility varies. There might be
bors (see ChapterÂ€21). Access to health care services can also total government control (Beveridge model), with the Â�system
be a problem for individuals from low-income groups. This is funded by taxes, or a more decentralized version (Bismarck
particularly true in the United States, which does not have a model), with the system funded by a combination of personal
national health care system (see ChaptersÂ€3, 4, and 21). As dis- contributions and taxes.
cussed later, access problems are still present, although not as Within these three basic models, there are many variations.
common, in other countries with national health care systems. Economic resources affect the type and extent of health care
available in a country but are not the determining influence on
Chronic Conditions the structure of health care delivery. For example, India, a devel-
Chronic conditions such as heart and pulmonary disease are oping country, has a national health care system; the United
more common in the developed world and, along with cancer, States, a very rich country, does not, although it may be moving
are leading causes of death (TableÂ€5-3). Longer life spans allow in that direction. Distinctions can be made between developed
more time for the development and progression of chronic ill- and developing countries with respect to the extent and type of
nesses. The developing world also experiences chronic condi- services a country can afford to provide to its people.
tions; however, these countries suffer a much higher burden of
infectious and communicable diseases compared with the more Health Care Systems in Developed Countries
developed world. The United States is the only industrialized country still with
One measure of chronic disease is the “Dallies,” or Disability- a mainly individualized free market approach to health care
Adjusted Life Years (DALYs). This measure describes the num- (see ChapterÂ€3). The others have developed some form of
ber of years of healthy (disability-free) living lost because of national health care system that provides coverage to all, or
illness or death. The total number of DALYs for a population, nearly all, Â�citizens (TableÂ€5-4). Each country's system varies in
representing its disease burden, serves as “a measurement of the its Â�organization and delivery of care. Roemer (1991) defined
gap between current health status and an ideal situation where four basic types of health care delivery. He identified the United
TABLEÂ€5-4â•…â•‡NATIONAL HEALTH CARE SYSTEMS

PLANNING AND DELIVERY OF
TYPE COUNTRY FINANCING ORGANIZATION SERVICES WHO IS COVERED
Entrepreneurial, United States Direct—out of pocket Decentralized Private sector Most
with some Indirect—private insurance, Direct health care practitioners citizens,
health public sector insurance, and responsibility of Limited government except for
insurance reform welfare private sector health care workers, 10 million
under way Limited public sector primarily in public not eligible
services, primarily health functions for, or
public health declining,
Majority of facilities coverage
in private sector programs
Welfare Germany Indirect—funding collected Government planning Independent Most citizens

Belgium by health or sickness Diversified ownership practitioners
France insurance funds or Hospitals may be Some government
Japan government payment government owned health care providers
Canada (may be co-payments) or private
India
Comprehensive United Kingdom Direct—government provides Government planning Government organized All citizens
New Zealand and pays for care through and ownership Practitioners are
Scandinavian taxes (may require salaried
countries co-payments)
Italy
Socialist Taiwan Direct (may now require Government (highly Government-salaried All citizens, with
Spain co-payments) centralized) workers priority given
Russia Limited services due to to workers and
Poland economic failures children due to
Yugoslavia limited resources
Cuba
Data from Roemer, M. (1991). National health care systems of the world. NY: Oxford University Press; Espring-Anderson, G. (1990). The three
worlds of welfare capitalism. Princeton: Princeton University Press; Physicians for a National Health Program. (2007). Snapshots of health systems
in 16 countries. Retrieved August 20, 2007 from www.pnhp.org/facts/international_health_systems.php?page=all; Johnson, J. A. & Stoskopf, C. H.
(2010). Comparative health systems: Global perspectives. Boston, MA: Jones & Bartlett; and World Health Organization. (2010c). World health
report 2010: Health systems financing—The path to universal coverage. Geneva: Author.
States as the sole example of the entrepreneurial model. The of the post–WWII health system in the United Kingdom. Unlike
United States has a very decentralized system, with limited gov- in welfare systems, government directs both the finance mech-
ernment planning for health care services. Government is the anism and the organizational structure. The national govern-
funder of last resort for some but not all of those who cannot ment assumes the major role in planning, organizing, financing,
afford care. Public health oversight and functions are a govern- and delivering care to all. Most health care providers are gov-
ment responsibility, but most of the planning and public health ernment employees, and services are provided in government-
activities are the responsibility of the individual states. operated health centers. Consumers have a choice of provider
The welfare-oriented system is often referred to as the Bismarck if the provider does not have a Â�client overload. Most such sys-
model, after the German leader who first championed this system. tems allow some element of private practice by providers.
Most people have medical care protection. The national government AÂ€small percentage of citizens use private practice. The United
assumes responsibility for financing and planning, but organiza- Kingdom, New Zealand, and all of the Scandinavian nations are
tion and delivery of care are shared with private enterprise. Care is examples of countries with comprehensive health care systems.
paid for by health insurance, which is subsidized by government for Socialist systems developed in the Communist bloc coun-
those who have no other means. Workers in Germany, for example, tries after WWII. These systems represent the most stringent
have health insurance through their employers. Everyone else either central control of health planning, funding, and services. When
has another form of insurance or is subsidized by government. developed, they were successful, providing a better standard of
Providers usually remain in independent practice, and consumers care than was previously available to most of the population.
may choose health care providers. Government owns most, but not The standard of care varied by country. Poorer socialist coun-
all, hospital facilities. Australia, Canada, Germany, Japan, and France tries such as Romania were able to provide more limited ser-
are examples of countries with welfare-oriented health care systems. vices than richer socialist countries such as Poland. Cuba, for
Comprehensive health care systems provide a broad scope of example, follows the socialist model. Until very recently, the
health care services to all citizens. Comprehensive Â�systems are level of health and access to health care services in Cuba were
commonly referred to as the Beveridge model, after the Â�developer substantially better than those in other countries in the region.
The demise of the Soviet system in the early 1990s has led to a Health Care Systems in Developing Countries
crisis in health care. Many of the socialist countries have expe- Health care in developing and middle-income countries Â�varies
rienced a deterioration in their health care structures, limited in quality and amount of care. Governments tend to provide
supplies, and increased mortality rates (Masterova, 2011). The public health services, but not at the level provided in devel-
rates of infectious diseases such as HIV/AIDS and TB have sub- oped countries. There is an element of a welfare-oriented
stantially increased (Moran & Jordaan, 2007; USAID, 2009a). approach, particularly with respect to public health Â�functions.
A limited number of affluent people are able to purchase care; Responsibility for public health resides with the ministry of
but many others go without. Now, at the beginning of the health. There is usually a network of local public health offices.
twenty-first century, the countries of Eastern Europe are still For example, China has a system of antiepidemic stations
struggling to improve health care. Some of the more afflu- located throughout the country. Depending on the country,
ent are moving toward less restrictive comprehensive or wel- these local offices might also provide some basic primary health
fare models, and some are experimenting with public-private care to the community.
partnerships in health care services. Developing countries have a mix of entrepreneurial and
welfare health care systems. The wealthy can pay for health
Differences in Health Planning care. For the many with few economic means, there are lim-
Countries with functioning national health care systems engage ited national health care systems. There are both Beveridge-
in more comprehensive health planning and provide all, or oriented systems (as in China, which hopes to have 90% of
almost all, citizens with comprehensive health care services. its population covered by formal insurance by 2011) and
Central planning is possible because government has the means Bismarck-influenced systems (as in India). Widespread
to influence services either by providing direct care or by reim- democratization in many developing countries has led to a
bursing the cost of care for most of its citizens. certain amount of decentralization of authority (Johnson &
In contrast, the United States has engaged in little cen- Stoskopf, 2010; Sein & Rafei, 2002; WHO, 2010e). The idea of
tral health planning until recently. The federal government is individual responsibility for health care is becoming popular.
becoming more involved in national health planning and has The poorest countries rely on nongovernmental organizations
established national health objectives (see ChapterÂ€1). These and intergovernmental agencies such as the WHO and the
objectives are only guidelines, however, and do not have the UNICEF for some or most of their health care services. Some
force of law. Those segments of the health care system not countries such as Malawi, Nepal, and Afghanistan are so poor
directly under federal control are free to ignore or address that services are extremely limited. Some other low-income
the objectives as they choose. The health insurance industry countries are managing to move toward nearly universal cov-
reforms in the Affordable Health Care Act, which became law erage in spite of scarce resources, for example, Rwanda, where
in March of 2010, are a first step toward mandating that all U.S. 91% of the people belong to one of three insurance Â�programs
citizens must have access to the health care services they need (WHO, 2010e).
(USDHHS, 2011).
Issues in Health Care Delivery Systems
Comparison of Health Care Expenditures and Health Status No health care system is perfect. Some do better than others, at
Indicators least in terms of comparison data such as life expectancy and
Most countries commit more public funds, provide more ser- infant mortality rates. To help evaluate the effectiveness of a
vices, and spend less of their GDP on health care compared with country's health care system, the WHO (2000) identified five
the United States (see ChapterÂ€3). In most countries, health care performance criteria. These are the following:
costs are rising. The Organization for Economic Co-operation • Level of health of the population
and Development (2010) reported that of 15 developed coun- • Degree of health disparities within the country's population
tries, all spend more of their GDP on health care today than they • Responsiveness of the health care system
did in 1990. Germany had the largest increase, related, in part, • Distribution of responsiveness within the population
to the increased health care demands since the reunification of • Distribution of financing for health services within the
East Germany and West Germany. Opponents of health care population
reform in the United States frequently point to the Canadian Responsiveness refers to how well the system (administra-
system as a reason not to provide universal coverage. Canada is tors and service personnel) can address the concerns of the
often presented as having many more problems compared with citizens and how the citizens themselves feel about the qual-
the United States. In TableÂ€5-5, some of the common criticisms ity of, and access to, their health care services. Distribution
are listed, and the validity of those concerns is explored. of finance looks at who pays for services and how much they
Differences in expenditure of public funds would be more pay. The WHO expects a country's poor to shoulder less of the
understandable if the U.S. system provided a better standard of financial burden for health care than do those who are better off.
health than that of other countries. That is not the case, how- Using these five benchmarks, the WHO rated France as having
ever. The United States ranked 28th in life expectancy and 43rd the best health care system among developed countries. Japan,
in infant mortality in 2010 (WHO, 2010f). In addition, the the United Kingdom, and Germany all ranked higher than the
United States infant mortality rate exceeds that of other coun- United States. Davis and colleagues (2007) conducted a com-
tries such as Cuba, the Czech Republic, Slovenia, and South parative study of six highly developed countries and reported
Korea (United Nations Committee on Trade and Development that the United States ranked last among the six with reference
[UNCTAD], 2010). Lack of comprehensive planning for prena- to life expectancy, quality of care, and access to health care ser-
tal care, a characteristic not shared by countries with national vices. In both instances, the most pressing concern about the
health care systems, is a significant contributor to the infant U.S. system was the number of people without health care
mortality results (WHO, 2010e; Williams, 2002). services, either through public or private sector funding.
TABLEÂ€5-5â•…â•‡ CANADIAN HEALTH CARE SYSTEM: MYTHS AND FACTS

CRITICISM RESPONSE REASON
• It is socialized No It is a social insurance plan similar to the U.S. Social Security System and Medicare. Doctors are not state
medicine. employees but have private practices.
• Health care is Yes and no There may be a wait for hospital beds, specialists, and diagnostic tests. Canadians do not have to wait to see
rationed. their primary physicians. Health care is rationed through the primary physician by immediate need versus
delayed need for special services, not by ability to pay. In contrast, in the U.S. system, care is rationed by
ability to pay (refer to ChapterÂ€4).
• There are not No The distribution of physicians is different; about 50% of physicians are primary care/family practice
enough doctors. physicians. U.S. residents are 3% less likely to have a family doctor.
• There are long Maybe There is no wait for a primary care physician. Certain high-technology procedures, e.g., lithotripsy, magnetic
waits for care. resonance imaging, and bypass surgery, usually require some waiting. Wait time for procedures has occurred in
some provinces. Hospitals operate at 95% of capacity and 1-day surgical procedures have increased (not unlike
in the United States). Approximately 3.5% of Canadians have unmet health needs because of long wait times
compared with 1% of U.S. residents. Overall, 7% of U.S. residents and fewer than 1% of Canadians have unmet
needs because they cannot offer to pay for health care.
• The quality of No Canada's infant mortality rate is lower and life span higher than in the United States. Canadians, although
health care concerned about what cost cuts might do to services, would not trade their system for a U.S.-type delivery
is poor. system. Inequality in access to health care and differences in mortality rates among income groups is far
less in Canada than in the United States.
• Administrative No The provider bills the government directly for all services and is paid within a month. Patients neither pay nor
costs are greater. are billed for services. Single-payer systems are more cost efficient with regard to administrative expenses.
In the United States, the administrative costs for Medicare and Medicaid are only 10% of the costs of
private insurance administration (see ChapterÂ€4).
• The system Yes and no The Canadian system has experienced increasing costs, and strategies have been initiated to keep costs
is troubled by down. Costs have remained below costs in the American system. Canada controls costs at the source; e.g.,
escalating costs. physician fees are set by negotiation between the health ministry and the physician's organization; patients
do not have out-of-pocket expenses.
• Physicians earn Yes Physicians in all national health systems earn less than U.S. physicians do; however, their overhead with
less. respect to administrative costs is less.
Data from Barer, M. L., & Evans, R. G. (1992). Interpreting Canada: Models, mind-sets, and myths. Health Affairs, 11(1), 44–61; The search for
solutions: Does Canada have the right answer? (1992). Consumer Reports, 57(9), 579–592; McKenzie, J. F., Pinger, R. R., & Kotecki, J. E. (1999).
An introduction to community health (3rd ed.). Boston: Jones & Bartlett; Deber, R. B. (2003). Health care reform: Lessons from Canada. American
Journal of Public Health, 93(1), 20–24; Kunitz, S. J., & Pesis-Katz, I. (2005). Mortality of white Americans, African Americans, and Canadians: The
causes and consequences for health of welfare state institutions and policies. Melbrook Quarterly, 83(1), 5–39; and Lasser, K. E., Himmelstein,
D. U., & Woolhandler, S. (2006). Access to health care, health status, and health disparities in the United States and Canada: Results of a cross-
national population-based survey. American Journal of Public Health, 96(7), 1300–1303; Davis, K., Schoen, C., Schoenbaun, S. C. etÂ€al. (2007).
Mirror, mirror on the wall: An international update on comparative performance of American health care. The Commonwealth Fund. Retrieved
January 29, 2007 from http://www.commonwealth fund.org/publications/publications_show.htm?doc_id=482678 ; and Duffin, J. (2011). The impact
of single-payer health care on physician income in Canada, 1850–2005. American Journal of Public Health 101(7) 1198–1208.
When health care systems are examined, economics and used by the United Kingdom (Beveridge model) appears to pro-
resources, rather than organizational model, appear to be the vide good care to its population, whereas in Germany, a more
deciding indicators of success. Nevertheless, all countries strug- decentralized method has produced satisfactory results (Hurst,
gle to develop strategies to deal with rising health care costs, 2000). The central planning model appears to help very poor
decide on the types of services that can be made available to their countries make rapid advances in health status. For example,
populations, and determine how to fund their health care pro- China and Cuba made substantial initial increases in the level
grams. In general, poor countries cannot deliver the same degree of health of their populations once central planning and con-
of health care services to their populations as can rich countries. trol were instituted. However, once initial health gains have
Economics alone does not account for the differences among been achieved and a degree of economic prosperity begins,
countries. For example, the United States spends more of its GDP central planning models do not appear to function any better
on health care than do other developed countries, yet the United than other organizational models. For instance, South Korea
States has poorer life expectancy and higher infant mortality than has operated under both models and has found little difference
comparable countries. Mexico spends less of its GDP on health between organizational types in terms of the health status of the
care than do poorer Latin American countries such as Nicaragua, population (Lee, 2003).
Barbados, Bolivia, and Columbia (WHO, 2007c, 2010c). The United States, with no national health insurance plan, has
The locus of decision making and health planning might a higher percentage of persons uninsured compared with other
have some influence on health status but is not the overriding developed countries, although recent reforms have loweredÂ�
determining factor. For example, the central planning model the number (Roberts & Rhoades, 2007; WHO, 2010e). Some
Â�countries with national plans, nevertheless, have uninsured citi- found in animals may mutate and cause diseases in new forms that
zens. The numbers of uninsured in these countries is declining are difficult to identify in humans, for example, AIDS, SARS, and
as incremental changes incorporate previously excluded groups. avian flu. All of these diseases pose biological threats for the future
For example, Germany started with employer-provided health (Global Health Council, 2011a).
plans to cover workers and gradually added other groups until, The May-June 2011 E. coli 0104.H4 outbreak in Europe,
by 2003, all citizens had insurance coverage (Altenstetter, 2003). mainly in Germany, is one example of a new disease with wide-
Developed and developing countries alike struggle to con- ranging effects. The human effect consisted of more than 3800
trol costs to the system. Developed countries have controlled people being sickened, over 800 of them with the type of kid-
costs by limiting certain services, although they cover medi- ney failure associated with the toxin-producing organism. More
cally necessary and appropriate care. For example, home care than 40 deaths occurred. Because of the initial incorrect conclu-
and prescription drugs are not provided as a benefit in Canada. sion by health authorities that cucumbers, tomatoes, and lettuce
Dental care and eye care are covered by supplemental insur- were the culprits, European farmers suffered major economic
ance or out-of-pocket payments in France. All developed coun- losses due to shunning of these vegetables. The deadly E. coli
tries face higher expenses in treating chronic illnesses as their was finally traced to sprouts from a farm in northern Germany
populations age. Beyond public health services, developing (CDC, 2011c; Thiesing, 2011).
countries also struggle with costs and the types of benefits they Old diseases can also re-emerge after being absent from
can afford or wish to provide to their populations. Often, the a region. One of the most serious of these is dengue fever, a
result is a two-tiered health system. Limited services provided mosquito-borne, flu-like illness that might progress to life-
by public employees are available to all. Extra services are paid threatening hemorrhagic fever. It is the second most common
out of pocket and provided by private sources. At the same vector-borne disease in the world (only malaria exceeds it), and
time, progress toward financial system development to support it is now endemic in more than 100 primarily tropical coun-
universal coverage is increasing worldwide, as seen in exam- tries. Globally, an estimated 50 to 100 million people contract
ples including Chile, Brazil, Thailand, Ghana, and Mongolia dengue fever every year, and at least 20,000 of them die from the
(WHO, 2010e). Â�illness. Global urbanization, increased travel and migration, and
climate change have contributed to the spread of dengue fever
in recent years. In May of 2010, the 28 cases of dengue fever
Jennifer Carson, a student nurse, is doing a clinical Â�experience
reported in Key West, Florida, marked the first infections in the
practicum in Mexico as part of her community health edu-
United States in 65 years. Since no cure, vaccine, or effective vec-
cation at Oregon State Health University. She is providing
tor control methods are yet available, the Key West outbreak was
care in a clinic, where she notices that the dentist has very
“a loud wake-up call” for renewed public health activities and
few patients. One day, she asks him why he does not have
work on vaccine development (Hosbach & Feldman, 2010).
many patients. Dr. Ortez tells her that the co-payment for
Another epidemic caused by an old disease circling back
dental services is $7 per visit. Ms. Carson does not think that
has been ongoing in Haiti since fall 2010. As of May in 2011,
is so bad, but Dr. Ortez tells her, “My patients have to choose
300,000 Haitians were sickened and nearly 5000 died from
between having their teeth cared for and buying bread for
cholera (CDC, 2010c). With 680,000 people still living in
their families.”
camps because of the January 10, 2010, devastating earthquake,
there is not adequate access to latrines and safe drinking water.
Low-income and middle-income countries face major policy “The fact that the disease is still spreading is a reminder of how
decisions as they struggle with the question of how to provide much more help Haiti needs and the consequences of contin-
health care to their people. Should it be tax funded, insurance ued neglect” (New York Times Editorial, 2011).
funded, self-funded, or funded by a combination of methods? HIV/AIDS is the most severe example of new diseases
Should there be central planning, local planning, or a combina- identified since the late 1970s. Others include Hantavirus
Â�
tion of both? Should health care professionals be government Â�cardiopulmonary syndrome, Legionnaires’ disease, SARS, Ebola
employees, self-employed entrepreneurs, or a combination of hemorrhagic fever, and West Nile encephalitis.
both? These are the issues countries continue to struggle with New infections are problematic because there is a time lag
as they attempt to improve health care services and the health between recognition of the problem and development of effec-
of their peoples. tive treatments. During this lag, the disease can spread to many
people and continents, with devastating results. Old diseases
NEW AND EMERGING HEALTH ISSUES reemerge because of failures in control or immunization, for
example, the resurgence of large measles outbreaks in Africa
At the turn of the twenty-first century, a number of health con- (CDC, 2011d). They are problematic because new strains are
cerns demand particular attention. Some diseases are receding often more resistant to management. As examples, the mos-
in importance, whereas others are becoming more problematic. quito responsible for carrying malaria is becoming resistant to
Concerns center around old or newly emerging diseases, the pesticides; control methods for dengue fever have not been able
deleterious effects of behavior on health, and the recognition of to eliminate the vector mosquito; and TB is becoming more and
health risks associated with terrorism and warfare. more multidrug resistant.
A major emerging disease concern is the possible threat of a
Old and New Emerging Infectious Diseases new flu pandemic rivaling that of 1918, in which at least 20 mil-
Novel, new, emerging infectious diseases such as SARS, H1N1, lion people died worldwide. Flu epidemics have a cyclical pat-
and avian flu “have important implications for global Â�politics, tern, with large outbreaks documented in 1946, 1957, and 1968.
health systems, and international migration and travel.” Organisms In early 1976, the swine flu virus (which was responsible for the
1918 flu) was detected in four seriously ill, previously healthy, associated with pollution will also increase (WHO, 2011c).
Army recruits at Fort Dix in New Jersey. Because of concern that Developing countries have few resources to police the polluters
this might be a sign that “the big one” was likely to occur soon, and are less inclined to do so because pollution control is seen
a swine flu vaccine was quickly made and administered to about as a threat to economic development. For example, Mexico City
one third of the American population. Fortunately, even though is one of the most polluted cities in the world. ChapterÂ€9 identi-
the time was right and the proportion of the population immu- fies some pollutants and their adverse effects on human health
nized was low, no epidemic occurred. Another “scare” began in and the environment.
the United States and Mexico in April 2009 and quickly spread When viewed broadly, the impact of the environment on
to the rest of the world. The outbreak was called an H1N1 influ- human health includes exposure to infectious agents, previ-
enza pandemic because 20% to 40% of the population in some ously discussed, as well as pollutants. The WHO (2011l) attri-
areas was infected. An effective vaccine was quickly developed, butes 25% of the global burden of disease to environmental risk
and H1N1 is no longer a dominant flu virus. In August 2010, the factors and estimates that approximately 13 million deaths each
Director-General of the WHO described the outcome as “H1N1 year would be prevented if the environment were made safer.
in the post-pandemic period,” due, in part, to “pure good luck.” We do not yet know the consequences of many environmental
He stated that the virus would probably be in circulation in a pollutants because of the lag time between exposure and mani-
seasonal form for some years (WHO, 2010b). festation of health problems.
In 2003, SARS (sudden acute respiratory syndrome, an atyp- Two measurable global environmental changes are depletion
ical pneumonia) could have become the next global epidemic of the ozone layer and accumulation of heat-trapping green-
of a respiratory disease. It appeared in 29 countries, causing ill- house gases. The UN Intergovernmental Panel on Climate
ness in over 8000 people and killing nearly 800 of them during Change reported in 2007 that these two problems are directly
an 8-month period. However, unusual international coopera- attributable to human actions (National Institutes of Health
tion and the preparedness of the WHO prevented a crisis. The [NIH], 2011; United Nations News Centre, 2007). The extent
swift, global, response using communication resources to limit to which these changes might affect the planet is still under
the spread serves as a model for handling cross-border diseases debate. Some of the possible issues associated with environ-
for which there is no vaccine or cure. The outbreak was totally mental change and pollution are the following (CDC, 2011a;
contained within 8 months. It is uncertain whether SARS will Environmental Protection Agency [EPA], 2011; NIH, 2011):
ever reappear (Global Health Council, 2011a). • Loss of biodiversity of plants and animals
Avian flu is very complex and still evolving. The H5N1 virus • Increases in invasive species that choke off or consume food
first appeared in sick chickens on Asian poultry farms in 2003. and water sources
This has necessitated worldwide surveillance of birds and massive • Impairment of food production because of depletion or
culling of poultry flocks since then, mainly in East Asian countries.
Â� stress, for example, overfishing
The avian flu virus has not yet made the mutation required for • Chemical pollution of soil, water, air, and food
efficient human to human transmission. However, 562 con- • Precipitation changes
firmed human cases (with a case fatality rate of 58.5%) were • Weather extremes, for example, more frequent and severe
reported to the WHO by June 22, 2011 (WHO, 2011b). The droughts and heat waves
hardest hit were Indonesia and Vietnam, which are East Asian • Shifts in plant and animal ranges
countries, where people traditionally live in extreme proximity Climate change and rising global temperatures due to green-
to their chickens and other fowl. An effective vaccine that limits house gas emissions could lead to serious health effects. Water-
the highly pathogenic avian flu in poultry is now available and is borne disease outbreaks may follow heavy rainfalls, which are
being widely used to vaccinate chickens in Indonesia. likely to increase with continued global warming. An increase
It is not yet known whether the H5N1 avian flu virus will in mosquito-borne diseases could result from the increased
cause a global human disease outbreak. Health officials in the infectiousness of mosquitoes, which is possible with just a half-
United States “are united in their belief that a pandemic is likely degree increase in temperature. Increased air pollution could
to emerge and have been working on preparedness efforts for the result in more respiratory and other illnesses. Global warming
past few years” (Davey, 2007, p. 57). Although the H5N1 virus could be a tremendous public health threat unless corrective
has not yet been found in the United States, it has been detected action is increased (Krisberg, 2007; NIH, 2011).
as far north and west as Nigeria and the United Kingdom from
its main location in East Asia (Global Health Council, 2011a). Tobacco Use
The WHO is acting as the coordinator for the global response Tobacco-related illnesses are the leading cause of premature
to human cases of H5N1 avian flu and for monitoring the threat death in industrialized countries. It is estimated that in 2011,
of a pandemic. However, it must be recognized that effective “the tobacco epidemic will kill nearly six million people.” Over
global surveillance for the prevention or management of a pan- five million of them will be current or former tobacco users,
demic is dependent on “the willingness of governments to engage and more than 600,000 of them will be nonsmokers who were
in robust cooperation” by transparent reporting rather than hid- exposed to second-hand smoke. By 2030, the death toll could
ing information about outbreaks (Lee & Fidler, 2007, p. 217). rise to eight million people a year worldwide. Tobacco use
accounts for 63% of deaths in the current, global, noncom-
Environment municable disease epidemic (WHO, 2011n). The incidence of
Industrialization has increased the amount of global pollution. tobacco use is shifting from developed countries to develop-
The more affluent nations create a disproportionately larger ing countries. As cigarette smoking has declined in developed
share of pollution. As more and more countries make economic countries, tobacco manufacturers have greatly expanded their
progress, the pollution burden will increase. Health problems marketing to developing countries. About 84% of all smokers,
The potential use of chemical and biological agents as ter-

ror weapons is a serious concern. Both the United States and
the UN have increased their preplanning efforts in this area.
The CDC is the most visible public health agency involved in
preplanning in the United States. Other offices of the govern-
ment at all levels—federal, state, and local—are also involved
in preparation. The WHO (2001) published a document with a
set of strategies to assist planning, titled Public Health Response
to Biological and Chemical Weapons, which advises countries to
do the following:
• Improve the national surveillance system to monitor out-
breaks of illness
• Improve communications and coordination of response
between responsible agencies (e.g., infrastructure support,
health care, and nuclear facilities)
FIGUREÂ€5-5â•‡Cigarette advertisement on a billboard in East
Africa. (Copyright Helen Kohler.) • Develop vulnerability assessments and communicate that
risk to both health care professionals and the public
• Prepare for handling the psychosocial consequences of delib-
or 800 million, live in developing and transitional countries erate acts of terrorism
(WHO, 2011g). If there is no change in smoking patterns, by the • Expedite contingency plans for a rapid and comprehensive
year 2030, approximately 70% of deaths caused by tobacco use response in the event of an incident
will occur in developing countries. FigureÂ€5-5 shows a billboard The UN designates conflicts involving at least 1000 deaths
cigarette advertisement in an East African country. on the battlefield annually as “major wars.” In mid-2005,
The WHO has identified smoking reduction as one of its there were eight such wars being waged worldwide plus
primary health objectives. The Tobacco Free Initiative aims to more than 20 “lesser” conflicts. Compared with World War
reduce and eventually eliminate cigarette smoking. The Global I, during which nearly all casualties were military person-
Treaty on Tobacco Control is a first step. The treaty, passed at nel, at least 75% of those killed or wounded in more recent
the 2003 World Assembly, includes the following actions: conflicts are civilians (Global Security, 2011). In addition,
• Endorses a global ban on tobacco advertisement and promo- enormous numbers of people become internally displaced
tion to children under 18 years of age during humanitarian crises, with the December 2010 esti-
• Places strict restrictions on advertisement and promotion mate totaling well over 27 million (Internal Displacement
to adults Monitoring Centre, 2011). Additional numbers fleeing to
• Prohibits tax-free, duty-free sales of tobacco products other countries are unknown, and all of them are in extreme
• Supports adoption of price and tax measures aimed at reduc- need of often unavailable public health aid. Countries in
ing consumption Africa experience war more often than any other region of
• Ends subsidies for tobacco production the world. Since 1960, there have been more than 20 major
• Cracks down on cigarette smuggling wars in African countries, including those in Rwanda,
• Limits exposure to second-hand smoke Somalia, Angola, Sudan, Liberia, and Burundi. These wars
• Improves product labeling and health warnings have caused extensive economic and social damages and
• Encourages smoking cessation “have condemned many of Africa's children to lives of mis-
In 2001, the European Union Parliament voted to ban tobacco ery” (Global Security, 2011).
advertisement in print media, on the radio, and onÂ€the Internet. Immediate needs in afflicted countries center on the usual
Tobacco advertisement was already banned on Â� television. basic services of sanitation and potable water. Relief then moves
The WHO teamed with the CDC, the International Olympic on to infectious disease control, attention to treatment of health
Committee, the Fédération Internationale de Football problems, and the rebuilding or repair of health care facilities.
Association, and the Fédération Internationale de l' Automobile For example, USAID is continuing its work in Afghanistan in
to ban cigarettes at all sporting events (WHO, 2002). Cigarette spite of ongoing, intense conflict there for 25 years. “The health
smoking is already banned at Olympic events. In recent years, status of Afghans is among the worst in the world,” with 20% of
a major focus of the WHO's Tobacco Free Initiative is to pro- children dying before the age of five, and it is “one of only four
mote the use of graphic pictures on cigarette packaging showing countries in the world where polio remains endemic.” To com-
the appearance of patients or body systems affected by tobacco bat these problems, USAID (2011) and other donors have done
related, late-term, illnesses (WHO, 2011j). the following:
• Increased access to basic health care for 85% of the population
Terrorism, War, and Natural Disasters • Increased the number of midwives from 404 to 1700 in 6Â€years,
Health problems associated with war, civil insurrection, and which helped lower infant mortality by more than 22%
terrorism appear to be escalating. No country is immune from • Overseen polio vaccination of more than 90% of the chil-
these threats, as the United States learned on September 11, dren under 5 years of age
2001. Health care professionals must deal with the health effects In addition, USAID constructed or repaired nearly 700Â€schools
of conflicts and terrorism. They must also develop plans for a and printed 60 million textbooks. Six million children are cur-
comprehensive public health response in the event of an inci- rently enrolled in primary and secondary schools, and 35% of
dent (see ChapterÂ€22). them are girls.
Beyond basic services, there are a myriad of other health • Including children and adolescents with mental and psycho-
issues facing health professionals in war-torn regions. Some of social disabilities in education programs
these are the following: • Improving social services for people with mental and
• Mass immunization needs and problems with supply of psychosocial disabilities
doses and personnel to administer vaccines “People with mental and psychosocial disabilities are among
• Treatment of the physical and mental damages of rape the most marginalized groups in developing countries” (WHO,
• Treatment of the effects of long-term malnutrition and 2010d). Although great advances have been made in the develop-
dehydration, which are especially severe in children ment of effective medications and treatments for mental disor-
• Reduction of the effects of exposure to depleted uranium ders, little is known “about how to prevent or reduce the stigma
used in some munitions against mental illnesses, which can be as damaging to a person's
• Potential damages associated with a large cache of unex- health and well-being as the illness itself ” (Palpant, 2011).
ploded land mines The new field of mental health stigma research received help
• The problem of child soldiers and their rehabilitation and from the Carter Center to launch the journal Stigma Research
safe reentry into society and Action in January of 2011. The publication provides a for-
• Reintroduction of displaced persons back to their home mal venue for sharing information about relevant projects.
environments A great deal of emphasis will be focused on “reshaping stubborn
• Long-term mental health issues associated with disasters attitudes and behaviors that have been intractable for genera-
and terrorism tions” in both developed and developing countries. People who
This list is only a sample of the problems encountered by have mental illnesses are waiting for improvement in how they
local and international health care professionals providing care are perceived and treated by other people in their communities
to populations caught in the midst of war and its aftermath. (Palpant, 2011).
Global public health security will depend on international coop-
eration and willingness to tackle new threats (WHO, 2007a). ROLE OF NURSING IN INTERNATIONAL HEALTH
Except for armed conflicts, the results of devastating
Â�natural disasters can be much like the effects of war, or even The work of community health nurses involves planning and
worse. Hurricane Katrina of 2005 has left some areas of the providing health care services to aggregates and populations
U.S. East Coast still uninhabitable. Earthquake and tsunami as well as direct care to individuals and families. Community
killed Â�thousands of people in Japan in 2010 and caused serious health nurses have a primary health care perspective and are
problems at nuclear power plants. Haiti experienced a severe involved in collaborative planning with other health care pro-
earthquake in 2010, and the resultant lack of safe drinking fessionals. Therefore, community health nurses are uniquely
water led to a cholera epidemic (discussed above under New qualified to provide health care services and leadership in inter-
and Emerging Health Issues). In the summer of 2011, extreme national health.
drought forced thousands of starving people to walk to camps Nurses can become involved in global health practice as
in North East Kenya. The need for public health activities and employees of international organizations, as political activists,
aid agency interventions after natural catastrophes like these is or as volunteers. Nurses are highly valued in international health
similar to the need during and after wars. efforts. Their expertise can enhance the volunteer programs of
any international organization. Nurses, and student nurses,
Mental Illness who are interested in international health as a career can start as
Globally, more than 450 million people have mental illnesses volunteers. Volunteering will not only provide Â�valuable experi-
(WHO, 2010c). It is likely that 1 in 4 persons will have a mental ence, it will help the nurse determine if international health is a
illness during his or her lifetime. More than 75% of people with realistic career choice.
mental disorders do not have access to any kind of treatment Nurses are employed in epidemiological studies, communi-
for their problems. In low-income countries, close to 10% of the cable disease control, health care planning, and the education
total disease burden is due to mental health conditions. Mental of nurses and other health care professionals. They are engaged
illness priority conditions include depression, psychoses, suicide, in direct care and program administration in most intergovern-
epilepsy, dementia, conditions due to use of alcohol and drugs, mental organizations (e.g., the WHO or the PAHO).
and mental health conditions in children. By 2030, it is possi- There are two nursing organizations with an emphasis on
ble that depression will be the second leading cause of disease international issues. Both organizations facilitate the exchange of
in middle-income countries, and the third in low-income coun- interests and concerns among nurses from many countries. The
tries. The WHO is asking development organizations to address International Council of Nurses (ICN) is a federation of national
the needs of people with mental disorders in their national level nursing organizations. There are representatives from 120 coun-
programs by doing the following (WHO, 2010d): tries. The primary goals of the ICN are the advancement of nurs-
• Recognizing the vulnerability of this group and including ing as a profession and the reduction of health disparities by
them in all development initiatives working for change in health policy. Sigma Theta Tau is the inter-
• Scaling up services for mental health in primary care national honor society of nursing. This organization is dedicated
• Including people in income-generating programs and pro- to supporting nursing leadership, research, and clinical excel-
viding social and disability benefits lence. Like the ICN, Sigma Theta Tau is committed to reducing
• Involving the people themselves in the design of develop- health disparities and improving health throughout the world.
ment programs and projects One of the overriding concerns of all health profession-
• Incorporating human rights protections in national policies als engaged in public health is the issue of distributive justice
and laws (see ChapterÂ€1). Distributive justice works toward Â�eliminating
inequalities. The very real global inequalities in health and practice, maintaining membership in international nursing
health care services should be a concern for all community groups, contributing funds to assistance projects, and engag-
health nurses. Regardless of whether their practices are in inter- ing in the political process are all ways to help. Together, these
national health or at the local level, nurses can help improve efforts will improve the health of the world—one person, one
global health. Volunteering, engaging in research and Â�clinical family, one community, and one country at a time.
KEY IDEAS
1. It is in the best interests of all countries to consider health as 7. The classic public health measures of sanitation, provision
a global priority. All nurses, whether they advocate, work, or of safe water, and vaccination produce the most dramatic
volunteer, can contribute to the goal of world health. results in developing countries.
2. Widespread health disparities exist among countries. 8. The problems associated with chronic diseases will increase
Health is inversely related to economic status. Richer coun- as health improves and life spans increase throughout
tries have healthier populations than do poor countries. the world.
3. Certain health interventions have been identified as “best 9. All developed countries except the United States have national
buys”; that is, if implemented in developing countries, these health care systems dedicated to providing universal health care
actions will have a substantial positive impact on the health services to their populations. Developing and Â�middle-income
status in these countries. countries continue to expand health care services to their
4. Intergovernmental organizations provide leadership, Â�populations as their economic situations improve.
financing, and organizational support to assist countries in 10. All countries, no matter their economic status, continue to
addressing the health problems of their people. struggle with the issues of escalating health care costs, types
5. There are many types of voluntary agencies working in of health services to guarantee to their people, and means of
world health. Voluntary agencies are free to concentrate on funding the services they provide.
a single health issue or geographical region or to diversify to 11. New infections, resistant old infections, the worldwide obe-
multiple health concerns and geographical regions. sity epidemic, environmental issues, illnesses associated
6. Epidemiological transition refers to the changing health with tobacco use, the effects of war and terrorism on human
conditions affecting populations as a country moves from health, and the scope of mental illnesses have emerged as
poverty to prosperity. global health concerns.
1. Identify an international nongovernmental agency that d. Do health disparities exist in each country? If so, which
addresses health issues. Explore its organizational structure, country has greater health disparity between economic
funding, staffing. What types of concerns does it address? groups?
Where does it concentrate its efforts? How effective has this e. What has each country identified as health priorities?
organization been at addressing its designated health areas? 4. Using the WHO (2000) criteria for the evaluation of health
2. Perform the same exercise for an intergovernmental agency care systems or criteria of your own design, rate how
of your choice. each country selected above has performed with reference
3. Pick a low-income country, a middle-income country, and a to improving health and access to health care services for
high-income country. its population.
a. What are the three leading causes of death and illness in 5. Reflect on your own health care experiences as a health care
each country? provider and as a consumer. Were your experiences positive
b. What are the infant mortality rates and life expectancy for or negative? What do you think is important in a system of
each country? health care? How would you finance such a system? How
c. What type of health care system does each have? How is would you allocate scarce resources?
it funded?

Carter Center: http://www.cartercenter.org/index.html Pan American Health Organization (PAHO): http://new.paho.org/
Centers for Disease Control and Prevention (CDC): http:// Sigma Theta Tau: http://www.nursingsociety.org/default.aspx
www.cdc.gov/ United Nations Children's Fund (UNICEF): http://www.unicef.org/
Bill and Melinda Gates Foundation: http://www.gatesfoundation. U.S. Agency for International Development (USAID): http://
org/Pages/home.aspx www.usaid.gov/
Global Health Council (GHC): http://www.globalhealth.org/ World Bank: http://www.worldbank.org/
International Council of Nurses (ICN): http://www.icn.ch/ World Health Organization (WHO): http://www.who.int/en/
WEBSITE
STUDY AIDS
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August 15, 2011 from http://www.who.int/ University Press.
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World Health Organization. (2011h). Metrics: from the British experience. American Journal of
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CHAPTER
6
Legal Context for Community/Public
Health Nursing Practice
Susan Wozenski*
FOCUS QUESTIONS
How are basic legal issues relevant to community/public health When might a community/public health nurse not be covered
nursing practice? by the employer's professional liability insurance?
What are the sources and purposes of public health law? What are the responsibilities of community/public health
What are the responsibilities or legal duties of community/ nurses in being accountable for their own practice?
public health nurses related to public health law? How are legal and ethical issues alike and different?
CHAPTER OUTLINE
Public Health Law Standing Orders
Community/Public Health Nurses and Public Health Law Client Education
Sources of Law Documentation
State and Local Statutes Agency Policies
Federal Statutes Public Health Law Enforcement
Administrative Rules and Regulations Referrals and Advocacy
Judicial or Common Law Special and Vulnerable Populations
Attorney General's Opinions Family Law
Contracts End of Life/Self-Determination
Classification of Laws and Penalties Environmental Protection
Criminal Laws Nurse Lobbying
Civil Laws How to Find out About Laws
Purposes and Application of Public Health Law Standards of Care
Protecting the Public's Health Definition of a Standard of Care
Advocating for Rights Internal and External Standards
Regulating Health Care Delivery and Financing Role of the Expert Witness
Regulating Professional Accountability Quality and Risk Management
Legal Responsibilities of Community/Public Health Continuing Education
Nurses Incident Reports
Practice within the Scope of the Law Timely Documentation and Communication
Informed Consent Professional Liability Insurance
Refusal of Care and Limits of Care Professional Involvement
Privacy Ethics and Law
KEY TERMS
Abandonment Block grant funding Claims-made policy
Accountability Case law Compilation of Patient Protection and
Administrative law Civil laws Affordable Care Act (ACA)
Agent Civil Rights Acts Contract
Americans with Disabilities Act (ADA)
*This chapter incorporates material written for the first three editions by Penny S. Brooke.
136
CHAPTER 6â•… Legal Context for Community/Public Health Nursing Practice 137
Criminal law Malpractice Respondeat superior and vicarious

Defendant Medical durable power of attorney liability
Expert witness Negligence Social Security Act
General witness Nurse Practice Acts Standard of care
Health Insurance Portability and Occurrence policy Statute of limitations
Accountability Act (HIPAA) Plaintiff Statutory law
Informed consent Public health law Tail coverage
Judicial or common law Public Health Services Act Tort law
Lobbyist
PUBLIC HEALTH LAW There are three levels of federal and state courts. District
courts conduct trials that assess the facts of a case and deter-
Public health law includes all laws that have a significant impact mine applicable law. Appeals courts review decisions of trial
on the health of defined populations. These laws originate courts to determine if proper procedures were followed and
from multiple sources, including the U.S. Constitution, state if the laws were interpreted correctly. Supreme courts review
Â�constitutions, treaties, statutes, legislative rulings, governmen- appeals court decisions. State courts also review state laws to
tal agency rules and regulations, judicial rulings, case law, and determine if they are in accord with the state or federal consti-
public Â�policies. Public health law shapes public health practice tutions. Federal courts can determine the constitutionality of
through the numerous sources of law and disciplines of legal state and federal laws. Decisions of the U.S. Supreme Court are
practice. Public health law also addresses the power and respon- Â�binding in all state and federal courts.
sibility of government to protect the health of the population Public health laws have played a critical role in health pro-
and defines the limits on the power of government to constrain motion and disease prevention. Legal interventions such as
the rights of individuals (Goodman etÂ€al., 2006). quarantine and isolation helped to stem epidemics as early
Under the authority of the U.S. Constitution, federal pub- as the middle ages. In the 1905 landmark case Jacobson v
lic health law exists to promote the general welfare of society. Massachusetts, the U.S. Supreme Court upheld Massachusetts’
Because states retain those powers not delegated to the federal authority to enforce a statutory requirement for smallpox vac-
government, much of public health law remains under state cination. The decision established the constitutionality of state
jurisdiction. As a result, there is significant variation among compulsory vaccination laws when they are necessary for public
states regarding specific public health laws. Local jurisdictions, health or public safety. The court indicated that the freedom of
such as counties, cities, or townships, receive their authority the individual must sometimes be subordinated to the common
from the state to enact public health laws. welfare and is subject to the police power of the state.
Statutory law is enacted through the legislative branch of Law has been instrumental in promoting the public's health
government. Laws of the legislative branches of the Â�federal in many areas including improved childhood immunization
and state governments are called statutes. Similar laws of rates, decreased environmental health hazards, decreased den-
local Â�governments are usually called ordinances. Statutes often tal caries, improved motor vehicle safety and workplace safety.
authorize new health initiatives and appropriate tax funds to Legal strategies have recently been used to address emerg-
Â�implement the law. Community/public health nurses can influ- ing threats from severe acute respiratory syndrome (SARS)
ence the political process by lobbying legislators and officials for and influenza. In 2000, the Centers for Disease Control and
or against specific statutes and ordinances. Prevention (CDC) initiated its Public Health Law Program to
Administrative law consists of orders, rules, and regulations assist health care professionals and policy makers in 1) acceler-
promulgated by the administrative branches of governments. ating and strengthening responses to bioterrorism, public health
For example, the state board of nursing is the administrative emergencies and infectious diseases, 2) using legal Â�strategies to
body that regulates the practice of nursing. Other examples address obesity and other chronic diseases, 3) enhancing injury
of administrative bodies are the U.S. Department of Health prevention strategies, and 4) facilitating partnerships and
and Human Services and state and local health departments. Â�mobilizing resources to achieve public health priorities (CDC
Administrative law often details the policies and procedures Public Health Law Program, 2011).
necessary to implement statutes. Community/public health
nurses can influence the development of administrative law by COMMUNITY/PUBLIC HEALTH NURSES AND
advocating for orders, rules, and regulations and commenting PUBLIC HEALTH LAW
on proposed orders, rules, and regulations during periods for
public review. Official (government) health agencies often enforce laws in
Judicial or common law, also referred to as case law, is devel- addition to providing health services; nurses working in these
oped through federal and state courts that resolve disputes in Â�agencies are often part of that enforcement process. In this
accordance with law. Courts interpret regulations and statutes, Â�chapter, legal issues in community/public health nursing are
assess their validity and create common law when decisions Â� broadly described, and the rights of the public and clients and
are not controlled by regulations, statutes or constitutions. the rights of nurses are discussed. It is important for nurses
Generally, the case before the court is compared to the facts and to be aware of the laws for which they will be held account-
law in previously decided cases to determine similarities and able. Federal laws and regulations apply to persons through-
differences in the context of current community or Â�professional out the United States, whereas state and local laws apply within
standards. the respective state and local jurisdictions. For example, state
138 CHAPTER 6â•… Legal Context for Community/Public Health Nursing Practice
or public Â�agencies might be protected by limited Â�immunity Â�

public welfare. Sometimes the laws within which nurses must
Â�statutes, whereas private agencies might not be included in work lend themselves to varied interpretations. In these cases,
these statutory protections. Facts and legal issues of case nurses and the agencies where they work should seek the opin-
law are used to evaluate potential liability and are constantly ion of their state's attorney general for clarification.
evolving. Community/public health nurses are responsible for Rules, regulations, and statutes guide the community/Â�public
Â�understanding the federal and state laws related to their practice. health nurse and are references with which the nurse must
become familiar. A specific law cannot be read in isolation; a
SOURCES OF LAW wider scope is needed to understand the nurse's total legal
responsibilities. For example, when communicable diseases are
All laws that govern society are designed to maintain order and reported, both state and federal laws must be considered. Local
to inform those who are accountable to the law of the expected ordinances and regulations also apply. TableÂ€6-1 provides exam-
behavior and of behavior that will not be allowed. Laws are ples of public health law from all three levels of government
Â�written to carry out the wishes of the majority and to protect the that a community health nurse might encounter in caring for
rights of the minority. Laws and policies are made by legislators, a family.
as well as administrators, regulators, boards, and committees.
Environmental and public health issues are of special Â�concern State and Local Statutes
and interest to communities. Laws in these areas are usually There are many public health statutes enacted by state legisla-
enacted by the legislative and administrative bodies of indi- tures that are of concern to community/public health nurses.
vidual states. Federal lawmakers provide the guidelines or the Statutes seek to protect the rights of both the health care Â�provider
“umbrella” laws. States must abide by federal laws and must and the consumer. Nurse Practice Acts are broad frameworks
avoid enacting state statutes that conflict with federal Â�guidelines. within which the legal scope of nursing practice is defined in
Both state and federal courts write case law or common law, each state. Community/public health nurses are accountable for
which reflects society's current beliefs regarding what best serves working within this legal framework. Protection of Â�professional
TABLEÂ€6-1â•…â•‡EXAMPLES OF LAW AFFECTING CLIENTS AND NURSING PRACTICE

Community Health Situation
A student nurse is asked to assess a family of five; a mother, age 36, caring for a 2-month-old infant; a 6-year-old child in school; a maternal
grandmother, 65, with diabetes; and a son, 21, who works as a short-order cook. The mother receives Temporary Assistance for Needy Families (TANF)
for the two youngest children. She desires to keep another youngster in her home. Neighbors have complained about the noisy dogs. The 21-year-old
has been diagnosed by stool culture as being infected with Salmonella.
SOURCES OF APPLICABLE LAW
LEVEL OF
GOVERNMENT LEGISLATIVE LAW ADMINISTRATIVE LAW JUDICIAL LAW
Local Nuisances (dogs) Procedure for hearings Previous decisions regarding nuisances
Leash laws; requirements for
rabies vaccinations
State Daycare licensing needed Details regarding who orients mothers
for daycare and what is included
Immunization requirements for Interpretation of what constitutes “initial Court decisions regarding religious
6-year-old series” of immunizations for various exemptions from immunizations
ages
Reportable diseases (Salmonella) Delegates authority to implement
under General Welfare; might programs to protect the public's health
detail that those with infectious
diseases cannot handle food
Nurse Practice Act enables students State board of nursing issues rules and
to practice regulations to allow student learners to
practice nursing
Federal Medicare for grandmother Forms and information necessary for Decisions regarding sexual discrimination
clients to enroll; delegates authority to in Social Security payments
implement
Medicaid for those on Temporary States must continue to provide
Assistance for Needy Families coverage to any family member who
(TANF) would have been eligible for TANF; can
Food stamps be cut off as a sanction if a family fails
to meet its work requirements
Same as Medicare for grandmother
Courtesy of Claudia M. Smith, PhD, MPH, RN-BC, former Assistant Professor, University of Maryland School of Nursing.
practice includes avoiding compromising Â�positions in which Immunity from legal action is afforded to health care provid-
one is expected to practice outside the scope of nursing. Each ers who, in good faith, report Â�suspected abuse of a client to a
state's Nurse Practice Act is available on the Web as well as legal Â�authority. Statutes also define penalties for not reporting
through employers, the state nurses' association, and the state known cases of abuse.
board of nursing. Statutes affording protection for privileged communica-
Many states also have statutes defining malpractice actions tion of confidential information might, but do not always,
against health care providers that pertain to community health include the community/public health nurse. It is important for
nurses. These laws have a statute of limitations for malprac- nurses to be aware of the scope of protection in their states. In a
tice actions that define a time frame within which a legal action Â�number of states, nurse–client communications do not have the
must be brought. Often, the specific procedures for bringing a Â�privilege of confidentiality.
lawsuit against a health care provider are outlined within these Community/public health nurses must be aware of the state's
malpractice statutes. laws pertaining to family privacy matters, such as Â�abortion,
Â�distribution of contraceptives to minors, and Â�family Â�violence.
Balancing Client Rights Versus Public Health Their clients might seek advice on these matters and their
State legislatures also enact statutes under health codes that Â�community/public health nurse should be able to advise them.
describe laws for reporting communicable diseases, laws regard- Community/public health nurses might also be asked to explain
ing school immunizations, and additional laws directed toward a living will statute, if one exists in their state, and the uses of a
promoting health and reducing health risks in the community. durable power of attorney (see ChapterÂ€28). Statutes that require
An individual's right to privacy may conflict with the public specific behaviors, such as the procedures for Â�pronouncing a
health duty to protect the general public. client dead or reporting abuse, vary among states. The board
Mandatory notifiable disease reporting protects the public's of nursing can clarify the specific expectations of community/
health by facilitating the proper identification and follow-up of public health nurses in that state.
cases. Public health personnel ensure that infected individuals
receive treatment; trace contacts who need vaccines, treatment, Federal Statutes
quarantine or education; investigate outbreaks; address envi- Federal statutes are important to the practice of community/
ronmental health hazards; and close facilities where spread has public health nurses. The Public Health Service and the CDC
occurred. States periodically update their lists of mandatorily were Â�created by Congress to coordinate the collection, sharing,
reportable diseases so it is essential to be up-to-date on your and analysis of data from all of the states and the U.S. territories
state's legislation and regulations. The regulations that govern on Â�certain diseases to protect the health of individuals and com-
mandatorily reportable diseases include limits on permissible munities. Guidelines for dealing with legal issues pertaining to
disclosures that vary from state to state. To become Â�familiar reporting requirements, such as the importance of maintaining
with the relevant state and local reporting and notification Â�confidentiality, are issued by the CDC. The Occupational Safety
requirements for disclosing otherwise confidential informa- and Health Administration (OSHA) also provides guidelines
tion, check your state and local health departments’ websites. for safe and healthy work environments.
There are special circumstances surrounding the handling of In August of 1996, Congress passed the Health Insurance
contacts of persons with human immunodeficiency virus (HIV)/ Portability and Accountability Act (HIPAA). Enforcement
acquired immunodeficiency syndrome (AIDS). All clinicians are of HIPAA privacy regulations began in April 2003. HIPAA
required by state law to report cases of AIDS to the local health Â�provides clients with greater control over their personal health
departments. Some states require HIV infection case reporting information (e.g., a client's condition, care, and payments
to the state health department. Most states hold the information for health care). HIPAA protects confidentiality by defin-
strictly confidential, which means that health departments are ing what privacy rights clients have, who should have access
not allowed to contact sexual partners or close contacts without to client information, how data should be stored by pro-
the permission of the infected person. Some states permit the dis- viders, what constitutes the client's right to confidentiality,
closure of HIV/AIDS to certain close contacts under certain con- and what constitutes inappropriate access to health records.
ditions. The National HIV/AIDS Clinicians’ Consultation Center Confidentiality concerns how records should be protected,
maintains an updated compendium of state HIV testing laws that and security involves measures the nurse and others must
can assist you in becoming knowledgeable about your state's laws take to ensure privacy and confidentiality (Frank-Stromborg
(National HIV/AIDS Clinicians’ Consultation Center, 2011). & Ganschow, 2002). Providers of care must notify clients of
their privacy policy and make a good faith effort to obtain a
Health Records written acknowledgment of this notification. It is the nurse's
The records required to be kept by health care providers are responsibility to protect client confidentiality. Nurses need to
usually described within a state's health code. State mandatory understand both the federal HIPAA regulations and the state
reporting laws usually address actions to be taken in reporting laws that are enacted to enforce those regulations, as well as
child abuse or neglect and the penalties associated with fail- any changes or updates to either of these. Employers affected
ure to report known or suspected cases of child abuse. A sum- by HIPAA are responsible for ensuring that the nurses they
mary of the statutes in all 50 states mandating persons to report employ comply with the regulations.
child abuse and neglect is available at the U.S. Department Another example of a federal statute that must be under-
of Health and Human Services (2011) Child Welfare stood by community/public health nurses is the Social
Information Gateway at http://www.childwelfare.gov/systemwide/ Security Act and its amendments. The Medicare and Medicaid
laws_Â�policies/state/. A growing number of states have enacted con- Â�programs were enacted as amendments to Social Security and
fidential Â�communications protection for sexual abuse acts. the Â�parameters of these programs should be understood by
Â�
community/public health nurses to best assist their clients Medicare, Medicaid, and Children's Health Insurance Program
(see ChapterÂ€4). Community health clients who are eligible for (CHIP); 3) strategies for increasing access to affordable care
either Medicaid or Services for Children with Special Health such as extending coverage to age 26 for young adults on
Care Needs should also be made aware of the Early and Periodic their parents’ plans, providing access to insurance for adults
Screening Diagnosis and Treatment (EPSDT) Program. These with preexisting conditions, rebuilding the primary care work-
programs are discussed in detail in ChapterÂ€27. force, and expanding community health centers’ services;
In March of 2010, Congress passed the Compilation of 4) provisions for holding insurance companies account-
Patient Protection and Affordable Care Act (ACA), which man- able, such as reducing premiums and strengthening Medicare
dates comprehensive health insurance reforms, the Â�majority of Advantage; and 5) adding expanded consumer protections such
which will be implemented by 2014. The law includes 1) new as prohibiting discrimination and allowing participants in clin-
consumer protections such as prohibiting the denial of coverage ical trials to maintain their insurance (HealthCare.gov, 2011).
for children based on preexisting conditions and eliminating Without an adequate knowledge base or understanding
lifetime limits on insurance coverage; 2) provisions for improv- of federally enacted programs, community health nurses will
ing quality and lowering cost, such as providing free preven- neglect to inform qualified clients of existing federal Â�programs.
tive care for specified screening and reducing fraud and waste in Other examples of federal statutory law are included in TableÂ€6-2.
TABLEÂ€6-2â•…â•‡FEDERAL LEGISLATION THAT INFLUENCES PUBLIC HEALTH

TITLE PURPOSE IMPACT OF LAW
Social Security Act and Amendments
Social Security Act of 1935 (PL 7427â•›t), To enable each state to furnish Created Title II, Federal Old Age Benefit payment to persons
Title I: Grants to States for Old Age financial assistance to aged needy over 65â•›years of age (Social Security); Title III, Unemployment
Assistance people. Compensation; Title IV, Aid to Dependent Children; Title V,
Maternal-Child Welfare to promote health, especially rural
health of women and children; Title VI, Public Health Work to
maintain public health services, including training of personnel;
Title VII, the Social Security Board; Title VIII, Taxes With
Respect to Employment; Title IX, tax on employers with eight or
more employees; Title X, Grants to States for Aid to the Blind;
Title XI, General Provisions.
Maternal and Child Health and Amends the Social Security Act to assist Expanded and improved maternal and child health in Services for
Retardation Amendments of 1963 (PL states and communities in preventing Children with Special Health Care Needs; provides prenatal,
88156) and combating mental retardation. maternity, and infant care to combat mental retardation.
Social Security Amendments of 1965 Provided funding to states to establish Established a state plan to provide medical assistance to families
(PL 8797), Title XIX: Grants to States medical assistance for the needy as with dependent children, the aged, the blind, and permanently
for Medical Assistance Program defined under the act. and totally disabled individuals whose income and resources are
insufficient to meet the costs of necessary medical care; also
established rehabilitation services to assist clients in obtaining or
retaining the capacity for independence or self-care.
Social Security Amendments of 1965 Established hospital and medical Provides specified health benefits to eligible clients. Benefits
(PL 8797), Title XVIII: Health Insurance insurance benefits for persons might vary from year to year; a monthly premium is paid (refer
for the Aged (known as Medicare; older than 65â•›years of age who are to ChapterÂ€4).
Tied into Railroad Retirement Act of residents of the United States (i.e.,
1937) a citizen or lawful alien who has
resided continually in the United
States during the preceding 5â•›years).
Social Security Amendments of 1977— Authorizes reimbursement for clinic Clinics that employ physician assistants or nurse practitioners
Health Clinic Services (PL 95210) services in rural areas designated as are eligible for reimbursement under Medicare or Medicaid if
a health manpower shortage area. the client population is below 3000 or there are no physicians
practicing within 5 miles of the clinic.
Public Health Services Act and Amendments

Public Health Services Act of 1944 Created federally coordinated Power to establish divisions was given to the Surgeon General,
(PL 78410) departments to address the who serves as the administrator of the Public Health
public health needs of the nation; ServicesÂ€Act.
established the office of the Surgeon
General and the National Institutes
of Health, the Bureau of Medical
Services, and the Bureau of State
Services; the divisions created are
administered by the Surgeon General.
TABLEÂ€6-2â•…â•‡ FEDERAL LEGISLATION THAT INFLUENCES PUBLIC HEALTH—CONT'D

Special Health Revenue Sharing Act of Amended the Public Health Services Programs affected by these grants include family planning
1975 (PL 9463) Act and related health laws to programs; community mental health center programs, including
revise and extend the health the requirements for the mental health centers; programs and
revenue sharing program, providing centers for migrant worker health; community health centers;
comprehensive public health and miscellaneous home health services, mental health and
services; grants to state health and illness of the elderly; the National Health Service Corps
mental health authorities were program; commissions on epilepsy, Huntington's disease, and
made to assist with the cost of hemophilia programs; assistance for nurse training and for
providing care. other purposes such as the advanced nurse training and nurse
practice programs, special projects, grants, and contracts.
Social Services
Omnibus Budget Reconciliation Act of Created to consolidate federal Increased flexibility for states in coverage of and services
1981, Block Grants for Social Services assistance to states for social for the medically needy. Human services affected by
and Health (PL 97-35) services into a single grant to Title VI include education of the handicapped; vocational
increase the states' flexibility rehabilitation programs; handicapped programs and services;
in using grants to achieve the older Americans' domestic volunteers and senior companion
goals of preventing, reducing, or programs; child abuse prevention and treatment; community
eliminating dependency; achieving services program; urban and rural special impact programs;
or maintaining self-sufficiency; or supportive programs to Head Start; Title VIII, School Lunch
preventing or remedying neglect, and Nutrition Programs; Title IX, Health Services Facilities;
abuse, and exploitation of children rodent control; fluoridation programs; hypertension;
and adults unable to protect their developmental disabilities; research; health planning and
own interests; to rehabilitate and maintenance; adolescent family, alcohol and drug programs;
reunite families and provide for Title XXI, Medicare, Medicaid, and maternal and child health
community home-based care. The reimbursement changes (changes in services and benefits);
Maternal and Child Health Services Title XXII, Federal Old-Age, Survivors, and Disability Insurance
Block Grant was created to ensure Program newly defined benefits; Title XXIII, Aid to Families with
low-income persons with limited Dependent Children (AFDC), Temporary Assistance for Needy
availability for health services Families (TANF)—past-due child support can be collected from
access to quality maternal and federal tax refunds.
child health services. Subtitle C
block grants for social services
consolidated federal assistance to
the states for social services into a
single grant.
Health Centers Consolidation Act (PL Community health centers, migrant Community health centers provide comprehensive case managed
104-299) 1996 centers, health care for the primary health care to medically indigent and underserved
homeless, and public housing service populations. Migrant health centers provide primary care to
grants are consolidated under one migrant and seasonal agricultural workers and their families.
grant program and reauthorized Health services for the homeless provide project grants to
through fiscal year 2001. Yearly community health centers and nonprofit coalitions, inner-
reauthorization thereafter. city hospitals, and local public health departments to deliver
primary care, substance abuse, and mental health services to
homeless adults and children. Public housing service grants are
awarded to community-based organizations to provide case
managed ambulatory primary help and social services in clinics
at or near public housing. Health centers that provide services
to medically underserved populations with high incidents of
infant mortality are eligible for such grants as well as health
centers that have experienced a significant increase in the
incidents of infant mortality. Authorizes grants to rural health
centers to ensure that people living in underserved rural areas
have access to health care. Grants are made for rural health
outreach, network development, and telemedicine.
Health-Related Amendments to the VA/ Amends the health insurance To prohibit insurance companies from issuing policies covering
HUD FY1997 Appropriations Bill (PL portability and accountability act. hospital stays for new mothers and babies of less than
104-204), Newborns and Mother's 48Â€hours for normal vaginal births or 96 hours for cesarean
Health Protection Act of 1996 deliveries.
Continued

Social Services—cont'd
Mental Health Parity Act of 1996 Requires health insurance plans that If the cost of providing health coverage results in an increase
(Spina Bifida Amendment) cover mental health services to of at least 1%, the law will not apply. The mental health
provide the same lifetime and annual provision does not apply to companies with 50 employees
limits on coverage that they provide or less. Veterans' benefits will be provided to children,
for physical conditions. Provides including medical care, rehabilitation, vocational training
veterans’ health benefits to children and education, and a cash allowance between $200 and
suffering from spina bifida, if at least $1200, depending on the degree of disability.
one parent was exposed to Agent
Orange in Vietnam.
Health Insurance Portability and The act sets minimum federal The act does not help the unemployed who are in
Accountability Act of 1996 (PL 104- standards that allow workers to transition, and their families, nor does it cover mental
191) (HIPAA) maintain their insurance coverage if health. Group health plans are prohibited from
they lose or leave their jobs. Medical discriminating against workers based on their health
savings accounts can be established, status or medical history. Limits to 12â•›months the period
allowing workers with high- of time by which group health plans might exclude
deductible insurance plans to set up coverage of a preexisting medical condition (i.e., those
tax-deductible savings accounts to conditions diagnosed or treated within 6â•›months from
use for medical expenses; increases enrolling in a plan). Newborns and adopted children
the amount self-employed workers are exempted from the 12-month waiting period for
can deduct from their income taxes; preexisting conditions. A medical condition is covered
gives tax breaks for long-term care within 30â•›days of birth, and adopted children are covered
insurance; and allows the chronically within 30â•›days of adoption or placement for adoption.
or terminally ill to collect benefits Pregnancy is no longer considered a preexisting condition
on their life insurance policy before from the 12-month waiting period.
death without a tax penalty. Also Workers who were covered by group health plans are
makes it a crime to transfer personal immediately eligible for coverage at a new job as long
assets to relatives and friends, as the new employer provides health insurance to its
nursing homes, or others in order to employees. The new law does not restrict employers from
qualify for Medicaid. imposing a waiting period for new employees to obtain
health insurance, usually 3â•›months. However, during this
period, the employee will be considered continuously
covered. Requires insurers to offer individual coverage to
people who lose or change jobs if the new employer does
not offer health insurance to its employees. Guarantees the
renewal of group and individual health insurance policies
except in cases of fraud and nonpayment of premiums.
Provides protection for client privacy Hospitals and other health care organizations must
and confidentiality of medical designate a privacy officer, provide education on HIPAA
information. Greater security over to employees regarding security of records, adopt written
medical records and sharing of privacy procedures, and obtain consent from clients
information is required. for most disclosures of protected health information.
A minimum amount of information necessary may only
be provided under HIPAA and only those with a need to
know client information may access client information
without consent.
Child Abuse Prevention and Treatment The community-based family resources Maintains a federal role in funding research, technical
Act (CAPTA) (1996 PL 104-235) program was funded in 1997. Each assistance, data collection, and information dissemination
state has a child's trust fund that on child abuse treatment and prevention. A number of
uses this money to make local grants new protections for children, such as limiting delays and
for child abuse prevention programs. termination of parental rights, filing of false reports,
Child abuse prevention and and lack of public oversight of child protection, are also
treatment are the focus of this law. included. The act repeats the temporary child care and
nursery's program and the McKinney Family Support
Center by consolidating their activities. The act also
provides the Department of Health and Human Services
(USDHHS) the ability to establish an office of child abuse
and neglect.

Social Services—cont'd
The Personal Responsibility and Work Transformation of the welfare It is estimated that 2.6 million people were no longer able to rely on
Opportunity Reconciliation Act of system, including provisions the federal programs previously relied upon before this welfare
1996 (PL 104-193) that relate to food stamps, child reform law. Temporary Assistance for Needy Families (TANF)
nutrition, child care, children's funding was frozen through 2002 at the amount that the states
Supplemental Security Income received from the federal government the prior year for AFDC,
(SSI), child protection, child support emergency assistance, and jobs. TANF abolished AFDC, jobs,
enforcement, and immigrants. and emergency assistance grants (EAG) and replaced them with
Referred to as welfare reform TANF in a block grant to the states. Under TANF, a fixed amount of
law, which ends 60â•›years of social federal funds is awarded to states each year regardless of need.
welfare policy, completely removing The states must have a plan approved by HHS to determine their
many federal programs for poor own eligibility requirements and the form the benefits will take.
families and children. States can transfer up to 30% of TANF funds to the child care
and development block grant and to the Title XX social security
block grant (SSBG). Children's SSI, which provides support to
low-income children with severe mental or physical disabilities,
received significant changes to the eligibility criteria. Children
who lost their SSI benefits did not necessarily remain eligible for
Medicaid, unless their family qualified on other criteria.
All current and future legal immigrants are barred from receiving
SSI and food stamps. Exempt immigrants include refugees,
asylees, veterans, aliens on active duty, and immigrants who
have worked 40 quarters. Future legal immigrants are barred
from receiving TANF, Medicaid, and Title XX for 5â•›years after
entering the country. All federal means tests benefits and
the income of their sponsor family are deemed as part of
their income when eligibility determinations are being made.
Illegal or not qualified immigrants are barred from all federal
public benefits, including retirement, welfare, disability,
public and assisted housing, health, postsecondary education,
unemployment benefits, and food assistance.
Families who qualify for TANF no longer have a guaranteed
legal right to child care. However, TANF prohibits states from
penalizing parents of children under 6â•›year of age who are
single and cannot find accessible child care.
Balanced Budget Act of 1997 To expand access to health care by Provides direct Medicare reimbursement to advanced practice
(PLÂ€105-33) Medicare beneficiaries. nurses, specifically nurse practitioners (NPs) and clinical nurse
specialists (CNSs) practicing in any setting.
State Children's Health Initiative To encourage health insurance States that develop health insurance plans that provide health
Program (SCHIP) (2001) coverage for children of needy insurance coverage to the children of families with low incomes
families. are provided matching federal funds to support these health plans.
Children's Health Insurance Expanded health care program to 4 million children and pregnant
Reauthorization Act (2009) women, including legal immigrants without a waiting period.
Compilation of Patient Protection To mandate comprehensive health Designed to improve quality and affordable care for all Americans
and Affordable Care Act (2010) insurance reforms. to improve access to public programs such as Medicaid, Children's
(PLÂ€111-148) Health Insurance Program (CHIP), and maternal and child health
services, to improve the quality and efficiency of health care, to
prevent chronic disease and improve public health, to improve and
increase the health care workforce, to increase transparency and
program integrity, to improve access to innovative therapies, to
establish a national voluntary insurance program for purchasing
community living assistance services and support, and to institute
revenue offsetting provisions.
Data from the U.S. Code, Congressional and Administrative News. (1935, 1937, 1944, 1963, 1965, 1975, 1977, 1981). St. Paul, MN: West Publishers;
Center for Community Change. (1996). Less money, fewer rules, more power to the state. The 104th Congress, Public Policy Department; U.S.
Government Printing Office. HIPAA, Health Insurance Portability and Accountability Act of 1996. Retrieved February 8, 2012 from http://www.gpo.
gov/fdsys/pkg/PLAW-104publ191/content_detail.html; and HealthCare.gov. (2011). Retrieved July 27, 2011 from http://www.healthcare.gov/law/
introduction/index.html.
Administrative Rules and Regulations might be appealed to the state court system. If a Â�community/
Rules and regulations are established by administrative bodies public health nurse is asked to perform a procedure that she or
of government, such as licensing boards and regulatory agen- he believes is beyond the scope of nursing practice, the nurse or
cies. Administrative bodies, including state nursing boards supervisor can receive clarification by requesting a declaratory
and health departments, are composed of experts in the field ruling from the state board of nursing.
who are considered to be better prepared than the average
Â�layperson to make decisions regarding the specific rules and A school nurse is asked by the principal to instruct school
regulations for safe practice. The authority to promulgate bus personnel and the teachers of a disabled child about
rules and Â�regulations is delegated to the administrative body replacement of an outer cannula for a tracheostomy. The
by the legislative branch of government—Congress for federal nurse does not believe it is appropriate to train lay people
rules and regulations and state legislatures for state rules and to perform this procedure on the student (see ChapterÂ€30).
regulations (FigureÂ€6-1). The nurse declines to instruct the personnel. The nurse's
Often the rules and regulations enacted by the administra- Â�supervisor insists. The nurse should ask for a ruling from the
tive body are intended to provide the details for implementation state board of nursing.
or clarification of a broader statute enacted by the legislature.
As an example, the Nurse Practice Act in most states provides Refusal to perform questionable duties until clarification is
broad guidelines defining the scope of nursing Â�practice. The received should be considered reasonable and safe practice, not
more specific rules and regulations promulgated by the state insubordination.
nursing board provide necessary details to give guidance to Examples of administrative rules and regulations that pro-
nurses in the state. Administrative rules and regulations cannot tect the public are those promulgated by OSHA. The occu-
conflict with the statute they seek to interpret, yet the details pational safety of workers is central to maintaining a healthy
that the rules and regulations provide can be very powerful in work force and employers must comply with the regulations
defining the scope of practice of nursing in the state. Regulations that define a safe and healthy work environment. For exam-
also provide guidelines for how to work within the health care ple, employers of health care workers are required to pro-
Â�system (e.g., how to submit an application to receive Medicare vide Â�protective equipment and conduct in-service education
or Medicaid and even who may apply). about universal precautions to prevent the spread of HIV and
Administrative lawmaking, the promulgation of rules and Â�hepatitis B virus.
regulations, is usually preceded by notice of the proposed rule or
regulation. Those who will be affected are given an Â�opportunity Judicial or Common Law
to provide input. For example, because nurses are affected by the Common or judicial law is based on common usage, custom,
state board of nursing rules and regulations, they may Â�provide and court rulings called case precedents. Case precedents are
input in writing or attend a hearing specifically held to discuss useful for interpretation of statutory language and for compar-
the proposed rule or regulation. ative purposes. The facts of a case at trial are compared with
Administrative law bodies are often empowered to revoke or cases previously ruled on and evaluated for similarities and
suspend professional licenses. Charges involving suspected vio- Â�differences. Rulings may also be based upon the testimony of
lations of the Nurse Practice Act or of administrative rules or witnesses, external standards, and common sense. Case law
regulations, or other charges brought against a nurse related to reflects the changes in society's views; cases might be over-
professional practice, are heard and decided by the state board turned or overruled and, therefore, might not be safely relied on
of nursing. The decision of the administrative rule-making body as the law in that state. Relying on the expertise of an attorney
who practices in health care law is recommended when engaged
in litigation.
The cases of most interest to community/public health
LEGISLATIVE BODY (U.S. Congress, state legislature, nurses involve circumstances that can be applied to the Â�practice
county council) writes and votes on laws of community/public health nursing. For example, court
Â�decisions might provide support for exemptions from immu-
nizations based on a person's religious beliefs or the parameters
LAW PASSES of obtaining informed consent when working in a community
health setting. Nurses need to understand the specific facts of a
case to safely assess their own situation or likelihood of Â�liability.
The Case Study in this chapter, which focuses on a nurse's
response to a child's asthma attack in school, demonstrates
REGULATORY AGENCY
interprets or defines how
Â�liability risks for school nurses.
the law will be implemented Roles that the community/public health nurse assumes
become legally binding duties and must be undertaken respon-
sibly. Some community/public health nurses might be required
to perform laboratory tests such as phenylketonuria (PKU)
PEOPLE/AGENCIES/JURISDICTIONS testing. Failure to adequately inform a client or guardian or
subject to the law and to the Â�performing a test improperly might lead to litigation. Nursing
interpretations and regulations judgments, such as the assessment of an individual's con-
developed by the regulatory agency
dition and the documentation of signs and symptoms sup-
FIGUREÂ€6-1â•‡ Relationship between laws and regulations. porting the nursing inferences, might be critical in deciding
the Â�severity of the illness or describing adverse reactions to The state attorney general's opinions provide guidelines
Â�prescribed Â�treatments. For example, when the nurse provides based on both statutory and common law interpretations. The
home health care to ill persons, blood pressure readings that attorney general's office evaluates the written law, including its
are outside normal parameters must be reported to the phy- legislative history, and provides an opinion as to how the law
sician or nurse practitioner in charge of the case. The com- should be applied. If a legal issue arises and the community/
munity/public health nurse might be the only person who has public health nurse has an attorney general's written opinion
direct contact with the community health client, which makes offering an interpretation of a particular issue or statute, the
communication between the health department or home care court will most likely view the nurse or the agency as having
agency, physician or other members of the health care team, acted reasonably and responsibly in seeking clarification of
and the community/public health nurse critical. The impor- what is appropriate. If the nursing action conforms with the
tance of accurate and timely communication has been tested in attorney general's opinion, the court will usually consider this
many legal cases involving nurses. favorably on behalf of the nurse or agency named as a defendant
Liability issues in health care have changed significantly over in a lawsuit.
the past 50 years. In the earliest cases, nurses were considered The basic underlying principle is that a nurse should be able
employees of physicians, hospitals, health Â�departments, etc., to rely on the professional advice of legal counsel. An attorney
which were responsible for the actions of their Â�employees, not general's opinion might differ from a second opinion from the
as a professional group with its own standards and accountabil- same office or an opinion from another attorney at a later date.
ity. The defense strategies of respondeat superior and vicarious Highly controversial issues, such as abortion and contraception
liability (i.e., being responsible for another's actions) trans- for adolescents, may be influenced by political concerns and
ferred liability from the nurse to the physician or the health may receive differing interpretations by different individuals in
department or hospital; nurses were not viewed as respon- the same office at different times.
sible for their actions or inactions. Now courts recognize the
Â�independent status of nurses as professionals and hold nurses Contracts
individually accountable for their professional actions. A contract is an agreement between two persons who have the
Supervisory liability is one of the few instances in which legal capacity and are competent to join into a binding agree-
vicarious liability occurs in current case law. As a supervisor of ment that is recognized under the law. Contracts Â�protect the
nurses, nurse's aides, or licensed practical nurses in an agency, rights of both clients and nurses. Community/public health
a community/public health nurse must not delegate tasks to nurses must be aware that promises made to clients that are
these workers that are beyond the scope of their knowledge meant to be reassurances might be interpreted by Â�clients as
base or the legal scope of their practice. If a person the com- binding promises of outcomes. It is best to avoid making
munity/public health nurse supervises harms a client while promises about things that are outside one's Â�control. There
providing care, the community/public health nurse's profes- are situations in community/public health nursing in which a
sional judgment when delegating such tasks will be assessed Â�formal contractual agreement is necessary. If one agency agrees
to determine whether the nurse's action was reasonable. Most to provide services to another agency, it is wise to have the
common law issues in nursing involve the torts of negligence understanding in writing. The purpose of a written Â�contract
or malpractice, which are discussed in this chapter's section is to provide evidence of what the parties are mutually
Â� agree-
on civil laws. ing to do.
Community/public health nurses might find themselves Employment contracts are an important issue for all nurses.
involved in the court process in one of several roles. As a defen- The customary practice in nursing has been to hire a nurse
dant, the nurse stands accused of causing harm to another; as without a written contract. In this situation, the policies and
an expert witness, the nurse testifies as to the standard of care procedures describing the duties and responsibilities of the
in community/public health nursing; and as a general witness, community/public health nurse are often the agency's legally
the nurse testifies regarding the specific facts at issue in a given binding employment agreement. If an employment agreement
case. Community/public health nurses currently enjoy greater specifies duties that are beyond the scope of nursing practice in
autonomy than many other nurses, which makes professional the state, nurses should not provide these services. The fact that
accountability even more critical. Court cases relating to the an agency might require a community/public health nurse to
practice of community/public health nursing will most likely perform a procedure will not protect the nurse as an individual
increase as a result of the shortened length of patient stays in if this practice is found to be outside the scope of nursing as
acute care facilities, which translates into increasingly com- defined by the state's Nurse Practice Act. The law will overrule
plex care being delivered to these patients, and more care being any agency policy or procedure. In a Texas case, a nurse testified
delivered in community settings. that she was following the physician's direction and the agency's
policy. The court ruled that the state's Nurse Practice Act was
Attorney General's Opinions the rule of law the nurse should be following. The fact that she
In many states, the attorney general is the official legal counselor relied on what the physician or her employer told her to do was
for public agencies, including health departments. Questions an insufficient defense (Lunsford v Board of Nurse Examiners,
pertaining to the legality of procedures or the scope of nursing 1983). Nurses who question whether they should perform some
practice within the state can be clarified with the attorney gen- of the services required of them by their community health
eral. The state attorney general provides both informal and for- agency should bring these concerns to the attention
Â� of their
mal opinions. If the legal issue is of such concern that the nurse supervisor. It may also be appropriate to request a declaratory
or agency believes the liability risks are great, a formal written ruling from the board of nursing to determine whether the
opinion should be requested. practice in question is within the scope of nursing.
Before signing an employment or other contract, the nurse home, it would be wise for the nurse to speak to the nursing
should read the contract carefully. If a person signs a contract supervisor to determine whether reporting the illegal activity is
without reading it, the court will not view this favorably. When mandated by law. The nurse must exercise judgment regarding
establishing a client contract, the community/public health the threat posed to society versus the impact on the nurse-client
nurse must make certain that the terms of agreement are writ- relationship.
ten out before asking the client for a signature.
Civil Laws
CLASSIFICATION OF LAWS AND PENALTIES Civil laws are written to regulate the conduct between private
persons or businesses. A private group or individual might
Laws are enacted by state legislatures or Congress, as described bring a legal action for a breach of a civil law. This private
previously, and specific categories of laws have associated group or individual is called the plaintiff. The person charged
Â�penalties. The authorities or bodies that enforce the laws are with violating a law or legal right is called the defendant. The
also unique to the particular classification of the laws, whether court's ruling may result in a plan to correct the wrong between
Â�criminal or civil. the two parties and might include a monetary payment to the
wronged party, commonly known as damages. The penalties for
Criminal Laws most civil wrongs do not include incarceration. Some civil cases
The laws that constitute the criminal code (criminal law) might discover violations of the criminal laws, which might
are written for the protection of the public welfare. For this then lead to criminal penalties.
reason, when a case is brought under the criminal code, the Community/public health nurses most often work auton-
defendant faces society, represented by a prosecutor, instead omously without the opportunity for on-site immediate col-
of an individual plaintiff. Criminal cases are prosecuted by laboration with other nurses or members of the health care
the government. The penalties attached to criminal violations team. Nurses as professionals are accountable for the nursing
tend to be more severe and include the possibility of incar- Â�judgments they make. Consumers see nurses as trustworthy
ceration. Examples of potential violations of the criminal experts in their field and rely on what nurses tell them. However,
code in community/public health nursing include the situa- if a client is harmed because of a nurse's action, inaction, or
tion in which the nurse believes that her or his own judgment incorrect advice, the nurse can be held legally accountable for
about the worth of a person's life is the correct one and acts the resulting injury.
to Â�hasten the death of that person. The criminal code refers Most cases involving nurses fall under the domain of tort
to this behavior as either murder or manslaughter. There has law. A tort is defined as civil wrong committed or omitted by
been an array of cases involving nurses who saw themselves as a person against a person or property of another that leads to
“angels of mercy” and hastened death in hospitals and long- injury to that person, property, or reputation. Tort law covers
term care facilities. both intentional and unintentional torts. An intentional tort is
A community/public health nurse who recklessly endan- found when an outcome is planned, whereas an unintentional
gers others can be criminally prosecuted. Some states are tort involves accidental or unintended behavior. Negligence and
becoming more willing to use criminal law rather than relying malpractice are considered unintentional torts. Negligence is
on state board sanctions to punish professional misconduct. based on the principle of reasonable care and is the failure to
For example, nurses in Denver were prosecuted for negligent do what a reasonable person would do under similar circum-
homicide in the case of a fatal drug overdose in addition to stances, which results in an injury. Malpractice is a specific
facing civil Â�prosecution for malpractice and state board sanc- type of negligence. Malpractice goes beyond the reasonable care
tions. Laws relating to theft and other property violations are standard and recognizes the specialized training and licensure
also found under the criminal code. Laws that prohibit abuse of members of a profession. Malpractice is the failure to exercise
of children or elderly people are criminal laws written to the training and skills normally provided by other members of
Â�protect these Â�segments of the public. Most states have statutes the profession, which results in harm to the client. Many cases
that require nurses to report suspected child or elder abuse result from failure to adhere to standards of care. To be found
(see ChapterÂ€23). guilty of negligence or malpractice, a nurse must have a duty to
It is not unusual to read about a nurse who has been the client, the breach of which has injured the client. The com-
Â�convicted of a crime and later discover that the state board of missions or omissions of the nurse must have directly caused
nursing has scheduled a hearing to consider whether the nurse's the injury.
license should be revoked or suspended. Certain crimes can be If a nurse unintentionally harms a client, a malpractice or
grounds for the loss of one's professional license if the behavior negligence case under the civil statutes would be the most likely
can be reasonably connected to the professional responsibilities result. If a community/public health nurse intentionally plans
of the nurse. Violations involving substance abuse might result an injurious outcome, a criminal case could result.
in suspension of a community/public health nurse's license The number of lawsuits alleging negligence or malprac-
until proof is offered that the nurse is no longer using the sub- tice brought against nurses has been increasing (National
stance in question. Because nurses are in a position to affect Practitioner Data Bank, 2005). However, lawsuits against nurses
the health and safety of consumers, nurses' personal habits and accounted for only 9.2% of all malpractice suits in 2006, and
behavior are linked to their professional licensure. malpractice payments involving nurses account for only 2.1%
A conviction for a criminal violation might result in impris- of all malpractice payments (National Practitioner Data Bank,
onment, parole, the loss of privileges (such as a nursing license), 2006). Most claims brought against registered nurses involve
a fine, or any combination of these penalties. If a community/ monitoring, treatment, and medication errors. A significant
public health nurse becomes aware of illegal activity in a client's number also involve obstetrics and surgical errors.
Malpractice cases involving nurses often involve the follow- PURPOSES AND APPLICATION OF PUBLIC
ing circumstances (Phillips, 2007, Eskreis, 1998): HEALTHÂ€LAW
• Medication errors
• Patient falls Public health laws are written for several purposes, includ-
• Improper use of equipment ing protecting the public's health, advocating for persons
• Retained foreign objects or Â�vulnerable groups who otherwise might not be served,
• Failure to communicate Â�regulating health care delivery and financing, and regulating the
• Improper treatment or negligent performance of a treatment Â�professional accountability of health care providers.
• Inadequate assessment and intervention in monitoring
Â�situational changes Protecting the Public's Health
• Failure to follow prescribed orders or agency protocols, poli- One of the main purposes of laws that apply to community/pub-
cies, and procedures lic health nursing is to protect the public. Examples of existing
• Working while impaired whether by inadequate sleep or laws that protect the public mentioned in this chapter include
controlled substances mandatory vaccination for specific communicable Â�diseases, man-
• Inappropriate delegation or supervision datory reporting of specific communicable Â�diseases, and manda-
• Failure to advocate for the patient tory reporting of child abuse. These laws are discussed in more
Expert witnesses, who are members of the profession, detail in relevant chapters (e.g., ChaptersÂ€8 and 23). As previously
Â�testify as to what would be expected in similar circumstances. noted, protection of the public health occasionally overrides the
In malpractice suits brought against community/public health personal rights of individuals.
nurses, expert witnesses can be called to testify as to the rea- Involuntary and emergency psychiatric admissions laws are
sonableness of the professional behavior of the defendant written to protect not only the public but also people who are
nurses. Expert witnesses focus on the recognized standard of a danger to themselves. The standards and procedure for invol-
care expected of community/public health nurses who work untarily committing a client to a hospital must be understood
in the same or similar situations. Expert witnesses may rely and acted upon in a timely manner. The nurse might be called
on the state's Nurse Practice Act, professional guidelines, on to provide evidence of the necessity of involuntary hospi-
institutional policies, standards in the jurisdiction, Â�nursing talization of a client for the client's own safety and protection
care plans, common sense, and previously decided cases. If or the safety and protection of the family or others. Emergency
the nurse is planning to rely on a previously decided case as psychiatric admissions against the client's will are time limited.
a defense, it must be determined that the standard of care State statutes usually identify the procedure for such admis-
applied in that case remains current and that the current law sions. The nurse must consider the need to protect the client's
is in good standing. autonomy when evaluating the need to initiate an involuntary
Few claims involve nurses working in community/Â�public hospitalization.
health practices. Several cases focus on the need to train and A growing number of laws focus on dangerous products.
supervise home health aides and nurses in the home care These laws seek to protect the public by imposing liability on
Â�setting. In Loton v Massachusetts Paramedical, Inc. (1987), the product's manufacturers. Producers of products are held
a home health aide left a disabled patient unattended in the to a high standard in an effort to protect the public from dan-
shower and was found negligent in her duties. The patient was gerous products. Environmental hazards and laws relating to
unable to control the water temperature and developed severe Â�occupational safety are discussed in ChapterÂ€9.
third-degree burns that necessitated multiple operations and
skin grafts to treat. On another level, this case also demon- Advocating for Rights
strates the need for supervising nurses to regularly assess the A second purpose of public health law is protecting the rights of
level of care delivered by nursing personnel under their charge. groups of people. In ChapterÂ€23, the rights of vulnerable chil-
Litigation in this area of community health practice can be dren and older adults are discussed. Examples of federal laws
expected to increase as the number of clients needing home that are written to protect special groups are laws addressing
care services increases. the rights and needs of children with disabilities in school (see
There can be both civil and criminal components to a case ChaptersÂ€27 and 30), laws protecting adults with disabilities (see
when behavior violates laws that govern the practice of any ChapterÂ€26), and occupational health and safety laws protecting
licensed professional. A violation of both civil and criminal stat- workers (see ChapterÂ€9). Many occupational health and safety
utes in community/public health nursing might occur when a laws focus on environmental hazards. Some laws are written to
state's Nurse Practice Act defines or restricts some functions of protect both the public and specified members of society. For
the nurse in a way that requires them to be performed under the example, laws that require parents to immunize their children
directions of a physician, nurse practitioner, or other appropri- protect both the child and the general public.
ate licensed professional. To act as a professional, explicit legal Other examples of federal laws enacted to protect the rights
authority must exist. Standing or written orders, such as for of groups of people include the Civil Rights Acts of 1964 and
medication administration, give the nurse authorization to act 1965 and the Americans with Disabilities Act (ADA) of 1990.
if the behavior is dependent on the directions of another appro- The rights of all people to move freely throughout our coun-
priately licensed professional working with the nurse. Custom try and to be treated equally and without discrimination in
or usual practice will not substitute for the specific author- the provision of services or employment are protected by the
ity required by law. A violation of a professional practice act Civil Rights Acts. If a community health agency has a limited
might be prosecuted as a crime, even if no actual harm occurs supply of needed vaccines and decides to reserve these limited
to a client. resources for only white male clients, a civil rights violation has
occurred. Such a policy would discriminate against all men of Practice within the Scope of the Law
other races as well as against women. The ADA and its amend- As stated earlier, community/public health nurses must Â�practice
ments protect people who have disabilities from discrimination within the scope of the Nurse Practice Act and all Â�relevant Â�statutes
based on their disabilities. and administrative rulings and relevant civil and Â�criminal law.
Community/public health nurses must also Â�carefully follow the
Regulating Health Care Delivery and Financing rules for reimbursable services under governmental programs.
Another purpose of public health law is to regulate or provide For example, under Medicaid and Medicare clients must be
health care delivery and financing. The federal government has screened for financial eligibility and clients’ signatures must
greatly affected society by regulating health care delivery and be witnessed after their rights and the legal contract for services
health care financing. The Social Security Act of 1935 and its are explained.
1965 amendments created both Medicare and Medicaid pro- The community/public health nurse must honor the
grams (see ChapterÂ€4). Â�contracts made with clients. Contracts might include both
The Public Health Services Act and its amendments were written and implied agreements between the client and the
promulgated through a federal regulatory statute. The Public nurse. If a contract cannot be carried out, documentation
Health Service was created to collect and analyze data on selected in the nursing notes should state the reason and the client
diseases from all of the states and territories of the United should be notified. If the client unilaterally ends the relation-
States. Efforts to control or regulate the control and spread of ship either explicitly or by consistently not keeping appoint-
disease are organized by both the Public Health Service and the ments with the nurse, this should also be documented. The
CDC. The 1975 amendments of the Public Health Services Act Â�community/public health nurse or a designate should contact
also provided grant funding to states for various categories or the client if the nurse must cancel an appointment, a clinic
“blocks” of public health services (see TableÂ€6-2). This funding visit, or other Â�service. The client should also be notified about
is often called block grant funding. any Â�substitutions of personnel.
Public health law includes appropriations for populations at The nurse might be charged with abandonment if follow-
risk. These populations might include vulnerable groups of per- through on contracted care is not completed. Abandonment is
sons who have been identified as needing special protection or the unilateral termination of a professional relationship Â�without
groups with specific health care problems. Amendments to the affording the client reasonable notice and alternative health
Social Security Act of 1963 addressed specific needs of mater- care services. Planning for the client's discharge from services
nal and child health, as well as planning for populations with Â�prevents abandonment. The client or family should be given
cognitive disabilities. The Social Security Amendments of 1977 adequate notice and should be informed about resources for any
and the Rural Health Clinic Amendments are directed toward necessary continuing care. After the client's written Â�permission
specific populations in rural communities. The Omnibus
Â� is obtained, a copy of the health records, including the nursing
Budget Reconciliation Act of 1981 created block grants for both plan of care, should be transferred to another provider.
maternal and child health and social services (see TableÂ€6-2). Refusal to work mandatory overtime places nurses at risk of
liability for abandonment, because client safety might be com-
Regulating Professional Accountability promised. Beginning in the late 1990s nurses started reporting
Public health laws not only are intended to protect the health increasing use of mandatory overtime as employers attempted
of our communities, advocate for public rights and needs, to cope with the nursing shortage. Since then, 16 states enacted
and regulate health care standards and financing, but also legislation prohibiting mandatory overtime to protect nurses
serve to regulate the professional accountability of health care and many other states have similar bills pending (American
providers. Nurses Association [ANA], 2011).
Accountability means being answerable for one's pro-
fessional judgment and actions within a realm of Â�authority. Informed Consent
Community/public health nurses are held accountable for Informed consent means that clients understand the risks and
upholding public health laws and regulations. Whether a com- benefits of potential treatment alternatives before they volun-
munity/public health nurse is working for a state, federal, or tarily consent to them. Clients must have adequate information,
private agency, an understanding of the appropriate and appli- explained in an understandable way, to make informed deci-
cable laws is needed. For specific interpretations of these laws, sions. When working with children, the parent or legal guardian
if unclear as to how they apply to nursing practice or clients' must be given enough information to understand the conse-
rights, the advice and counsel of the agency's attorney is recom- quences of his or her decision. For example, the significant risks
mended. Professional accountability is further defined through and benefits of immunizations, as well as alternatives, must be
accrediting body guidelines, standards and ethical codes of disclosed to the parent or guardian before consent is obtained.
professional organizations, and agency policy manuals (see Gaining proper permission from the client, parent, or guard-
ChapterÂ€1). ian to obtain or transfer medical records is another example of
informed consent. Website Resource 6A provides an exam-
LEGAL RESPONSIBILITIES OF COMMUNITY/ ple of a consent form to obtain or release client medical record
PUBLIC HEALTH NURSES information.
Community/public health nurses must be aware of informed
The duties of all nurses are legally binding responsibilities for consent legislation in their state. Because community/public
which the nurse is accountable. In addition, the community/ health nurses work autonomously in the field, the acquisition
public health nurse has many responsibilities that are unique to of informed consent might become the nurse's responsibility. In
a practice focused on public health. most other settings it is considered a physician's duty to obtain
informed consent and the nurse's role is limited to reinforcing which the release is being granted (see Website Resource 6A).
the scope of services and witnessing the client's signature. Such releases are very common in community/public health
Many nursing procedures are performed with implied Â�consent. nursing because the nurse is often the case manager who coordi-
Implied consent occurs when the nursing procedure is explained nates care among a variety of health care and social services pro-
to the client and the client's actions, such as exposing an injection viders and agencies. A relatively new area of concern is the sharing
site, indicate a willingness to proceed. A good rule to follow in of medical information among health care agencies, utilization
deciding whether to rely on implied consent or to require a writ- reviewers, and health insurers facilitated by Â�computer-generated
ten form is the following: the more intrusive the procedure, the data banks and electronic medical records. In community health,
greater the likelihood that requiring a written and signed consent agencies and nurses must provide as much protection as possible
form will be in the client's and nurse's best interest. If a procedure for clients' confidential records.
is performed against the client's will or without consent, charges In some jurisdictions, the communications between a nurse
of assault (the threat of touching) and battery (the actual touch- and client enjoy a statutory legal privilege that protects the pri-
ing of the client) can be brought against the nurse. vacy of this communication. Not all states or jurisdictions have
Informed consent might be especially difficult to obtain if the enacted statutes that attach this legal privilege to nurse–client
nurse is involving the client in research, because all the poten- communications. A legal privilege is a legislatively created pro-
tial risks might not be known in many cases. Informed consent tection that the nurse will not be forced to disclose confidential
should be obtained by the researcher, who can also explain the communications with a client. If a legal privilege does not exist
benefits of the research. in a state, the nurse can be called on to disclose conversations
Community/public health nurses might be asked to witness with the client. A legal privilege does exist between a lawyer and
the signing of forms related to nursing services as well as to his or her client and is intended to encourage the client to be
non–health-related matters (e.g., wills). Witnessing a signature totally truthful about his or her participation in the events at
means that the witness is stating that the individual signed vol- issue in the case. There might be instances in which even statu-
untarily, understood the document, and intended his or her sig- torily created legal privileges do not apply. For instance, most
nature to mean agreement with the contents of the document. child and elder abuse reporting laws require that the nurse
“Witnessing to signature only” means that the witness has seen Â�disclose reasonable suspicions of abuse. Nurses should be aware
another person sign his or her name. This might be written in of the legal protections for nurse–client communications in the
when witnessing a signature on a non–health-related docu- state where they practice.
ment, such as a will. All forms signed by the client, parent, or
guardian, and the date each form was signed, should be listed Standing Orders
on the health care record. Some agencies use standing orders. Community/public health
nurses need to protect themselves by ensuring that standing
Refusal of Care and Limits of Care orders are regularly reviewed and updated as well as by having
An issue of growing concern is the client's right to refuse treat- the physician sign the standing order that is acted upon by the
ment. If a community/public health nurse is unaware that the nurse. The community health nurse must be especially cautious
client has created a living will, a special directive, or a durable to clarify orders when following verbal or standing orders.
power of attorney that specifically states that certain procedures, Verbal orders can be a source of risk to the community/Â�
such as resuscitation, are not desired, the nurse might act with- public health nurse. The dangers of miscommunication are
out the client's consent and in a manner that is not in the client's greatly heightened when communication is verbal. The like-
proclaimed best interest. A client can deny consent to treatment lihood of injuring a client and the nurse's liability increases
or withdraw previously granted consent at any time. Even a ver- when the nurse allows verbal order giving to become a pattern
bal withdrawal of consent is valid and must be communicated within the agency. When a verbal order has been acted upon by
immediately to members of the health care team. Documentation the nurse and a client is injured, there is no written evidence
of the refusal or withdrawal of consent is critical. of what the physician ordered. The nurse will have difficulty
Â�demonstrating that the doctor's verbal order was followed accu-
Privacy rately. Therefore, written confirmation of verbal orders must be
The legal right of the client to maintain privacy and confiden- obtained as soon as reasonably possible.
tiality in the nurse–client relationship must also be protected
(Mahlmeister, 2008). Because community/public health nurses Client Education
often deal with clients who have special privacy concerns (e.g., Caring for the client in home, clinic, school, and other commu-
minors who desire contraceptives or clients with sexually trans- nity settings always includes the duty to teach the client.
mitted diseases), nurses should be extremely cautious when Community-based teaching might include both preventive and
leaving telephone or electronic messages for clients. The nurse self-care information. Community/public health nurses must
should leave her or his name and a short message that does remember that the client's ability to understand what is being
not provide specific information about the nature of the call taught is of utmost importance. It is good practice to have the
or identify the type of care facility (e.g., sexually transmitted client explain or demonstrate to the nurse his or her under-
disease clinic, maternity/family planning clinic). If a transfer standing or perception of what has been explained. In this way,
of information regarding a client is requested, the community the nurse can be sure that the client understands the directions
health nurse must obtain a signed release form from the client (see ChapterÂ€20). If the client does not speak English and the
before transferring this information. nurse does not speak the client's language, the nurse might need
Release forms should identify exactly what information is the assistance of an interpreter. If the nurse is not sure whether
allowed to be released, to whom, and the duration of the time for the client is capable of understanding the instructions and if the
patient consents, it is helpful to involve a family member or Â�

history for future health care providers to determine what
other persons who will be involved in providing the client's care has been provided for the client and what still needs to
ongoing health care. If the client is a child, the parents or guard- be done. The nurse's records are part of the client's health care
ian should be fully informed about how to perform the care that history. In documentation, as in all other community/Â�public
the community health nurse is teaching. health nursing procedures, it is important to comply with
the Â�employer's policies and procedures. If a lawsuit ensues,
Alla Orhan, a home health nurse, was assigned to ensure that the Â�documentation prepared by the nurse will be reviewed to
Mr. Fredplay, a client with newly diagnosed diabetes, under- establish the Â�reasonableness of the care provided by the nurse.
stood how to inject his insulin. She arrived at his home at It is difficult, if not impossible, to remember everything done
the appointed time to find that he had not done his early for every Â�client if thorough recording is not completed at the
morning insulin injection. She asked Mr. Fredplay what he time of care delivery. The records of the community/public
had been taught in the hospital and how many injections health nurse can be subpoenaed in a trial to determine whether
he had done. He replied that the hospital nurse had drawn the nurse caused harm to the client.
up Â�insulin into one syringe and then helped him to inject
himself. He said that he was not sure how much insulin to Agency Policies
draw up; the nurse had told him something about swabbing Community/public health nurses must be informed about
the top of the bottle with alcohol, but he couldn't remember their employers' written policies and procedures. Deviations
how to inject and was scared to do the injection. Because he from policies and procedures can often become common prac-
was 3 hours overdue for his injection, Ms. Orhan drew up tice in an agency, but this does not make these practices legally
and Â�administered his insulin. She demonstrated the correct sound, and deviations may be viewed as substandard care. If
procedure as she did so. After she administered the medica- employer policies and procedures do not comply with rea-
tion, she had Mr. Fredplay repeat the instructions back to sonable Â�nursing care or have not undergone periodic review,
her, and wrote the instructions down in his presence so he it is important for nurses to be involved in changing them to
would have a “cheat sheet” to which he could refer when he conform to safe practice within the scope of the state's Nurse
was alone. She also had him draw up the solution several Practice Act. Community/public health nurses should vol-
times and practice injecting into an apple until he was sure unteer to serve on their agency's policy and procedure review
of his technique. She also showed him how to use the inject- committee to assure the timelines, safety, and appropriateness
able insulin pens. She then made arrangements to come to of the policies and procedures that guide their practice. Periodic
his home at 7:30â•›am the next morning to watch him repeat review, at least every 2â•›years, of agency policies and procedures
the injection. is sound Â�nursing practice.
The employing agency's policies and procedures are stan-
It is essential that the community/public health nurse teach dards against which the community/public health nurse's
the client accurately. If the nurse needs references to provide behavior will be measured if a lawsuit is brought. Therefore, it
correct information, she or he should postpone answering a is important for the nurse to follow the agency's policies and
question until the information is gathered. It is essential that procedures once the nurse is assured that these policies and
the information taught be accurate and up-to-date. If the nurse Â�procedures are legally sound. If the nurse has questions about
is unsure about how to answer a question asked by the client, it the legality of any Â�policies or procedures, she or he should
is neither unprofessional nor will it affect the nurse's credibil- Â�consult the agency's attorney. Shortcuts or lack of knowledge
ity to tell the client that she or he will check and get back to the about the standards set by an employer can increase the nurse's
Â�client with accurate information. risk of a malpractice suit.
Documentation Public Health Law Enforcement

It is important for the community/public health nurse to be Community/public health nurses also have the legal respon-
consistent in recording the care provided to clients. Thorough, sibility to enforce laws, especially laws enacted to protect the
accurate, and timely recording demonstrates quality of care, Â�public health. Public health nurses might be hired by local, state,
helps ensure reimbursement for services, and reduces the risk or federal authorities that have enacted rules and regulations
of lawsuits. Information regarding client visits and care should requiring specific enforcement of laws in areas such as infection
be documented as soon as possible after the care. When pro- control and reportable events.
viding care in the home, the nurse might need to record some
immediate brief notes that are then used as the basis for more Nurse's Role and Public Health Law
thorough documentation in the client's health record when the State public health codes define the duty to report communica-
nurse returns to the agency. In some agencies, portable com- ble diseases. Community/public health nurses are often involved
puters are available for documentation on electronic medical in investigating and treating communicable disease, performing
records during nurse–client encounters. contact investigations and filing follow-up reports to local and
Documentation is important not only as a means of state health departments and the CDC. Other conditions that
Â�communicating with other health care providers who might be are reportable by all community/public health nurses under law
working with a client but also as the ongoing written Â�memory include suspected abuse and neglect of children, elderly Â�persons,
of the nurse. If the client later develops a problem, accurate or persons being cared for by others. Selected Â�immunizations
and timely documentation of the care provided will supply are required by law for school Â�attendance. It is usually the
the nurse with a record of what has or has not been done for school nurse who reviews health records for compliance
Â� with
the client and why. Documentation also provides an Â�ongoing Â�mandatory immunization.
Nurse as Agent of Employer might be the client's greatest problem. Laws written to Â�protect
A community/public health nurse is an agent of her or his the uninsured,
Â� persons who reside illegally in the United States,
employer. The legal meaning of agent, in this sense, is that the the homeless, and migrant workers should be explored by the
nurse, as an employee, represents the employer and has the del- Â�community/public health nurse. Laws related to housing
Â� and
egated authority to carry out the purposes of the employer. For the rights of the renter or tenant are also important to under-
example, if a nurse is working for a state health department, the stand. Many state legislatures have enacted laws to protect
nurse is an agent of the state. The legal liability and responsibili- Â�families from eviction under certain circumstances.
ties of the community/public health nurse vary depending on
the employer. The hiring agency's policies and procedures state- Family Law
ments, and in some cases an employee manual, should inform The community/public health nurse very often will deal with
the nurse of any special duties or responsibilities. Examples of laws considered to be family law. Issues of guardianship or the
public settings in which community/public health nurses work legal right and power to decide for another might arise and it
are public schools, health departments, and federal employee is important for the community/public health nurse to under-
health programs. Community/public health nurses might also stand how to advise clients on how to acquire guardianship
be found working in private schools, clinics, or organizations and the obligations that go along with being a guardian. If the
such as Planned Parenthood. nurse is obtaining consent for a procedure to be performed on
Community/public health nurses hired by a public agency a minor or on a person who is incompetent, the guardian must
might also be required to enforce laws for licensing and inspec- sign the consent form for treatment. In the case of a divorced
tion of daycare facilities and nursing homes, such as insuring couple, the spouse who has been awarded custody of the chil-
that licensed facilities comply with regulations aimed at pro- dren is the legal guardian of those children and the person from
viding a safe environment for clients of daycare or long-term whom consent must be obtained.
care facilities. Laws are constantly being enacted and revised. To Determining who has the right to consent to treatment for
be of the greatest assistance to their clients, community/public minors is a growing problem in health care. When the parents
health nurses must be aware of the laws related to their practice, are divorced or children do not live with their parents the legal
knowledgeable about changes in existing law, and prepared to process of consent becomes complicated. All health care provid-
enforce federal and state laws. ers need to determine whether the person giving consent is
legally entitled to do so.
Referrals and Advocacy
Nurses need to be familiar with the laws that have been enacted Alice Gomez, a community/public health nurse, is conductÂ�
to protect their clients' rights and with the legislated services ing a contact investigation of tuberculosis. She visits the
their clients are likely to be eligible to receive. The community/ Morales family because Sara Morales, a 10-year-old girl, is a
public health nurse is often placed in the position of serving as close school contact of an individual with active disease. At
the client's advocate. Advocating for patients is a special duty home with Sara are her aunt, Alicia; her cousin, Maria; and
of nurses, and one that is recognized as such in the American her grandmother, Alva. Ms. Gomez wants to do a Mantoux
Nurses Association (ANA) Code of Ethics (Fowler, 2008). Many test with purified protein derivative (PPD) to screen for
states specifically identify patient advocacy as a responsibil- tuberculosis and is granted permission to do so by Sara's
ity within their Nurse Practice Act. As an advocate, the nurse aunt. The aunt tells Ms. Gomez that she is Sara's legal guard-
should be able to identify available community resources and ian. After the home visit, Ms. Gomez finds out that Sara's
assist clients in pursuing the rights that are legally afforded actual guardian is her mother, Consuela, who lives in the
them. For example, the community/public health nurse might household but was not present during her visit. As a result,
become aware that a client is being unduly harassed by a creditor the nurse has violated the consent laws.
and might be able to help by directing the client to a Â�consumer
Â�protection agency that can assist the client in resolving his or her Issues surrounding family privacy and reproductive rights
financial difficulties. Providing referrals to available Â�community are also very relevant. Not only are there federal legislation
resources is a valuable responsibility of the community/public and court rulings, but many state legislatures and courts have
health nurse. Â�created laws affecting the legality of providing information
The nurse should be familiar with the legal aid services avail- about contraception to minors (see ChapterÂ€24). It is Â�important
able for low-income clients. Providing referrals to appropriate for the community/public health nurse to be aware of the
legal services is a community/public nursing function. These Â�abortion laws in the state in which the nurse is practicing. The
services ensure that all of the public's rights are Â�protected. People U.S. Supreme Court decisions have encouraged states to Â�handle
who could not otherwise afford legal services can be Â�represented the Â�abortion issue, within certain guidelines, in a manner that
by legal aid staff. Federal cutbacks in funding, Â�however, have reflects their own community standards. The community/Â�
forced legal aid offices to limit the number and prioritize the public health nurse must understand her or his own state's
types of cases they handle, which has reduced available legal Â�standards to advise and correctly inform Â�community health
Â�services for low-income clients. clients.
Special and Vulnerable Populations Parental Consent

Laws related to special populations affect the community/Â�public The legal age of consent in most states is 18â•›years of age. In
health nurse's clients. Such laws have been enacted Â�specifically exceptional cases, some minors are considered emancipated and
to protect the rights of persons with disabilities, foster chil- have legal independence from parents or guardian. In Â�general,
dren, elderly persons, and the abused. Access to health care persons under 18â•›years of age who are married or in the military
are emancipated. In addition, teenagers who are pregnant or and Swan's frequently cited 1989 study on child fatalities from
have a child, are self-supporting, or are living apart from their Â�religion-motivated medical neglect reported that at least 172
parents are considered independent in some states. deaths of children from easily treatable conditions occurred
Parental consent is generally required before a minor receives over the 20-year period ending in 1995 (Asser & Swan, 1998).
medical treatment but exceptions are becoming widespread The American Academy of Pediatrics, despite these state exemp-
(TableÂ€6-3). Many states permit minors to consent to contra- tions, supports the rights of children to receive lifesaving medi-
ceptive services. All states permit minors to seek diagnosis and cal care even in cases where the parents’ religious beliefs oppose
treatment of a sexually transmitted disease. Prenatal care and intervention (Jenny, 2007). Because of the complexity of this
delivery services can be accessed by minors in many states with- issue, nurses must know the laws in their states and consult with
out parental consent. The majority of states mandate parental supervisors and legal counsel to ensure that, when parents cite
involvement in a minor's decision to obtain an abortion (Alan religious exemptions, their actions are legally and professionally
Guttmacher Institute, 2011). Minors who are parents have the responsible.
authority to make all decisions regarding their infants. A juve-
nile may even relinquish her baby for adoption without her End of Life/Self-Determination
parents' consent in most states. In addition to rights related With the movement toward shorter hospital stays and discharge
to reproductive issues, adolescents are afforded other consent of persons to home for long-term care of terminal illnesses, a
rights by states. Most states permit minors to seek medical care growing area of discussion between community health nurses
and counseling. Many states grant minors confidential access to and their clients involves the clients' wishes as they plan for
outpatient mental health services. Some states allow a minor to death. Most states have enacted living will statutes that define
marry without parental consent when the minor is expecting a how clients may let their wishes be known when death is immi-
child and some states allow teenagers to drop out of high school nent. Some of the living will statutes apply only to terminally
without their parents' permission. ill clients. Clients must have the capacity to create a living will
or, in other terms, must be deemed competent to make these
Parental Refusal to Seek Medical Care for Minors important decisions for themselves.
Sometimes community/public health nurses are aware of sit- Persons might assign a medical durable power of attorney
uations in which parents of a sick child do not seek medical to a trusted person, who then becomes empowered to act as a
care for that child. If the cases are tied to suspected child abuse surrogate decision maker if the client becomes incompetent or
or neglect issues, the nurse should follow the prescribed proce- is unable to make his or her desires known to health care pro-
dure for reporting the abuse or neglect (see ChapterÂ€23). Parents viders. Laws support the idea that clients should have the right
might also be reluctant to seek care if they lack health insur- to make choices and give consent for treatment. Community
ance coverage. In these cases, the nurse can refer the family to health nurses can be most supportive of their clients by inform-
an emergency clinic or to appropriate social services to obtain ing them of their rights and of possible ways to formally
treatment and work out payment options. Â�document their wishes that care be provided or withheld under
A community/public health nurse might come in contact certain circumstances. Specific directives will be the most clear
with parents who refuse to seek medical treatment for children and convincing evidence of a client's wishes. The competent
for religious reasons. For example, Jehovah's Witnesses do not Â�client's wishes should always be followed when legally possible.
consent to blood transfusions, and Christian Scientists do not Even when a client has created a living will or special directive,
accept some medical interventions, such as chemotherapy for family members might object to the client's decision to deny
cancer. Most states have religious exemptions from civil child treatment. The community health nurse's role, as client advo-
abuse and neglect laws that allow parents to deprive children of cate, can become more complicated when the client's family
health care; however, the scope of these laws varies significantly. Â�disagrees with the client's wishes. The law specifically protects
Several states have exemptions from criminal law (Children's a person's right to refuse treatment, but in reality, the family
Healthcare, 2011). Although these situations are rare, Asser is not always in support of their loved one's choosing to refuse
TABLEÂ€6-3â•…â•‡STATE CONSENT LAWS FOR UNMARRIED MINORS

CONTRACEPTIVE PRENATAL CARE SEXUALLY TRANSMITTED
SERVICES SERVICES INFECTIONS SERVICES
Total allow consent* 27 33 51
Total require parental consent 20 â•‡5 â•‡0
or notice or have other restrictions
Total no specific law â•‡4 13 â•‡0
ABORTION SERVICES MEDICAL CARE FOR CHILD PLACE CHILD FOR ADOPTION
Total allow consent* â•‡3 31 29
Total require parental consent or 42 â•‡0 10
notice or have other restrictions
Total no specific law â•‡6 20 12
*Includes the District of Columbia.
Data from Alan Guttmacher Institute. (2012). State policies in brief: An overview of minors' consent law. New York: Author. Retrieved February 8,
2012 from http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf.
lifesaving medical procedures. The community health nurse BOXÂ€6-1â•…â•‡TIPS FOR VISITS TO LEGISLATORS
needs to stay in close communication with the client's physi-
cian and the family members to support the client in ultimately 1. Call ahead to make an appointment to meet with the legislator.
maintaining the right to consent or to deny consent to treat- If the legislator is unavailable, ask to meet with the staff person
ment. The Client Self-Determination Act of 1992 requires that who handles health issues.
facilities that receive federal funding (including hospitals, nurs- 2. Be prepared. Know the background of the legislator and the history of
ing homes, home health agencies, hospices, and prepaid health the bill or issue you are discussing. Contact the government relations
Â�
care organizations) inquire whether clients being admitted to staff at your professional nursing organization to let them know
their services have executed a living will or special directive (see about the visit. They might be able to provide important information
Â�
about the issue, the political climate, your legislator's previous record
ChaptersÂ€28 and 31).
on this issue, and the overall lobbying strategy on this issue.
Environmental Protection 3. At the beginning of the visit, introduce yourself and state what
you want to discuss. Specify the issues and bills.
Nurses can also encourage their clients to pursue their rights 4. Ask the legislator what his or her position is on the issue or bill.
and to protect themselves through laws relating to environmen- 5. Many legislators and staff might not be familiar with nursing
tal hazards. Laws related to the use of seat belts and infant car practice or legislative concerns. Be prepared to discuss them in
seats should be discussed with clients. Other environmental basic terms. If possible, be prepared with facts about nursing
hazard laws include those pertaining to chemical use or waste— practice in your state or district.
including medical waste—disposal. Food preparation laws 6. Ask if he or she has heard from others who support this issue or
apply where food is being prepared for service to the public. bill. Ask what the supporters are saying.
Laws related to sanitation and other environmental issues are 7. Ask if he or she has heard from opponents. Ask who the oppo-
often carried out by local and state health departments. Many nents are and what their arguments are.
states have separate divisions to propose and support legislation 8. Offer to provide additional information if you do not have data at
and implement environmental hazard laws. hand, but do not make promises you cannot keep. It is better to
admit you do not know than to promise and not deliver or to con-
Nurse Lobbying vey erroneous information.
The practice of a community/public health nurse is greatly 9. Follow up with a thank you note and share your reflections on the visit.
affected by legal responsibilities. Nurses should become actively 10. Keep a written record of your visit. Notify government relations
involved and lobby through the legislative and administrative staff of your professional nursing organization so that they can
processes. Nurses serve as client advocates when they lobby for follow up with the legislator.
improved health care. A lobbyist informs decision makers and 11. Spend more time with your legislators, even if their positions are
educates others who need to understand community health not in agreement with yours. You might lessen the intensity of
their positions and maintain contact for subsequent issues.
care issues. Nurses are informed providers of care who can serve
12. Invite legislators to meet you and your colleagues at your work
as experts in teaching lawmakers and policy makers about the
site to help expand their understanding of nursing and health
needs of the community and specific clients. care issues.
The American Public Health Association and the ANA lobby
on behalf of public health and nursing issues. These two orga- From Reinhard, S. C., & Cohen, S. S. (1993). Lobbying policy makers:
nizations also provide information to their members about Individual and collective strategies. In D. Mason, S. Talbott, & J. Leavitt
(Eds.), Policy and politics for nurses: Action and change in the workplace,
upcoming legislation and its impact on health and nursing.
government, organizations, and community (2nd ed.; p. 493). Philadelphia:
N-Stat (Nurses Strategic Action Team), a program of the ANA, Saunders.
provides up-to-date action alerts to nurse members on Â�pending
federal legislation. Nurses can use this information to commu-
nicate their positions to their legislators. BoxÂ€6-1 outlines an Law schools or the state attorney general's office generally
effective approach nurses can use to interact with their elected provide excellent law library resources. Law librarians can assist
legislators. the nurse in locating the sources and references to review. Legal
aid services and state offices of consumer affairs can also be help-
HOW TO FIND OUT ABOUT LAWS ful to the nurse and the community health client. Computerized
search engines, such as Lexis, Scorpio, and FindLaw, provide
Because laws have important ramifications for community/ information about resources such as books and journal articles,
public health nursing practice, nurses must be informed. There as well as current case law and legislation.
are a number of information sources regarding laws affecting There is a growing body of literature developed by advo-
nursing practice. Many of these are available on official federal, cacy groups concerned about the public's health and welfare.
state and professional organization websites on the internet. If a Community/public health nurses must continue to update
nurse is employed by a community health agency, the attorney their knowledge of health-related laws and become familiar
who represents the agency should be the nurse's legal advisor. with updated materials on developing trends in health care law.
The agency's attorney will be able to direct the nurse to appro- Numerous continuing education programs related to commu-
priate health codes and local or state health department Â�policies. nity/public health nursing and the legal aspects of nursing are
Agency protocols often dictate the appropriate channels of available in many communities. Attendance at these continuing
Â�communication. Nurses should consult first with their super- education programs is highly recommended. Professional asso-
visor or health officer regarding questions or concerns about ciations and the media often provide initial information about
existing policies or procedures before consulting the agency's current or potential changes in laws that affect a community/
attorney. public health nurse's practice.
STANDARDS OF CARE nursing behavior entails. The practice of professionals, such

as nurses, is not common knowledge understood by the
The standard of care defines the legal responsibility of the com- Â�average person.
munity/public health nurse. It serves as the measuring rod of The expert witness in a case must be truly qualified as
what appropriate professional nursing care should include. an expert in the area of nursing in the case being decided
There are both internal, organizationally based, standards of (Mahlmeister, 2008). The expert witness must be certified by
care and externally established standards by which professional the court as having the credentials and the knowledge to pro-
behavior is evaluated. vide the court with an accurate and up-to-date evaluation of
prudent community/public health nursing. Once the expert is
Definition of a Standard of Care recognized by the court, the expert's opinion or testimony is
A standard of care is defined by the courts as the care that a given no greater weight than the testimony of any other witness.
reasonably prudent professional, such as a community/public Although juries might be influenced by the credentials and the
health nurse, would provide under similar circumstances. If expertise of an expert witness and might tend to give the testi-
the nurse has an advanced nursing degree, a higher Â�standard mony more weight than that of other witnesses, the rules of the
of competence is expected. The standard of care may also court do not demand this.
be related to what is called the locality rule where specific Both parties to a suit are allowed to introduce expert wit-
Â�geographic areas or similar communities (rural or urban) are nesses and testimony. Often, the differing opinions of experts
compared when Â�identifying the standards for nursing care. It is serve to reduce the credibility or impact of both experts' testi-
important, Â�however, to recognize that the locality rule is used mony. Plaintiffs, defendants, or their attorneys seek to find an
less frequently as a standard due to the increasing access to expert who agrees with their views of the behavior of the nurse.
Â�professional guidelines and literature that establishes evidence- For example, if a plaintiff 's attorney hires an expert to evaluate a
based standards. case and that expert returns an opinion that the Â�defendant nurse
acted reasonably and prudently as expected of a community/
Internal and External Standards public health nurse, the plaintiff 's attorney will not Â�introduce
The professional behavior of a community/public health this expert's testimony at the time of trial.
nurse is measured against both internal and external standards A community/public health nurse who is being sued
of reasonableness. Internal standards include policies and deserves to have the nursing care she or he provided analyzed
Â�procedures and can be viewed as organizationally based stan- by a community/public health nurse who operates in a compa-
dards of the employing agency. The community/public health rable setting. If the nurse holds a master's or doctoral degree,
nurse's job description is an internal standard within which the expert witness most likely will also be required to have com-
the nurse must work. If the nurse's job description Â�identifies parable educational preparation. Therefore, a higher standard
duties that are outside the scope of nursing, the Nurse Practice of care will be applied to community/public health nurses hold-
Act takes Â�priority over this internal standard. Courts review ing advanced degrees. Nurses are also held accountable for the
these internal standards to evaluate whether they are in knowledge they should have gained in their education, as well
accord with what professionals in the field have determined is as for staying abreast of the current literature in their area of
desired performance. Hospital or agency rules are admissible practice.
as Â�evidence of standards of care in the Â�community. Another Standards of care change with the growing body of knowl-
internal Â� standard used to evaluate the reasonableness of edge and expectations of what care community/public health
Â�nursing Â�practice is the nursing care plan. If the nurse outlines nurses will provide. The ANA standards of care for community/
a care plan for a client and then deviates from this plan, the public health nurses are discussed in ChapterÂ€1. Community/
court might determine that the nurse strayed from a reason- public health nurses must attend community education
able standard of care. Nursing care plans are the most direct Â�programs to keep current with the evolving trends in practice.
Â�evidence of Â�nursing care judgment. The courts will not evaluate the actions of a nurse who received
External standards of the reasonableness of the care provided a degree 10â•›years previously by the standards of care taught in
by a community/public health nurse are determined by review- the nursing curriculum at that time. Examples of changes in the
ing the nurse's actions in relation to the Nurse Practice Act or the standards of care include the community/public health nurse's
rules and regulations of the state board of nursing. Other exter- involvement in abortion and contraception advice and the care
nal standards that courts use in evaluating the reasonableness of needed to treat communicable diseases, such as hepatitis and
nursing care include the guidelines promulgated by accrediting HIV/AIDS.
agencies and professional associations, national standards such
as the CDC's universal precautions, well-established standards QUALITY AND RISK MANAGEMENT
of care, and the nursing theories of recognized authorities (see
Chapter 1). It is a common court procedure to introduce authori- Nurses can reduce the possibility that they will be Â�financially
ties in the field, as expert witnesses, to verify the standard of care. and emotionally devastated by a lawsuit by using quality
management information to identify and reduce risks and
Â�
Role of the Expert Witness thereby prevent injury to clients. Quality management involves
The standard of care serves as a means of comparing what a learning from past experiences and avoiding known risks to
reasonably prudent nurse would do with what the defendant clients. Evaluating care and the outcomes of care produces an
in a court case actually did. In a legal case involving profes- assessment of quality. Risk management is a component of
sional behavior, an expert witness is required to explain to quality management and serves to indicate where special atten-
the jury or judge what reasonable community/public health tion might be needed both to minimize risks and to improve
quality of care. The responsibility for ensuring quality care Â�

performed in a timely manner. If care is not documented in
rests with the individual provider, as well as with the employer. a timely Â�manner, other health care providers might perform
AÂ€nurse who comes to work overly tired automatically increases their services for Â�clients based on inaccurate or incomplete
the need for risk management. The nurse's role is too impor- information. It is also important that nurses, as members of
tant to the client's well-being for the nurse to attempt to provide the health care team, communicate in a timely manner with
services while functioning with diminished capacity, regardless other team members. When the potential for a lawsuit is being
of the reason. The employer's policies and procedures should evaluated, the nurse's notes are very often the first record to
also provide for a safe level of care. If the nurse does not follow be reviewed by the Â�plaintiff 's legal counsel. If the nurse's cred-
these guidelines and protocols, the client can be placed at risk. ibility seems questionable based on these documents, a greater
For example, the nurse in an immunization clinic must always risk of Â�liability exists for the nurse.
inquire about a client's allergies before administering a Â�vaccine
to avoid the risk of an allergic reaction. In one home care case, Professional Liability Insurance
a nurse failed to follow agency protocol to monitor antibiotic Professional liability insurance might be considered a means of
blood levels twice weekly when administering intravenous risk management. Liability insurance will not prevent the nurse
Â�gentamicin. The client suffered inner ear damage and the nurse from being sued but will rather serve as a safety net to protect
was held accountable (Eskreis, 1998). the nurse's personal resources and ability to be defended against
a lawsuit. Many nurses rely on their employer's professional lia-
Continuing Education bility insurance policy as their total Â�coverage. If the employer
From a legal standpoint, one of the best ways for the nurse to and the nurse find themselves in the position of Â�having a con-
maintain quality assurance in community/public health prac- flict of interest (e.g., the nurse did not follow the agency's
tice is by keeping updated on new theories and evidence-based policy and procedures), it is likely that the nurse will be less
advances in client care. Nurses are also accountable for having protected by the policy than the employer. It is recommended
knowledge of and functioning within the laws of the Â�country that nurses carry their own personal professional Â� liability
and the states in which they practice. The fact that a nurse does insurance in addition to that provided by their employers.
not realize that she or he is breaking the law is not a sound A professional liability policy is a contract between the insured
defense. Ignorance of the law does not protect nurses from legal professional and the insurance company. If nurses carry their
liability. own liability coverage, they are buying the Â�protection of the insur-
ance company, provided they comply with all of the conditions
Â�
Incident Reports of the policy.
Incident reports are a means of risk management or quality When the nurse is selecting a professional liability policy, it is
assurance. They should be the community health care agency's suggested that the nurse seek an occurrence policy rather than a
internal source for identifying real and potential risks. They can claims-made policy. An occurrence policy provides protection
be used to alter existing patterns of care and can even provide if the incident occurs while the nurse is insured by the policy.
the basis for rewriting policies and procedures to ensure a high Under a claims-made policy, not only does the incident have to
quality of care. An example of an incident that would need to occur while the nurse is insured by the company, but the pol-
be reported by a community/public health nurse is giving the icy also has to be in force at the time the plaintiff brings suit
wrong vaccine to a client. This incident might encourage better against the nurse. Statutes of limitations in various jurisdictions
labeling of vaccines and improvements in clarifying the client's limit the time under which a plaintiff may bring suit against a
identity before proceeding with any procedure. health care provider. If the statute of limitations is 2â•›years, the
Incident reports should be written carefully in compliance nurse could be sued by a client she or he has not seen during
with an agency's procedures for reporting actual or poten- that period. Therefore, under a claims-made policy, the nurse
tial harm to a client. Because public policy desires to encour- would have to continuously maintain the same policy or buy tail
age practices that reduce the risks for harm, incident reports Â�coverage from the insurance company. Tail coverage extends
were traditionally protected from use in lawsuits against the policy's protection beyond the term of the policy and can
health care providers. However, the current trend is to allow be very expensive.
these reports to be used as evidence. It is therefore of impor- Community/public health nurses might be asked to Â�provide
tance that the statements in incident reports describing the assistance that is not within the scope of their employment and,
occurrence be extremely precise. Nurses should describe the therefore, is not within the coverage of the employer's liability
event in factual terms without assigning blame for the inju- insurance. Although the nurse might be covered by the employer
ries that resulted. It is always safest to document facts rather during travel between visits to clients, automobile trips to
than opinions. As with all documentation, incident reports and from work are not within the scope of employer insur-
should be truthful, should be submitted in a timely fashion ance. Another risk involves transporting clients in the nurse's
and should follow the agency's protocol for filing an incident automobile. If an accident occurs and the client is injured, the
report. fact that the nurse is driving the client in the Â�capacity of an
employed professional might diminish the nurse's Â�protection
Timely Documentation and Communication on her Â�personal policy. If the nurse is participating in a health
The nurse's notes are a risk management and quality assur- screening clinic that is sponsored by an agency other than the
ance tool not only for the employer but also for the individ- nurse's employer, the employer's liability insurance likely does
ual nurse. A nurse's documentation can serve as proof that not cover the nurse when the nurse is acting in that capacity.
the nurse acted reasonably and safely. As discussed Â�earlier, The nurse's membership on community boards, if she or he is
documentation should be accurate and thorough, and
Â� not acting as a representative of the employer, and any Â�private
Â�
nursing business also is not covered under an employer's and her Â�newborn, community/public health nurses were very
Â�liability insurance policy. likely to confront problems that were not detected in the hos-
pital before the mother and Â�newborn were discharged, and
Professional Involvement the number of Â�newborns undergoing PKU testing dropped
Professional involvement in organizations or on committees dramatically.
that define the standards of care for community/public health The managed care environment is now virtually the entire
Â�nursing is another means of risk management. Nurses also health care system in which nurses work. A nurse does not have
Â�benefit their profession when they participate on community to be employed by a health maintenance organization to see his
boards. Nursing input is very valuable when future planning or or her practice change markedly. Capitation, shifting Â�financial
current community issues are being discussed. Nurses must be incentives, and efforts to shift care from intensive Â�inpatient
willing to represent nursing and client perspectives regarding services to other settings, such as community-based and
Â�
community needs and future directions. Membership in pro- extended care facilities, affect virtually every nurse and every
fessional nursing Â�organizations, such as the ANA, the National client. Ethics requires that practitioners review all appropriate
League for Nursing, and state nursing associations, is also services with their clients. The ANA, specialty nursing groups,
important. The viewpoint of nurses becomes more powerful other health care providers, and consumer protection groups
when nurses work together to create an organized and cohesive have combined efforts to ensure that restrictions in health
profession. care plans do not adversely affect clients. Of particular con-
cern are whistle blower protection, elimination of financial
ETHICS AND LAW incentives to delay or deny health care services, and Â�hospital
length-of-stay issues. Additional concerns are Â� implementing
Ethical and legal issues are closely related to other areas of con- federal and state mental health parity legislation (National
cern for nurses. Legal and ethical issues surround the right to Conference of State Legislatures, 2011) (see ChaptersÂ€25 and 33)
choose how one will live while dying and who should have the and ongoing effort at both the federal and state levels to limit
right to make decisions regarding the treatment plan. Because managed care's immunity from prosecution for medical errors
nurses work in a society that is based on laws, they must help or for denial of services.
to change laws that do not reflect nurses' ethical values. Ethical A nurse's right to speak out on issues in health care deliv-
issues reflect moral ideas of right and wrong, whereas laws deal ery is sometimes protected by whistle blower laws, which vary
with the regulation of social behavior. Laws are passed to pro- from state to state (Markus, 2006). In one instance, a nurse,
tect society as a whole or segments of the population that need Linda Carl, was fired in retaliation for reporting that her
special protection. The ethical implications of these laws are employer's Â�treatment facilities were not in compliance with
related to legal responsibilities in community/public health state Â�regulations. She sued for damages. A Texas court awarded
nursing. The community/public health nurse's moral beliefs her a judgment of $1.16 million (Monarch, 2002). In another
and values regarding the rights of family members to deal with case, the National Labor Relations Board provided some pro-
privacy matters, including contraception and abortion, coexist tection for whistle blowers, ruling that nurse Barry Adams had
with legal responsibilities for nurses. been Â�illegally fired for speaking out against unsafe Â�nursing care
Ethical decision making can be very difficult and emotion- (NLRB judge rules for Massachusetts nurse, 1998). The nurses
ally charged. Decision makers with differing values should in both cases were supported by the respective regional chap-
attempt to be fair to the people involved while determining ters of the ANA. Although both nurses were successful, they
what is considered wrong or right or where the duties, obliga- Â�experienced job loss, loss of seniority, stress, and a protracted
tions, and responsibilities lie. Consensus is not easily achieved. legal battle. Both Â�verdicts were appealed by the employers.
When an ethical issue becomes important to society, laws In the current health care environment, nurses can expect to
may be passed that provide guidance about how society has encounter many more such situations that have both ethical
determined health care providers should respond. Because
Â� and legal ramifications. There are a wide range of federal and
ethical issues are highly emotionally charged, the legal system state laws that offer whistle blowers protection from retaliation.
does not intervene until there is a clear mandate from society Check your state laws and the Nurse Practice Act to determine
to make a decision.
Â� Current court decisions on the client's right your state's level of protective legislation for nurses and other
to refuse or Â�terminate Â�lifesaving treatment are examples of how health care workers who report quality of care and client safety
one ethical issue—the right to die—has become a legal issue concerns.
with implications for nursing care delivery. Whereas ethics is influenced by attitudes, values, and beliefs
The managed care environment has been criticized for that determine what is right, wrong, or fair, laws generally address
disproportionately focusing on cost savings and profit mar- only what is wrong in a particular society. It is not always possible
gins. As an example, the initial public outcry regarding pre- or desirable to attempt to translate ethical principles into legal
mature Â�discharge of newly delivered mothers has resulted in terms. Laws might restrict or protect personal freedoms. Ethics
legal protections that ensure newborns adequate time in the is a broader, more universal concept than law, which is narrower
Â�hospital to be observed and screened for PKU before being and deals with the system of compliance in a given society. As
sent home. The issue was not just the length of hospitaliza- advocates, nurses might provide a bridge between ethics and law.
tion but also the quality of postpartum care that was provided. Justice, or the principles of fairness and equity, is needed in law
Without an opportunity to observe and assess the mother and in ethics.
KEY IDEAS
1. Community/public health nurses need a clear understand- states' Nurse Practice Acts. They should be clear about their
ing of the laws that govern their nursing practice, including responsibilities related to physician orders (both standing
federal and state laws and regulations, and criminal law, civil and verbal), documentation of services, and the relation-
law, and family law. ship between their employing agencies' policies and their
2. Most environmental and public health laws are enacted professional responsibilities.
at the state level but must conform to broad directives in 7. Nurses must be aware of client rights, including the right
Â�federal legislation. to informed consent, the right to privacy, and the right to
3. Administrative bodies are responsible for formulating the select or reject health care services as well as determine the
rules and regulations that clarify and interpret the intent of limits of health care services received.
legislation. The state board of nursing is an example of an 8. Nurses whose practice includes vulnerable populations,
administrative body that interprets the legislative intent of such as persons with disabilities, children, elderly persons,
the state's Nurse Practice Act. and victims of abuse, have a duty to understand the law
4. Nurses interested in affecting or changing laws must under- regarding their professional responsibilities and the rights
stand the importance of lobbying administrative agencies of their clients.
as well as legislative representatives. 9. The legal yardstick against which any nurse's professional
5. Community/public health nurses might incur both crimi- competence is judged is the standard of care, or what a
nal and civil sanctions for acts performed in the course of Â�reasonably prudent nurse would do in a similar situation.
their nursing practice. Civil negligence and malpractice are 10. Community/public health nurses should be vigilant in
the most common actions. Criminal prosecution is usually monitoring and influencing laws that affect their profes-
reserved for egregious acts, such as mercy killing. sional practice and the health of individuals, families, and
6. All community/public health nurses have a duty to be communities.
knowledgeable about and practice within the scope of their
CASE STUDY
Understanding a Nurse's Legal Responsibilities
In a case involving a community/public health nurse, the court deter- by authorizing the use of another student's asthma inhaler (Schlussler
mined that the nurse was negligent in failing to properly assess the v Independent School District, 1989).
seriousness of a schoolchild's asthma attack. Several nursing actions might have helped the community health nurse
The child came to the school nurse's office seeking help. The nurse in this case to provide safe, appropriate care in these circumstances:
gave another child's inhaler to the student and sent her back to class • Better physical assessment skills might have enabled the nurse to
but soon learned her classmates were still concerned that she needed determine the severity of the student's signs and symptoms and to
help. The nurse assessed the student and determined that neither an conclude that, without available medication, emergency care was
ambulance, supplemental oxygen, nor a wheelchair was needed for the appropriate.
student to travel to her physician's office. Within minutes, the student • The nurse might have consulted with other nurses and physicians
collapsed and stopped breathing; she died following a brief comatose to develop written criteria to determine when emergency care is
period. needed in selected circumstances.
The plaintiff presented expert testimony from a registered nurse and • The nurse might have followed the basic standard of care and laws
an asthma specialist. Their opinions were that the defendant nurse governing prescription medications by not giving the student some-
deviated from the standard of care in the community for school nursing one else's medication.
and directly caused the student's death. Three experts testified on the • The nurse might have monitored the student for a longer period of
defendant's behalf that the nurse did not deviate from the standard of time, recognized that the asthma attack was not abating, and then
care or cause the death of the student. called for emergency services.
The jury concluded that the nurse was negligent and ordered the • The nurse might have followed school policy and informed the
defendant to pay the child's family $142,289. The nurse's failure to Â�parents of the student's illness, in which case the parents might
Â�provide the needed care in a timely fashion was found by the court to have come to the school in time to initiate a request for emergency
be directly related to the child's death. The nurse had also violated the services.
school district's policy by not calling the student's parents. • The nurse might have created a health form to be completed by
The court found that the school nurse has a higher duty of care than Â�parents and, for those students with chronic illnesses, requested
a hospital nurse to make an assessment of the need for emergency orders from the students' physicians regarding individualized
medical services. The nurse was not expected to provide medical care, treatment.
but rather to determine the need for emergency care. The nurse's See Critical Thinking Questions for this Case Study on the
action also fell below the required standard of reasonable judgment book's website.
1. Review your state's procedure for enacting laws. Contact there are any health-related cases on the court schedule. If so,
your state legislature for a copy of the process or visit your attending the trial will give you some idea of how a health-
local library for the information. Information may also be related matter is handled within the court system.
found online. 5. Read the local newspaper. Identify a health-related issue
2. Identify your district representatives to your state legisla- that is under consideration by either the legislature or an
ture. Find out if any of them serve on committees that help administrative agency. Follow the progress of the debate or
to determine public health or professional practice legisla- hearings via the news. Try to identify the various interested
tion. Most pending legislation is available online; if not, call parties and their positions on the issue. Write, call, or visit
or write, asking them for copies of the current issues before your legislator or the administrative agency and express your
their committee and their position on those issues. views on the issue.
3. Contact your state board of nursing; check its websites. Learn 6. Contact your state nurses' association and obtain a list of
about pending hearings regarding a rule, regulation, or disci- issues that are critical to nursing. Determine your Â�association's
plinary matter. If possible, attend hearings that are relevant position on the issues and its rationale for that Â�position. Ask
to your practice. If you are not able to attend, check the web- how your nursing organization lobbies for its positions with
sites for updates on the hearings or ask the board to send you the legislature and administrative agencies.
information on a proposed change or new rule or regulation. 7. Obtain a copy of your state's Nurse Practice Act and read it.
Review the proposal and try to identify what impact it would 8. Review the policy and procedure manual from a Â�community/
have on your practice. public health nursing agency. Identify forms that must be
4. Courtrooms are open to the public. Attend a trial or hear- signed by clients to receive services, transfer medical records,
ing as an observer of the legal process. Ask a court clerk if and authorize reimbursement.
WEBSITE

• NCLEX Review Questions 6A: Consent to Obtain or Release Client Medical Record Information
• Care Plans
• Healthy People Updates
• Glossary
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NLRB judge rules for Massachusetts nurse in whistle- American Nurses Association. (2011). Code of ethics Morbidity and Mortality Weekly Report.
blowing case. (1998). American Nurse, 30(1), 7. for nurses. Retrieved August 25, 2011 from http:// (2011, May 13). Summary of notifiable
Phillips, D. L. (2007). Malpractice suits against www.nursingworld.org/MainMenuCategories/ diseases—2009. Retrieved August 19, 2011
nurses on the rise. Retrieved August 24, 2011 EthicsStandards/CodeofEthicsforNurses.aspx. from http://www.cdc.gov/mmwr/PDF/WK/
from http://www.dprnesq.com/pages/news/ Child Welfare Information Gateway. (2010). mm5853.pdf.
malpractice-suits-against-nurses-on-the-rise. Mandatory reporters of child abuse and neglect: Springhouse Publishing Company Staff. (2004).
Schlusser v Independent School District, 1989. No. Summary of state laws. Retrieved February Nurse's legal handbook (5th ed.). Philadelphia:
200, et al. Case number MM89-14V. Minnesota 6, 2012 from http://www.childwelfare.gov/ Lippincott Williams & Wilkins.
Case Reports. systemwide/laws_policies/statutes/manda.cfm. Swan, R. (2011). Letting children die for
U.S. Department of Health and Human Services. Croke, E. M. (2003). Nurses, negligence, and the faith.Â€Free Inquiry Magazine, 19, 1.
(2011). Child welfare information gateway. malpractice: An analysis based on more than 250 Retrieved August 24, 2011 from http://www.
Retrieved August 11, 2011 from http://www. cases against nurses. American Journal of Nursing, secularhumanism.org/index.php?section=library
childwelfare.gov/systemwide/laws_policies/state/. 103(9), 54-63. &page=swan_19_1.
Goodman, R., Hoffman, R., Lopez, W., etÂ€al. (2007).
Law in public health practice. NY, NY: Oxford
SUGGESTED READINGS University Press.
Guido, G. W. (2010). Legal and ethical issues in
Aiken, T. D. (Ed.), (2004). Legal, ethical and political nursing (5th ed.). Upper Saddle River, NJ:
issues in nursing. (2nd ed.). Philadelphia: F. A. Davis. Prentice Hall Publishers.
U N I T
2
Core Concepts for the Practice
of Community/Public Health
Nursing
â•‡7 Epidemiology: Unraveling the Mysteries of Disease
andÂ€Health
â•‡8 Communicable Diseases
â•‡9 Environmental Health Risks: At Home, at Work, and
inÂ€the Community
10 Relevance of Culture and Values for Community /Public
Health Nursing
160
CHAPTER
7
Epidemiology: Unraveling the
Mysteries of Disease and Health
Gina C. Rowe
FOCUS QUESTIONS
What is epidemiology? history of a disease, used in assessing health, planning
How does the diagnosis of the health status of a population programs, and evaluating the quality of health care
differ from an assessment of a family or an individual? delivery?
What statistical measures are used in epidemiology? What is known from epidemiological data about the overall
How are data used in determining the health status of a health of the American population and aggregates?
community? How is epidemiological information used to frame or focus
How are epidemiological concepts and methods, such as health-related research?
incidence and prevalence or knowledge of the natural
CHAPTER OUTLINE
Interests of Population-Based Data Demographic Data
A Few Statistics Aging Population
Crude, Adjusted, and Specific Rates Gender, Race, and Life Expectancy
Types of Epidemiological Investigation Department of Commerce Health-Related Studies
Descriptive Studies Major Causes of Death
Analytic Studies Leading Causes of Death in the United States: Trends
Experimental Trials Health Profiles or Status and the Life Cycle
Understanding Aggregate-Level Data Patterns of Mortality and Morbidity during Pregnancy and
Concepts Related to Prevention, Health Promotion, and Infancy
Disease Patterns of Mortality and Morbidity in Childhood
Natural History of Disease Patterns of Mortality and Morbidity in Adolescents and
Multiple Causation of Disease Young Adults
Levels of Prevention Patterns of Mortality and Morbidity in Adults
Health Information Systems Patterns of Mortality and Morbidity in Older Adults
Vital Statistics Health Profiles or Status of Populations at High Risk
Surveillance Patterns of Mortality and Morbidity in Persons with Low
Surveys Incomes
Records Patterns of Mortality and Morbidity among Minorities
Analysis of Data from Multiple Sources Continuing Issues
KEY TERMS
Analytic studies Health information systems Ratio
Case-control Incidence Records
Cohort Morbidity Secondary prevention
Correlation Mortality Surveillance
Descriptive studies Pandemics Surveys
Epidemics Prevalence Tertiary prevention
Epidemiology Primary prevention Vital statistics
Experimental trial Rate
161
162 CHAPTER 7â•… Epidemiology: Unraveling the Mysteries of Disease and Health
“Too Much Heart Surgery?” “Where Do We Stand in the Fight A Few Statistics
against Cancer?” “What Doctors Don't Know about Women: Rate, ratio, incidence, and prevalence are common terms used
NIH Tries to Close the Gender Gap in Research.” “Baby Boomers to help describe illness and disease among population groups.
Enter Their Fifties.” “Decline of Birth Rate in United States.”
“Evaluation of Health: Haves and Have Nots.” “Increasing Rates and Ratios
Global Burden of AIDS.” A rate is a statistic used to describe an event or characteristic.
What is the source of the information that produces these In epidemiology a rate is used to make comparisons among
headlines? Who collects it? How is the information used in populations or to compare a subgroup of the population (spe-
nursing and health care? Understanding health problems, con- cific rate) with the total population. The numerator of a rate is
ditions related to health, and ways to improve the well-being of the actual number of events, and the denominator is the total
a population requires a systematic approach to gathering factual population at risk. In epidemiology the rate is usually con-
information. This chapter does the following: verted to a standard base denominator—such as 1000, 10,000,
• Presents an overview of basic formulas and methods of epi- or 100,000—to permit comparisons between various popula-
demiological investigation tion groups (BoxÂ€7-1). A rate description includes time, per-
• Explores how epidemiology helps identify the impact of son or population, and place specifications (e.g., the number
environment, heredity, and personal behaviors and relates per year [time] in uninsured children [population] in a specific
these factors to the health status of individuals and groups city [place]).
• Identifies the most important health issues for all age groups Using standard base rates makes comparing the magnitude
in the United States of an event (e.g., illness, death) in different population groups
The last objective is a critical first step in assessing the health easier. For example, if city A had 125 teenage pregnancies in
needs of populations, aggregates, and target groups. an at-risk population group of 120,602 female teenagers (14 to
Epidemiology is the discipline that provides the struc- 19â•›years old), the rate of teenage pregnancies in city A could be
ture for systematically studying the distribution and determi- expressed as 125 per 120,602. If city B had 492 teenage pregnan-
nants of health, disease, and conditions related to health status. cies in an at-risk population of 194,301 female teenagers, the rate
Epidemiological concepts are used to understand and explain of teenage pregnancies in city B would be 492 per 194,301 (see
how and why health and illness occur as they do in human pop- BoxÂ€7-1). Comparison of these two rates is difficult because no
ulations. Nursing and medical science employ these concepts to common reference point exists. However, if the denominators of
help guide clinical practice and influence health outcomes. For these two rates were converted to a common at-risk population
example, the Healthy Babies Program, which includes home vis-
iting by a nurse during an infant's first year, was established to
decrease infant mortality and promote health. BOXÂ€7-1â•…â•‡ RATES AND RATIOS
Florence Nightingale, the first nurse epidemiologist, pio-
A. Rates
neered the use of statistics to improve public health. During
1. A rate is:
the Crimean War, Nightingale collected data and systemized
record-keeping practices to improve hospital conditions. She Number of events
× 100,000 (or another standard base number )
invented pie charts and other graphical illustrations to depict Population at risk
mortality rates and show how improvements in sanitary condi-
Example:
tions would lead to a decrease in deaths. By focusing on health
City A's teen pregnancy specific rate is arrived at by:
and disease trends among populations, Nightingale saved or
improved the lives of countless individuals, the ultimate goal 125 (number of pregnancies) 125
or
of epidemiology. 120,602 (population at risk) 120,602
2. In epidemiology, this rate is converted to a common base such as
INTERESTS OF POPULATION-BASED DATA 100,000, which is accomplished by multiplying the specific rate by
the common base:
In community health nursing, the community or the total pop-
ulation under investigation replaces the individual as the focus 125
× 100,000 = 103 or 103 teenage pregnancies per
of concern and study. Nursing at the community level extends 120,602
100,000 adolescents 14 to 19 years old
the boundaries of practice beyond those that are traditionally
associated with caregiving activities. The thinking and decision Example:
making that a community health nurse uses to define the health Converting city B's specific rate of 492/194,301 to a common base
status of a community are markedly different from those used of 100,000:
in assessing individual clients or families. Applying the nurs-
ing process to the entire community is complex and generally 492
× 100,000 = 253 or 253 teenage pregnancies per
requires educational preparation at the graduate level. 194,301
100,000 adolescents14 to 19 years old
The concepts and methods employed in assessing health sta-
tus that affect program planning in health care, as well as anal-
B. Ratios
ysis and applications of epidemiological data, form the basis
Ratios are expressed on a common base. Thus, the ratio of city A
of this chapter. An in-depth understanding of statistics is not
to city B is 103 to 253, which is expressed as 103:253. Dividing 253
required to understand epidemiology. Computation of the sim- by 103 equals 2.4563, or a ratio of 1:2.4563, which is expressed as
ple formulas used in this chapter requires only basic mathemat- approximately 1:2.5.
ical skills: addition, subtraction, multiplication, and division.
CHAPTER 7â•… Epidemiology: Unraveling the Mysteries of Disease and Health 163
of 100,000, city A's rate would be 103 per 100,000, and city B's
rate would be 253 per 100,000. Common base rates permit accu-
rate comparisons and are much easier to understand.
Health statistics are sometimes reported as a ratio, which
is simply the comparison of one number with another. A ratio Recovery
is often used to compare one at-risk population with another.
Ratios are usually simplified by reducing the numbers so that
the smallest number becomes 1. To use the example of cities
A and B, the ratio of teenage pregnancies in city A to those in Incidence
city B would be 103 (city A) to 253 (city B), or 103:253, which
can be reduced to approximately 1:2.5; in other words, city B
Death
has approximately 2.5 times as many teenage pregnancies per
100,000 female teenagers aged 14 to 19â•›years as does city A.
Suppose you were told that more homicides occurred in Los
Angeles than in Washington, DC. How would you compare the PREVALENCE
rates, rather than just the numbers? Would you need to know
the total population at risk for each city? In 2010 there were
293 homicides in Los Angeles, a city of 3,841,707 people, and
132 in Washington, DC, a city of 601,723 people. The murder
rate for Los Angeles was 7.63 per 100,000 people compared with
21.94 per 100,000 people in Washington, DC (Federal Bureau of
Investigation, 2011a, 2011b). The murder rate for Washington,
FIGUREÂ€7-1â•‡Prevalence pot: the relationship between inci-
DC was almost three times higher than that for Los Angeles. dence and prevalence. (From Hebel, J. R., & McCarter, R. J. [2006].
A study guide to epidemiology and biostatistics [6th ed.]. Sudbury, MA:
Measures of Morbidity and Mortality Jones & Bartlett.)
Statistics on mortality (death rates) and morbidity (illness
rates) are collected routinely and used to describe the frequency
of death or disease for a given time, place, and group of per- diabetes mellitus can help to control blood glucose levels and
sons. Morbidity statistics also include measures related to spe- prevent serious disease complications, such as heart attack,
cific symptoms of a disease, days lost from work, and number blindness, and limb amputation, but they will not affect dia-
of clinic visits. In the United States, the law requires that death betes incidence; only health promotion and disease prevention
records be kept; they are tabulated by the National Center for efforts targeting behavioral change in diet and exercise patterns
Health Statistics and help determine trends in the United States. have the potential to decrease incidence of this chronic disease.
Incidence and Prevalence Rates Crude, Adjusted, and Specific Rates

Incidence refers to the rate at which a specific disease develops A rate can be expressed for the total population (crude or
in a population. The incidence rate is the number of new cases adjusted rate) or for a subgroup of the population (specific rate).
of an illness or injury that occurs within a specified time. In BoxÂ€7-2 presents the formulas for frequently used mortality
contrast, prevalence measures all of the existing cases at a given rates. Age-specific and age-adjusted rates are often quite helpful
point in time. Prevalence includes the new cases (incidence) in making comparisons among populations.
plus all of the existing cases. The prevalence rate is influenced
by how many people become ill and how many people recover
Boca Raton, Florida, is a retirement community populated
or die (FigureÂ€7-1).
by a high proportion of persons older than 65â•›years of age.
Prevalence is important in determining measures of chronic
Orlando, Florida, also has a significant population of retir-
illness in a population and is affected by factors that influence
ees, but the personnel of many corporate headquarters and
the duration of the disease. Thus prevalence rates have relevance
young people who work at Disney World also live there.
for planning for health care services, resources, and facilities;
Comparing mortality rates in the two cities would not be jus-
for determining health care personnel needs; and for evaluating
tified unless the death rates of, for example, 65-year-olds and
treatments that prolong life.
25-year-olds are compared for each city. This comparison
Conversely, incidence rates are used as tools for studying
would be age-specific. If each age-specific rate in Boca Raton
patterns of both acute and chronic illness. Incidence rates are
were compared with the age-specific rate in a standard popu-
important because they are a direct measure of the magnitude
lation, the number of deaths of people in that age group in
of new illness in a population and provide assessments about the
Boca Raton would then have been adjusted to reflect the age
risk associated with particular illnesses. For example, the inci-
distribution of the standard population. The same adjust-
dence of certain childhood illnesses, such as measles, polio, and
ment would need to be performed on data from Orlando
whooping cough, was drastically reduced in the United States
to ensure that any differences were not the result of differ-
during the twentieth century with the introduction of vaccines
ences in the age distribution of the two cities. Similar adjust-
effective in preventing these diseases. Because they reflect only
ments can be made for gender, race, and socioeconomic class
the development of a disease, incidence rates may be influenced
if the researcher wants to exclude the effects of these factors
by preventive health measures but typically remain unchanged
in making comparisons among populations.
by new medical treatment patterns. New drugs to treat type 2
BOXÂ€7-2â•…â•‡FREQUENTLY USED MORTALITY An example of a prevalence study is “Vitamin D Deficiency

RATES and Seasonal Variation in an Adult South Florida Population”
(Levis etÂ€al., 2005). At winter's end, the researchers found defi-
Total number of deaths during a year cient levels of vitamin D in 38% of men and 40% of women in
Crude death rate = × 1000
Total population at mid-year the study. These prevalence rates were higher than expected in
Cause-specific death rate = a southern region, which indicated that health care providers
in Florida should still consider vitamin D deficiency as a pos-
Total number of deaths from specific cause during a year sible factor when assessing patients for osteoporosis.
× 1000
Total population at mid-year An example of a correlational design is a study conducted
Age-specific death rate = by Burnett-Zeigler and associates (2011) exploring preva-
Total number of deaths from a specific cause lence and correlates of alcohol misuse among Army National
× 1000 Guard service members recently returned to Michigan from
Total mid-year population of the given age group
Afghanistan and Iraq. Results indicated that the rate of alco-
Total number of maternal deaths hol misuse was high (36%) and associated with male gender,
Maternal death rate = × 1000
Total number of live births younger age, and reported symptoms of depression or post-
Infantmortality rate = traumatic stress disorder. Major barriers to accessing mental
health services cited by those who met misuse criteria were
Total number of deaths of children < 1 year related to perceived stigma. In contrast, concern by a spouse,
× 1000
Total number of live births during the same year physician, peer, friend, or family member was most com-
Neonatal death rate = monly cited as positively influencing pursuit of mental health
Total number of deaths, birth to 28days of age care. Thus, the study identified associations, or correlations,
× 1000 between alcohol misuse and possible contributing factors, and
Total number of live births plus fetal deaths during year
proposed early outreach and social support as potential inter-
Fetal death rate = ventions to improve mental health care linkages. Descriptive
Total number of deaths during 20-28 weeks' gestation studies may employ cross-sectional timing in their design, in
× 1000
Total number of live births plus fetal deaths during year which information on risk factors or exposures and informa-
tion on outcomes or diseases is all gathered at the same time.
Because data are gathered at only one point in time, it can be
TYPES OF EPIDEMIOLOGICAL INVESTIGATION difficult to determine which actually occurred first, suspected
risk factors or disease. Does alcohol misuse contribute to devel-
People who are engaged in epidemiological research frequently oping depression, or do depressed people tend to misuse alco-
observe rather than manipulate variables believed to influence hol more often? Associations between variables may be noted
the health of the human population. An observational meth- in descriptive studies, but these are not necessarily due to
odology means that the researcher has far less control of the cause-and-effect relationships.
factors under study and that extraneous factors may not be
well controlled for in the study design. Epidemiological stud- Analytic Studies
ies, however, do identify nonrandom patterns of health and dis- Like descriptive studies, analytic studies use observational
ease and serve as the basis for determining the circumstances methodology, but in contrast to simple descriptive designs,
in which experimental studies would be beneficial. They also analytic studies begin to answer questions about cause-and-
are of value in planning and evaluating health care services. effect relationships between a potential risk factor
Â� and a
Epidemiological studies can be divided into three major types: Â�specific health phenomenon or disease condition. Hypotheses,
descriptive, analytic, and experimental. which are statements of possible relationships, are used to
predict the causal association among the variables. Being able
Descriptive Studies to predict risk thus points to factors that, if changed, may
Descriptive studies, including prevalence and correlation prevent the disease from occurring or reduce its risk. The
studies, customarily describe the amount and distribution of hypotheses are tested through studies using cohort or case-
disease within a population. This approach relies primarily on control designs, and these studies may be Â�retrospective or
collection of existing data and answers the following questions: prospective.
• Who is affected (person)? Cohort studies are useful in identifying factors associ-
• Where is the disease distributed in the human population ated with increased risk of developing certain diseases. The
(place)? Framingham Heart Study is a classic example of a prospec-
• When is the disease present (time)? tive cohort study, which follows originally healthy people over
• What is the overall effect of the disease (population)? time to observe risk factors and the development of disease.
The National Health Interview Survey, sponsored by the The study was begun in 1948 with funds from the National
U.S. Department of Health and Human Services (USDHHS), is Heart Institute in Framingham, Massachusetts, to identify
administered to a random sample of individuals in the United factors contributing to cardiovascular disease. It is still going
States. Descriptive information from this survey provides on today in collaboration with Boston University and now
demographic and health information for the nation. The results includes data on three generations—the original study sub-
of this survey are available to the public, and researchers who jects, the offspring of the original cohort, and the generation
are seeking to test their own hypotheses can conduct secondary III cohort (National Heart, Lung, and Blood Institute, 2011).
analyses of this descriptive data set. Landmark findings from the Framingham Heart Study have
provided information about obesity and elevated lipid levels of cardiovascular mortality by 44% (Steering Committee
as risk factors for Â�atherosclerotic disease and about tobacco of the Physicians’ Health Study Research Group,Â€1989), but
use, sedentary lifestyles, hypertension, and diabetes as risk fac- Â�long-term beta-carotene supplementation had no effect on
tors for cardiovascular disease. the incidence of cancer or cardiovascular disease (Hennekens
Other examples of cohort studies are the Nurses' Health etÂ€al., 1996). Because of ethical concerns about not causing
Studies (NHS) I and II, initiated by Dr. Frank Speizer in 1976 suffering or exacerbation of illness, experimental studies usu-
and expanded by Dr. Walter Willett and colleagues in 1989 ally involve the testing of hypotheses related to disease preven-
with funds from the National Institutes of Health. The pri- tion, health promotion, or, in some situations, the treatment
mary goal of NHS II was to gather long-term information of a specific disease.
about oral contraceptive use, diet, and lifestyle risk factors in Because community health nurses are asked to plan, imple-
women younger than the original NHS cohort. Over 81,000 ment, and evaluate health care services for specific populations,
nurses between 25 and 42â•›years of age were recruited and understanding epidemiological concepts and principles is
answered surveys about health and lifestyle every 2 to 4â•›years important. For example, epidemiological investigations can
over 26â•›years (Chiuve etÂ€al., 2011). Chiuve and colleagues evaluate the extent to which a program that is provided by
found that adherence to a low-risk lifestyle (i.e., regular exer- nurses and designed to increase access to early prenatal care is
cise, not smoking, following a Mediterranean-style diet, and successful in reducing prematurity and low birth weight.
maintaining a normal body mass index) was associated with Epidemiological methods may also be used to evaluate the
a 92% lower risk of sudden cardiac death in this population. effectiveness of primary intervention strategies and thus
A new, more diverse cohort of nurses has now been recruited improve nursing practices. The trend toward outcomes research
for NHS III, which will be conducted online and examine and evidence-based practice is reflected in studies using these
effects of hormones, diet, and occupation on women's health types of methods.
and fertility; the principal investigator is Susan E. Hankinson,
RN, ScD. Nurse Maria Herrera worked in a community clinic in which
Case-control studies are retrospective because the study she evaluated three children in 1â•›week who had confirmed
begins after the health outcome has already occurred. lead levels above acceptable limits. Ms. Herrera partnered
Researchers select a group of case subjects with a known dis- with the local nursing school and public health department
ease or health outcome and compare them to a group of control to organize a community-wide free screening and educa-
subjects who do not have the disease or health outcome. King tional intervention focused on small children. The aim of
and associates (2005) used a case-control design to investigate the program was to teach community members about the
potential relationships between stillbirths in Nova Scotia and dangers of lead poisoning and to formulate strategies to
Eastern Ontario, Canada, and chlorine disinfection by-products eliminate lead exposure. During the screening, the nurses
found in public drinking water sources. They found that still- discovered that a large number of the children who tested
birth cases were more likely than live birth controls to have been positive for lead came from one public housing unit. The
exposed to some types of these drinking water disinfection by- nurses enlisted public health officials in reducing the expo-
products (trihalomethanes) but not to others (haloacetic acids). sure threat in this housing complex.
Case-control studies are advantageous in assessing multiple
exposures or risk factors for diseases or health outcomes that UNDERSTANDING AGGREGATE-LEVEL DATA
occur infrequently, because they can be done with smaller sam-
ple sizes than those needed to study rare or infrequent health A primary focus of community health nursing is the defini-
outcomes in cohort studies. tion of health-related problems (assessment) and the posing
of solutions (interventions) for populations or aggregates of
Experimental Trials people. Population-level decision making requires a different
If the evidence suggests that some relationships are appropri- understanding from that used in direct caregiving to individu-
ate for further study to confirm cause and effect, an experi- als. The questions for analysis are different. At the population
mental study, usually known as a clinical or experimental trial, level, pertinent questions might be the following:
may be conducted. Experimental trials always begin with care- • What are the prevalence rates of diabetes mellitus type 2
fully designed questions, hypotheses, and research protocols among various age, gender, and racial groups?
that specify the criteria for selection of the people (subjects) to • Which subgroups have the highest incidences of diabetes?
be studied, the methods for random assignment of subjects to • Who is at high risk for developing diabetes?
the experimental and control groups, the treatment procedure, • What programs are available for diabetes prevention and
the follow-up of subjects, and the details of the data analyses. early detection?
In experimental studies, the researcher always manipulates • What would be required to further reduce the risk of diabe-
variables, such as a nursing intervention or a health-teaching tes mortality or morbidity for the entire population?
approach, in the experimental and control groups. An exam- Given the focus of community health on the well-being of
ple of an experimental epidemiological study is the Physicians' the community, emphasis is necessarily placed on what makes a
Health Study. In this randomized, placebo-Â�controlled study, healthy community. This includes the interrelationship between
22,071 male physicians aged 40 to 84â•›years were randomly the health status of the population and the potential for healthy
assigned to one of four treatment groups to study the effects actions within the population, factors that influence health sta-
of aspirin and beta-carotene use on cardiovascular disease tus, and the ability of the health care system to allocate appro-
(Physicians’ Health Study, 2011). The study found that low- priate resources and respond effectively to the needs of the
dose aspirin use (325â•›mg every other day) reduced the risk population. The projected trend for health care reform and the
increased prevalence of managed care delivery systems call for person, the environment, and the causative agent that increase
nurses to assume more responsibility for clients in the commu- the potential for disease. This period leads to the stage of adap-
nity. Therefore, the need for nurses to understand and practice tation, in which changes in the body occur in response to some
nursing at the population level is more urgent. agent or stimulus, but these physiological or immune system
In an attempt to respond effectively to these health care chal- reactions are still part of a normal adaptive response. Although
lenges, the USDHHS published a report establishing national factors are present that increase risk during the period of pre-
health objectives for each decade. Healthy People 2020 is the pathogenesis, no disease exists. For example, obesity in combina-
current report outlining national objectives for health promotion with a sedentary lifestyle and smoking increases a person's
tion and disease prevention (see the Healthy People 2020 box chances for developing coronary heart disease. Because some
below and the discussion in ChapterÂ€2). This report identi- risk factors can be altered, understanding the natural history of
fies the goals and priorities toward which health care planners a disease is important. Awareness of the presence of risk allows
and providers should work to improve the health of the U.S. the nurse to initiate preventive measures against the disease or
population. Although the goals are directed toward healthier limit its development.
lives for all Americans, particular emphasis is given to special For diseases in which detection through symptoms occurs
cohorts. A cohort is a group of people who share similar char- late in the disease trajectory, early detection may be possible by
acteristics. For example, people born in the same decade repre- technological screening procedures. In the case of breast can-
sent an age cohort. Healthy People 2020 targets certain cohort cer, for example, mammography can detect the disease before
groups: newborn babies, boys and girls, adolescents and young symptoms emerge. Many diseases, such as acute or infectious
people, women and children, and people in their later years diseases, run their course, and a person experiences complete
(USDHHS, 2010). recovery. Changes resulting from chronic diseases or condi-
tions, however, may have long-term effects. Symptoms generally
HEALTHY PEOPLE 2020 become more fixed and are less reversible as the disease contin-
What's New for 2020 ues. With advancing disease, functional changes may produce
marked disability and lead to death.
1. Focus on Determinants of Health. Identifying, measuring, tracking, Analyzing the natural history of a disease involves the use
and reducing health disparities through renewed focus on the deter- of the epidemiological triangle (FigureÂ€7-2). A change in any
minants of health, including biology and genetics, individual behav- of the factors represented in this triangle (the person, the
ior, physical environment, social environment, and health services. causative agent, or the environment) has the potential to
change the balance of health. For the person or host, demo-
2. New topic areas, including a life cycle approach targeting Adolescent
Health, Early and Middle Childhood, and Older Adults. Other new topic
graphic characteristics, the level of health and history of prior
areas include: Blood Disorders and Blood Safety; Dementias, including disease, genetic predisposition, states of immunity, body
Alzheimer Disease; Genomics; Global Health; Healthcare-Associated defenses, and human behavior should be examined (BoxÂ€7-3).
Infections; Health-related Quality of Life and Well-Being; Lesbian, Causative agents may include biological, physical, chemical,
Gay, Bisexual and Transgender Health; Preparedness; Sleep Health; nutritional, genetic, or psychological factors that have the abil-
and Social Determinants of Health. ity to affect health and disease in the person. The environment
includes anything external to the person or agent, including
3. Tools and resources for implementing Healthy People 2020. the presence of other persons or animals that potentially affect
health and disease.
4. Evidence-based interventions and resources from the U.S. Preventive
Services Task Force Clinical Preventive Services, the Guide to
Community Preventive Services, and healthfinder.gov's Quick Guide Calhoun County, Michigan, has a population of 136,000.
toÂ€Healthy Living Information for Consumers. In March 1997 a total of 153 cases of hepatitis A were
reported in the county. The incidence rate for Calhoun
From U.S. Department of Health and Human Services. (2010). Healthy
County was 89 per 100,000, well above the national rate
People 2020. Retrieved June 10, 2011 from: http://www.healthypeople.
gov/2020/default.aspx. of 27.9 per 100,000 (Moyer etÂ€al., 1996). Of the 153 case
patients, 151 were students or staff at schools in four dif-
ferent school districts (Centers for Disease Control and
CONCEPTS RELATED TO PREVENTION, HEALTH Prevention, [CDC], 1997a).
PROMOTION, AND DISEASE
Three major concepts are crucial to understanding epidemi-
ology: the natural history of disease, the levels of prevention, Susceptible person or host
and the multiple causation of disease. These concepts are an
important foundation to help in planning appropriate nursing
interventions for cohorts, aggregates, and populations.
Natural History of Disease

Diseases evolve over time. Leavell and Clark (1965), in their clas-
sic description of the disease process, delineate two distinct peri-
ods: prepathogenesis and pathogenesis. The prepathogenesis Causative
Environment
period encompasses the stages of susceptibility and adaptation. agent
During the stage of susceptibility, interactions occur among the FIGUREÂ€7-2â•‡ Epidemiological triangle.
BOXÂ€7-3â•…â•‡SOME HOST, AGENT, AND are analyzed by statistical methods to determine whether a
ENVIRONMENTAL FACTORS causal relationship exists between various factors and health
THAT AFFECT HEALTH status. Understanding these interactions and relationships
is even more important and complex as one considers the
Host Factors natural history of noninfectious diseases, chronic condi-
Demographic characteristics: age, sex, ethnic background, race, tions, and the health and well-being of a population. In these
Â�marital status, religion, education, and economic status instances, multiple causes or factors are usually interacting
Level of health: genetic risk factors, physiological states, anatomical to affect health status.
factors, response to stress, previous disease, nutrition, fitness A significant number of multiple causation models in
Body defenses: autoimmune system, lymphatic system Â�epidemiology can be found. The model of Dever (1991) rec-
State of immunity: susceptibility versus active or passive immunity ognizes input from human biology, lifestyle, environment,
Human behavior: diet, exercise, hygiene, substance abuse, occupa- and the health care system in the development of a par-
tion, personal and sexual contacts, use of health resources, food ticular health condition. The Web of Causation model is a
handling
Â�metaphoric model that has been used in epidemiology texts
Agent Factors (Presence or Absence) since the early 1960s to describe the multifactorial causes of
Biological: viruses, bacteria, and fungi and their mode of transmission, disease (Krieger, 1994).
life cycle, virulence All the models point to the interplay of numerous factors
Physical: radiation, temperature, noise in the presentation of a specific disease. FigureÂ€7-3 illustrates
Chemical: gas, liquids, poisons, allergens factors associated with heart disease. Some of these factors are
easily amenable to change, whereas others are not. One way to
Environmental Factors remember the categories of causes for disease is the acronym
Physical properties: water, air, climate, season, weather, geology, used in the BEINGS model of disease causes. These categories
geography, pollution include the following:
Biological entities: animals, plants, insects, food, drugs, food source • (B)â•‡ Biological factors and behavioral factors
Social and economic considerations: family, community, political • (E)â•‡ Environmental factors
organization, public policy, regulations, institutions, workplace,
• (I)â•‡ Immunological factors
occupation, economic status, technology, mobility, housing popu-
• (N) Nutritional factors
lation density, attitudes, customs, culture, health practices, health
• (G) Genetic factors
services
• (S)â•‡ Services, social factors, and spiritual factors
Obviously, the factors in some of these categories are harder
to change than others. For example, genetic factors remain the
Investigation by public health officials did not identify a most difficult to manipulate, whereas nutritional factors are
single event, food handler, or contaminated water supply as a more easily changed.
source for this outbreak. However, most case clients ate lunch
in schools, and further analysis revealed a strong association Levels of Prevention
between illness and consumption of food items containing fro- Because disease occurs over time, there are many potential
zen strawberries. points at which intervention may prevent, halt, or reverse the
The strawberries linked to this outbreak were grown in pathological change. A three-level model developed by Leavell
Mexico and shipped to a southern California company, where
they were processed, packed, and frozen in 30-lb containers to
be distributed to U.S. Department of Agriculture–Â�sponsored
school lunch programs. Whether the strawberries were contam- Factor A Factor B
inated in Mexico or in the processing company in California
was uncertain. Further investigations continued to track the or
source of the contamination. Meanwhile, the Centers for
Disease Control and Prevention (CDC) notified the health Cardiovascular
Factor C Factor D
Disease
departments in six other states to which strawberries from the
same lots as those sent to Calhoun County had been shipped. or
Immunoglobulin postexposure prophylaxis was offered to per-
sons who consumed frozen strawberries from the suspected lots Factor E Factor F
through school lunch programs, but only when it could be initi-
ated within 14â•›days of their exposure.
Can you think of some ways that the epidemiological concepts A Work stress
of host, agent, and environment relate to this clinical example? B Family history of heart disease
C High blood cholesterol level
Multiple Causation of Disease D Hypertension
E High fat diet
The theory of multiple causation of disease is critical to F Sedentary life style
understanding epidemiological problems. Causality is gen- FIGUREÂ€7-3â•‡An example of multiple causal factors in heart
erally considered in terms of a stimulus or catalyst that pro- disease. Each individual factor is neither sufficient nor neces-
duces a single effect, result, or outcome. In epidemiology the sary by itself for disease to occur. (Adapted from Gordis, L. [2008].
interactions of the agent, person (host), and environment Epidemiology [4th ed.]. Philadelphia: Saunders.)
The natural history of any human disease
Interrelations of agent, host, and environmental Reaction of the host to the stimulus
factors Discernible Advanced
Production of stimulus Early pathogenesis Convalescence
early lesions disease
Prepathogenesis period Period of pathogenesis
Health promotion
Health education Specific protection

Good standard of Early diagnosis and
Use of specific prompt treatment Rehabilitation
nutrition adjusted
immunizations
to developmental Case-finding measures, Disability limitation Provision of hospital
phases of life Attention to personal and community
individual and mass
hygiene Adequate treatment to facilities for retraining
Attention to personality Screening surveys
development Use of environmental arrest the disease and education for
sanitation Selective examinations process and to prevent maximum use of
Provision of adequate further complications remaining capacities
Protection against Objectives:
housing, recreation, and sequelae
and agreeable working occupational hazards To cure and prevent Education of the public
conditions disease processes Provision of facilities and industry to utilize
Protection from
to limit disability and the rehabilitated
Marriage counseling accidents To prevent the spread
to prevent death As full employment
and sex education Use of specific of communicable diseases
To prevent complications as possible
Genetics nutrients
and sequelae Selective placement
Periodic selective Protection from
examinations carcinogens To shorten period of Work therapy in hospitals
disability Use of sheltered colony
Avoidance of allergens
Primary prevention Secondary prevention Tertiary prevention
Levels of application of preventive measures
FIGUREÂ€7-4â•‡ Levels of prevention in the natural history of disease. (Redrawn from Leavell, H. F., &
Clark, E. G. [1965]. Preventive medicine for the doctor in his community: An epidemiologic approach. New
York: McGraw-Hill.)
and Clark (1965) based on the idea that disease evolves over Secondary Prevention
time continues to be used in the conceptualization and struc- Secondary prevention is aimed at early detection and prompt
ture of health programs (FigureÂ€7-4). treatment either to cure a disease as early as possible or to slow
its progression, thereby preventing disability or complications.
Primary Prevention Screening programs in which asymptomatic persons are tested
Primary prevention is aimed at altering the susceptibility or to detect early stages of a disease are the most frequent form
reducing the exposure of persons who are at risk for developing of secondary prevention. Early case finding and prompt treat-
a specific disease. Primary prevention includes general health ment activities are directed toward preventing the transmission
promotion and specific protective measures in the prepatho- of communicable diseases, such as the spread of impetigo in a
genesis stage, which are designed to improve the health and school. Preventing or slowing the development of a particu-
well-being of the population. Nursing activities include health lar disease or condition and preventing complications from a
teaching and counseling to promote healthy living and lifestyles. disease, such as scoliosis in teenage girls, are also examples of
Specific protective measures aimed at preventing certain risk Â�secondary prevention.
conditions or diseases—such as immunizations, the removal of
harmful environmental substances, protection from ultraviolet Tertiary Prevention
rays, or the proper use of car safety seats for infants and chil- Tertiary prevention is aimed at limiting existing disability in
dren—are also primary prevention activities. Recent advances persons in the early stages of disease and at providing rehabilita-
in genetic screening have initiated a debate over its role in dis- tion for persons who have experienced a loss of function result-
ease or disability prevention. Although genetic scientists hail ing from a disease process or injury. Nursing activities include
research advances as one step on the road to ridding the world education to prevent deterioration of a person's condition,
of disease and disability, others view that step more as a slip- direct nursing care, and referrals to resources that can help cli-
pery slope. Is a child with less potential for disease or disability ents minimize the loss of function.
a more perfect child? If we have the technology to produce such
a child (by selective abortion or gene manipulation), does the HEALTH INFORMATION SYSTEMS
public have the right of access to this technology? What message
does this send to the disabled community? From a community Health information is the data collected about the significant
perspective, what other dilemmas can you imagine surfacing in health-related events that occur over a period within a popula-
relation to genetic screening? tion. Health information systems are data collection systems
for gathering health statistics and other health-related informa- Factor Surveillance System. These surveillance systems are also
tion at the population level and may include collection of vital ongoing, but data are collected only periodically, and only from
statistics, surveillance, surveys, and records. samples. In 1973, the National Cancer Institute (NCI) estab-
Data used in epidemiology are systematically collected by lished the Surveillance, Epidemiology, and End Results (SEER)
government agencies and private groups to measure the size program to provide data on cancer incidence and track patients
and scope of health problems and factors contributing to them; diagnosed with cancer. SEER contracts with 18 population-
to study trends and predict the future course of health prob- based local and state registries that submit cancer data cov-
lems; to identify subgroups to target for interventions; and to ering approximately 26% of the U.S. population twice a year
evaluate the outcomes of intervention programs and their costs. (NCI,Â€2011).
Types of health information collected include vital statistics
and health statistics on morbidity and disability, health behav- Surveys
iors, nutrition, and health care access, utilization, and costs. Because ongoing national surveillance systems result in
Data on personal, behavioral, environmental, and occupational incomplete data on morbidity and disability, the CDC's
risk factors associated with illness are collected and analyzed, National Center for Health Statistics, the National Institutes
and sometimes information on related political and economic of Health, and other agencies periodically conduct a num-
issues that affect health is also collected. ber of large-scale, representative surveys on samples of the
Much epidemiological information is now available on total population. Examples include the National Health and
the Internet, for example, the home pages of the U.S. Census Nutrition Examination Survey (NHANES) and the National
Bureau and the CDC. These two websites also contain many Survey on Drug Use & Health. Surveys use random samples
helpful links to other websites. (See the resource list at the end drawn from multiple geographical areas. NHANES, first
of the chapter for additional information.) conducted in the early 1960s, focuses on chronic disease
prevalence and related biophysical measures. AÂ€segment on
Vital Statistics nutrition was added in 1971.
A major source of information about a population comes
from the vital statistics that are recorded about them. Vital Records
Â�statistics is the term used for the data collected from the ongo- Hospital records, such as patient charts, are no longer often used
ing registration of vital events, such as death certificates, birth except when local data are being gathered, because national and
certificates, and marriage certificates. These data are system- state organizations such as the American Hospital Association
atically collected by agencies such as the National Center for and the Institute of Medicine now survey hospitals, analyze the
Health Statistics and the World Health Organization (WHO). data, and provide much information in organized, easily avail-
Many other governmental agencies within the CDC and the able formats. The CDC's National Center for Health Statistics
USDHHS, as well as private groups such as the Children's also conducts regular surveys to collect data on diseases treated
Defense Fund, also make use of these statistics and issue and health care provided, such as the National Ambulatory
reports related to particular health concerns. One example Medical Care Survey, the National Hospital Discharge Survey,
of such a publication is the Morbidity and Mortality Weekly and the National Nursing Home Survey.
Report (MMWR) published by the CDC. Other organizations that routinely use health statistics, such as
local health departments, regional planning agencies, and other
Surveillance local and state governmental agencies, are additional data sources.
Surveillance is the ongoing systematic collection, analysis, and TableÂ€7-1 shows the breakdown of visits to hospital emer-
dissemination of health information for the purpose of moni- gency departments by leading diagnoses for gender and age
toring and containing specific, primarily contagious, diseases. groups in 2008. Which diagnosis is seen more commonly in
An example of a surveillance and response system is the WHO's girls under 15â•›years of age than in boys of this age? (You are cor-
Global Outbreak Alert and Response Network, a group of col- rect if you identified acute pharyngitis as a leading cause of hos-
laborating institutions formed to rapidly identify, confirm, and pital visits for girls but not boys under 15â•›years of age.) Are there
respond to internationally important disease outbreaks, such as any diagnoses listed for boys that are not listed for girls? What
avian influenza (WHO, 2011). The National Notifiable Diseases other interpretations are possible from the data in TableÂ€7-1?
Surveillance System in the United States is operated by the CDC
and the Council of State and Territorial Epidemiologists to pro- Analysis of Data from Multiple Sources
vide weekly reports (MMWR) and annual reports (Summary of Many government agencies and private groups synthesize and
Notifiable Diseases, United States) on the occurrence of notifi- analyze the data collected by multiple health information sys-
able diseases, a list of which is provided in ChapterÂ€8. Notifiable tems to produce reports about health status and trends in health
disease reports are received from all U.S. states and territories, care. One example of a report of this nature is information col-
but morbidity data from surveillance efforts are not as accu- lected and published in the National Diabetes Fact Sheet, 2011
rate as mortality data collected by vital statistics registration, for (CDC, 2011a). FigureÂ€7-5 shows the percentage of adults by race
several reasons: (1) state laws mandate disease reporting, but or ethnic background who have diabetes. Which group has the
reporting to the CDC is voluntary; (2) not all cases receive care highest risk of diabetes? Which group has the lowest risk? Non-
and not all treated cases are reported; and (3) the completeness Hispanic whites have the lowest risk. The other ethnic groups
of reporting varies. Noninfectious chronic diseases, such as dia- are at higher risk, with American Indians and Alaska Natives
betes, arthritis, and asthma, are not notifiable. The CDC does (AIANs) at the highest risk. Over 16% of AIAN adults have been
coordinate other surveillance systems, such as the Pregnancy diagnosed with diabetes, although rates for those 20â•›years of age
Risk Assessment Monitoring System and the Behavioral Risk and older vary by region (from 5.5% among Alaska Natives to
TABLEÂ€7-1â•…â•‡VISITS TO HOSPITAL EMERGENCY DEPARTMENTS BY DIAGNOSIS: 2008

RATE/1000 RATE/1000
LEADING DIAGNOSIS NUMBER (1000) PERSONS1 LEADING DIAGNOSIS NUMBER (1000) PERSONS1
Men Women
All ages 56,742 388 All ages 67,020 440
Under 15â•›years2 12,762 409 Under 15â•›years2 10,395 348
Acute upper respiratory infections3 1,129 36 Acute upper respiratory 916 31
infections3
Otitis media 826 26 Otitis media 696 23
Open wound of the head 742 24 Pyrexia of unknown origin 650 22
Pyrexia of unknown origin 718 23 Contusion with intact skin 363 12
surfaces
Contusion with intact skin surfaces 577 18 Acute pharyngitis 308 10
15-44â•›years2 23,246 379 15-44â•›years2 31,763 516

Open wound, excluding head 1,264 21 Abdominal pain 2,103 34
Contusion with intact skin surfaces 1,186 19 Complications of pregnancy, 1,394 23
childbirth, & the puerperium
Cellulitis and abscess 921 15 Contusion with intact skin 1,121 18
surfaces
Chest pain 869 14 Chest pain 1,121 18
Sprains and strains, excluding 765 12 Spinal disorders 1,048 17
ankleÂ€& back
45-64â•›years2 12,542 333 45-64â•›years2 13,793 346

Chest pain 786 21 Chest pain 850 21
Open wound, excluding head 565 15 Abdominal pain 701 18
Spinal disorders 512 14 Spinal disorders 512 13
Abdominal pain 452 12 Contusion with intact skin 433 11
surfaces
Cellulitis and abscess 373 10 Cellulitis and abscess 389 10
65â•›years & older2 8,192 511 65â•›years & older2 11,069 522
Chest pain 456 28 Chest pain 628 30
Heart disease, excluding ischemic 442 28 Contusion with intact skin 541 25
surfaces
Pneumonia 356 22 Heart disease, excluding 537 25
ischemic
Contusion with intact skin surface 254 16 Abdominal pain 459 22
Chronic and unspecified bronchitis 241 15 Urinary tract infection, site not 316 15
specified
1
Based on U.S. Census Bureau estimated civilian noninstitutional population as of July 1.
2
Includes other first-listed diagnosis, not shown separately.
3
Excluding pharyngitis.
Data from: U.S. Census Bureau. (2012). Statistical abstract of the United States, 2012 (131st Ed. Table 170). Washington, DC: U.S. Government
Printing Office. http://www.census.gov/statab/www/.
33.5% among American Indians in southern Arizona). Diabetes DEMOGRAPHIC DATA

rates also vary widely among adult Hispanics in the U.S. accord-
ing to ethnic background, from rates among Cubans and Age, sex, race, ethnicity, social class, occupation, and marital
Central and South Americans at 7.6% to rates of 13.3% among status are demographic characteristics that are frequently used
Mexican Americans and 13.8% among Puerto Ricans. when describing human populations. These factors contribute
In the United States, approximately 25.8 million people to variations in health status, health-related behaviors, and use
(8.3% of the total population) have diabetes, either diagnosed of health care services.
or undiagnosed (CDC, 2011a). Primary prevention aimed at Major demographic findings reported by the U.S. Census
reducing health risks and increasing healthy behaviors to reduce Bureau provide specific information that describes the pop-
the incidence of diabetes not only would be beneficial for the ulation. This information is collected every 10â•›years in the
health of individuals but also would decrease the nation's health national census. In addition to the overall profiles of the pop-
care costs. Nurses using prevalence data can target intervention ulation, many specific reports are issued each year, for exam-
to high-risk groups. In the case of diabetes, all of the higher-risk ple, age, gender, marital status, and educational level reports.
groups should be targeted. A report of national population trends and projections might
Racial & Ethnic Differences

• The prevalence of mild to moderate dementia in this age
in Diagnosed Diabetes, 2007–20091,2
group
Percent of People Aged 20 Years or Older • The number of persons age 65 and older with incomes
below the poverty level
From this information, the nurses were able to identify and
AIAN survey eligible persons in the community to determine if a
need for such a program existed. In the course of their sur-
vey, the group found that the Latino seniors and their fami-
NHB lies might be hesitant to make use of such services because
of a cultural expectation that people should take care of
their own. When the grant was written, strategies to encour-
H
age Latino family caregivers to take advantage of respite care
were incorporated into the proposal. The plan was funded,
and the program attracted an average daily attendance of
AA
23Â€persons. Caregivers and attendees expressed appreciation
for the program.
NHW
Aging Population
0 5 10 15 20 The number of elderly persons in the United States has been
increasing at a moderate rate, but growth in the age group
AIAN – American Indians Percent 65â•›years and older is expected to accelerate over the next few
& Alaska Natives
decades, due to the aging baby boom generation and increasing
NHB – Non-Hispanic
Blacks
life expectancies (FigureÂ€7-6). The number of elderly persons in
H – Hispanics
the population is important information for community health
AA – Asian Americans
nurses and other health care planners, because this age cohort
NHW – Non-Hispanic
requires more health care services.
Whites Although the overall growth of the population is expected
1 Age adjusted to 2000 U.S. census populations
to slow and possibly stop around 2045, the average life span
2 Diagnosed diabetes among AIAN was calculated using 2009 data from the
Indian Health Service National Patient Information Reporting System;
race/ethnicity-specific estimates of diagnosed diabetes for other groups were
calculated using 2007–2009 National Health Interview Survey data. 90000
FIGUREÂ€7-5â•‡ Racial and ethnic differences in diagnosed diabe-
tes, 2007-2009. (Drawn from data in: Centers for Disease Control and 80000
Prevention. (2011). National diabetes fact sheet: national estimates and
general information on diabetes and prediabetes in the United States, 70000
2011. Atlanta: U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention.) 60000
Population
50000
include information about the overall population, as well as 40000

information about the number of women of childbearing age,
30000
the baby boom generation (born between 1946 and 1964), and
growth resulting from net immigration. Such a report may also 20000
include data related to the trends of the population younger
than 25â•›years, such as preschool children, and those older than 10000
65â•›years, as well as life expectancy for those with a given birth
0
year. Community health nurses will find this information use-
2000 2010 2020 2030 2040 2050
ful in planning health care services and anticipating the needs of
target groups in the population. FIGUREÂ€7-6â•‡Actual and projected elderly population in the
United States (65â•›years and older) in thousands. (Compiled from
U.S. Census Bureau. Actual population data for 2000 and 2010 from:
Community health nurses in Miami-Dade County, Florida, U.S. Census Bureau. [2010]. Current population survey, annual social
wanted to provide an adult daycare program for persons and economic supplement, 2010. Internet release date: June 2011.
Retrieved June 24, 2011 from http://www.census.gov/population/www/
with mild to moderate dementia or Alzheimer disease. To socdemo/age/older_2010.html and U.S. Census Bureau. [2000]. Current
apply for a funding grant, the nurses needed to estimate the population survey. Retrieved June 24, 2011 from http://www.census.
number of persons in the community who might access the gov/population/www/socdemo/age/ppl-147.html. Projected Â� population
daycare program. National and local statistics were used to data for 2020-2050 from U.S. Census Bureau, Population Division.
determine the following: [2008]. Projections of the population by selected age groups and sex
• The number of persons over age 65 in the community for the United States: 2010 to 2050 [NP2008-T2]. Retrieved June 24,
2011 from http://www.census.gov/population/www/projections/summ-
• The number of such persons living alone
arytables.html.)
100 that black men and black women are expected to make the most
gain, compared to years of life in 1970. Now make some guesses
as to possible reasons for the higher gains for both black men
and black women.
80 • What might be a social reason for the difference? What is
known about the relationship between socioeconomic status
and health status?
• What reason related to health risk behavior might account
for the difference? What is known about health screening
60
patterns among the black population?
• What health service barrier might contribute to the differ-
White females Black females ence? Who have been the primary subjects of health care
White males Black males research?
0 For a more detailed discussion of race and ethnicity and
1970 1975 1980 1985 1990 1995 2000* 2007* 2010**2015** 2020** health variables, refer to ChapterÂ€10.
*Life expectancies for 2000 - 2007 were calculated using a revised
methodology and may differ from those previously published.
**Projections for 2010, 2015 and 2020. DEPARTMENT OF COMMERCE
Year White female White male Black female Black male
HEALTH-RELATED STUDIES
2000* 79.9 74.7 75.1 68.2 U.S. Department of Commerce studies determine which areas
2007* 80.8 75.9 76.8 70.0 of the country are growing the fastest and which states are
2010** 81.3 76.5 77.2 70.2 projected to have inhabitants with the highest median age. The
2015** 81.8 77.1 78.2 71.4 department publishes other records, including information
2020** 82.4 77.7 79.2 72.6 on city and urban growth and decline, households and fam-
FIGUREÂ€7-7â•‡ Life expectancy at birth for black and white men ilies, marital status and living arrangements, fertility among
and women: 1970 to 2020. (Redrawn from U.S. Census Bureau. women, percentage of women in the labor force, labor force
[2011]. Statistical abstract of the United States, 2011: The national data and occupations, poverty, unemployment, and race and eth-
book [130th ed.]. Washington, DC: U.S. Government Printing Office.) nicity. For example:
• The Hispanic population is growing more rapidly than the
non-Hispanic population in the United States. Estimates are
Â�continues to rise. The real and projected gains in life expec- that by 2020, 17.8% of the U.S. population will be Hispanic,
tancy are presented in FigureÂ€7-7. An interesting exercise is and by 2050, 24.4% of Americans will be Hispanic (U.S.
to compare the age profile of the population of the United Census Bureau, 2010a).
States with that of an underdeveloped country, such as the • The proportion of families headed by married couples has
Dominican Republic (FigureÂ€7-8). The Dominican Republic declined for whites, blacks, and Hispanics between 1970 and
profile more closely resembles a right triangle, with signif- 2010. In 2010, 19% of families were headed by a single woman
icantly more children and young adults (under the age of and 7% by a single man (U.S. Census Bureau, 2010b).
35â•›years). The proportion of older people (over 55â•›years) is • The poverty rate declined dramatically during the 1960s
small. The United States distribution is not as triangular, (from 22.4% in 1959 to 12.1% in 1969). From 1978 to 1983
with less dramatic differences in age distributions. There is the actual number of poor people increased again (from 24.5
a noticeable “bulge” in the 45 to 64â•›year old ranges in the to 35.3 million, or by 44%). The poverty rate in the 1990s
United States’ age distribution. What might account for these was higher than at any time since the 1970s until recently
different age distributions? (Proctor & Dalaker, 2002) (see ChapterÂ€21). In 2009, the
recession pushed the income of even more Americans (43.6
Gender, Race, and Life Expectancy million, or 14.3%) below the poverty level (U.S. Census
Healthy People 2020's vision for the nation's population is a soci- Bureau, 2010c).
ety in which all people live long, healthy lives (see the Healthy
People 2020 box on page 166). To that end, Healthy People 2020 MAJOR CAUSES OF DEATH
has committed to ending the discrepancies in morbidity and
mortality found between the sexes and among racial and eth- The leading causes of death are frequently the focus of epide-
nic groups, as well as health disparities based on sexual iden- miological study; however, the bigger challenge lies in under-
tity, disability, socioeconomic status, and geographical location standing the factors that contribute to the development of
(USDHHS, 2010). the disease, or death, or both. In 2000, the CDC updated
The information presented in FigureÂ€7-7 has been expanded estimates of the actual causes of death, using methodology
to a table that allows comparisons of projected gains in average first described by McGinnis and Foege (1993, 1999). These
life expectancy between two groups (TableÂ€7-2). Closely analyze researchers argued that major external (nongenetic) fac-
the table and make hypotheses as to the difference in net gain. tors are responsible for approximately one half of the deaths
What might be some possible reasons that women live lon- in the United States (TableÂ€7-3) and advocated for change
ger than men? in the way that causes of death are reported. For example,
Give thought to what is presented in TableÂ€7-2. Which groups when a person who smoked for 45â•›years dies of lung cancer,
are expected to experience the highest net gain by 2020? Notice they would list the cause of death as cigarette smoking, not
United States: 2010
100
Male 95-99 Female
90-94
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
16 14 12 10 8 6 4 2 0 0 2 4 6 8 10 12 14 16
Population (in Millions)
Dominican Republic: 2010
100
Male Female
95-99
90-94
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
600 500 400 300 200 100 0 0 100 200 300 400 500 600
Population (in Thousands)

FIGUREÂ€7-8â•‡ Distribution of the populations of the United States and the Dominican Republic
by age and sex, 2010. (Redrawn from U.S. Census Bureau. [2011]. International database. Washington, DC:
U.S. Government Printing Office; and U.S. Census Bureau. Retrieved June 24, 2011 from http://www.census.
gov/population/international/data/idb/informationGateway.php.)
cancer. This method would emphasize the modifiable (life- Leading Causes of Death in the United States: Trends
style, behavioral, and environmental) causes of death, thus In 2007, 2,423,712 deaths occurred in the United States (CDC,
focusing attention and health resources on disease preven- 2010a). The death rate for 2007, the latest year for which com-
tion rather than treatment. Clearly, the public health bur- parable statistics are available, was 760.2 deaths per 100,000.
den imposed by causes such as tobacco use, diet and activity The 15 leading causes of death in 2007 accounted for 81.4% of
patterns, alcohol use, firearms, sexual behavior, motor vehi- the total deaths in the United States (TableÂ€7-4). The 2007 rank-
cle accidents, and illicit use of drugs will guide and shape ing of the first five leading causes of death remain basically the
future health policy priorities, including public health nurs- same as that in 1992. Starting with deaths occurring in 1999, the
ing priorities. These actual causes offer a different perspec- United States began using the tenth revision of the International
tive in considering quality of life and causes of disease. The Classification of Diseases, which affected the categorization of
work of McGinnis and Foege validates nursing's strong com- deaths due to respiratory diseases (the fourth leading cause) and
mitment to disease prevention and the well-being of the primary hypertension and hypertensive renal disease. Diabetes
overallÂ€population. remained the seventh leading cause of death in 2007. In 2007,
TABLEÂ€7-3â•…â•‡ACTUAL CAUSES OF DEATH IN

TABLEÂ€7-2â•…â•‡REAL AND PROJECTED GAINS
THE UNITED STATES: 2000*
IN YEARS OF LIFE FOR MEN
AND WOMEN FROM 1970 ESTIMATED PERCENTAGE OF
CAUSE NUMBER TOTAL DEATHS
2020 2020 Tobacco 435,000 18.1
2007 (PROJECTED) 2007 (PROJECTED) Diet/activity patterns 365,000 15.2
ALL MEN ALL WOMEN Alcohol 85,000 3.5
75.4 77.1 80.4 81.9 Microbial agents 75,000 3.1
1970 –67.1 –67.1 –74.7 –74.7 Toxic agents 55,000 2.3
Gain in years 8.3 10.0 5.7 7.2 Motor vehicles 43,000 1.8
Firearms 29,000 1.2
WHITE MEN WHITE WOMEN
Sexual behavior 20,000 0.8
75.9 77.7 80.8 82.4 Illicit drug use 17,000 0.7
1970 –68.0 –68.0 –75.6 –75.6 Total 1,124,000 46.8
Gain in years 7.9 9.7 5.2 6.8 *Calculated with methodology established by McGinnis & Foege.
BLACK MEN BLACK WOMEN (1993). Actual causes of death in the U.S. Journal of the American
Medical Association, 270(18); 2207–2212.
70.0 72.6 76.8 79.2 Compiled from Centers for Disease Control and Prevention. Mokdad,
1970 –60.0 –60.0 –68.3 –68.3 A. H., Marks, J. S., Stroup, D. F., etÂ€al. (2004). Actual causes of
Gain in years 10.0 12.6 8.5 10.9 death in the United States, 2000. Journal of the American Medical
Association (JAMA), 291(10), 1238-1245. Erratum in JAMA, 2005,
Data from U.S. Census Bureau. (2011). Statistical abstract of the 293(3), 293-294, 298.
United States, 2011: The national data book (130th ed.). Washington,
DC: U.S. Government Printing Office.
TABLEÂ€7-4â•…â•‡DEATHS AND DEATH RATES FOR 1992, 1998, AND 2007 FOR THE 15 LEADING
CAUSES OF DEATH: UNITED STATES
RANK NUMBER OF DEATH RATE DEATH RATE RANK DEATH RATE RANK
2007 CAUSE OF DEATH DEATHS 2007 2007 1998 1998 1992 1992
All Causes 2,423,712 803.6 864.7 853.3
â•‡1 Diseases of heart 616,067 204.3 268.2 1 282.5 1
â•‡2 Malignant neoplasms 562,875 186.6 200.3 2 204.3 2
â•‡3 Cerebrovascular diseases 135,952 45.1 58.6 3 56.3 3
â•‡4 Chronic lower respiratory 127,924 42.4 — — — —
diseases
Chronic obstructive pulmonary — — 41.7 4 35.8 4
diseases and allied conditions
â•‡5 Accidents (unintentional injuries) 123,706 41.0 35.4 5 33.8 5
â•‡6 Alzheimer disease 74,632 24.7
â•‡7 Diabetes mellitus 71,382 23.7 24.0 7 19.7 7
â•‡8 Influenza and pneumonia 52,717 17.5 34.0 6 29.8 6
â•‡9 Nephritis, nephrotic syndrome 46,448 15.4 9.2 10 8.8 12
and nephrosis
10 Septicemia 34,828 11.5 8.8 11 7.8 13
11 Intentional self-harm (suicide) 34,598 11.5 11.3 8 11.7 9
12 Chronic liver disease and 29,165 9.7 9.3 9 9.7 11
cirrhosis
13 Essential hypertension and 23,965 7.9 — — — —
hypertensive renal disease1
Atherosclerosis — — 5.7 14 6.3 14
14 Parkinson disease 20,058 6.7 — — — —
15 Assault (homicide) 18,361 6.1 6.8 13 10.4 10
Other infectious and parasitic — — 7.5 12 — —
diseases
Human immunodeficiency virus — — 4.8 15 13.2 8
infection
1
Cause-of-death title was changed in 2006 to reflect addition of secondary hypertension.
Data from: U.S. National Center for Health Statistics, Health, United States, 2009, and Xu, J., Kochanek, M. A., Murphy, S. L., etÂ€al. (2010). Deaths,
final data for 2007. National Vital Statistics Reports, 58(19). See also http://www.cdc.gov/nchs/hus.htm.
homicide (the tenth cause in 1992) had slipped to number 15; include advancing age and family history. Men have higher rates
suicide (the ninth cause in 1992) dropped to number 11; influ- of coronary heart disease than premenopausal women, but rates
enza and pneumonia dropped from sixth to eighth; and human for women after menopause become similar to those for men,
immunodeficiency virus (HIV) infection (the eighth cause in and risk for stroke is comparable in women and men. Other risk
1992) dropped out of the top 15 causes of death. Deaths from factors include psychosocial stress and low socioeconomic status.
Alzheimer and Parkinson diseases appeared in the ranking of
leading causes in 2007 at numbers 6 and 14, respectively. When Cancer
the 1992 and 2007 data are compared, it appears that the United About 11.7 million Americans who were alive in 2007 had a his-
States has made some progress in reducing influenza, pneu- tory of cancer, but over half of these were diagnosed 5 or more
monia, HIV deaths, and deaths by suicide and homicide. In years earlier and were considered cured (generally defined as
the meantime, deaths resulting from chronic diseases (diabe- being symptom free for 5â•›years after treatment); others still had
tes, Alzheimer and Parkinson diseases, and nephritis, nephrotic cancer diagnoses and may have been being treated (American
syndrome, and nephrosis) and from septicemia have risen. Cancer Society [ACS], 2011). For some types of cancer, a person
is considered cured after a shorter period, but for other forms
Heart Disease and Stroke follow-up may be required for a longer time.
In 2007, over 750,000 Americans died of diseases of the heart In 2011, the American Cancer Society (ACS) expected more
and stroke. More than 300 risk factors have been associated with than 2 million cases of basal and squamous cell skin cancer
cardiovascular disease, but in developed countries, over a third and 1,596,670 cases of other new cancers to be diagnosed, and
of cardiovascular disease can be attributed to five major risk about 571,950 deaths from cancer (more than 1500 per day)
Â�factors: (1) tobacco use, (2) alcohol use, (3) high blood pressure, (ACS, 2011). According to the ACS, the cancer mortality rate
(4)Â€high cholesterol level, and (5) obesity (Mackay & Mensah, in the United States has risen steadily since the mid-1940s and
2004). Other modifiable risk factors include lack of physical cancer is now the second largest cause of mortality, accounting
activity, a diet low in fruits and vegetables and high in saturated for almost 1 in 4 deaths. Major increases have occurred in both
fat, and diabetes mellitus. High levels of total cholesterol, low- male and female death rates due to lung cancer, whereas rates
density lipoprotein cholesterol, and triglycerides, and low lev- for cancer at other sites have declined or leveled off (FiguresÂ€7-9
els of high-density lipoprotein cholesterol increase risk for both and 7-10). By 1990, lung cancer had surpassed breast cancer as
coronary heart disease and stroke. Nonmodifiable risk factors the leading cause of cancer death in women.
Age-Adjusted Cancer Death Rates,* Females by Site, United States, 1930-2007

100
80
Rate per 100,000 Female Population
60
Uterus† Lung and bronchus

Breast
40
Stomach Colon and rectum

20
Ovary Pancreas
0
1930 1940 1950 1960 1970 1980 1990 1999 2007
*Per 100,000, age-adjusted to the 2000 U.S. standard population. †Uterus cancer death rates are for uterine cervix and uterine corpus combined.
Note: Due to changes in ICD coding, numerator information has changed over time. Rates for cancers of the liver, lung and bronchus, colon
and rectum, and ovary are affected by these coding changes.
*Age adjusted death rate for stomach cancer based on patient deaths in 2003-2007.
FIGUREÂ€7-9â•‡Age-adjusted cancer death rates for women by cancer site, United States, 1930 to
2007. (Data from U.S. Mortality Public Use Data Tapes 1960–1999, U.S. Mortality Volumes 1930–1959, Centers
for Disease Control and Prevention [CDC], National Center for Health Statistics, 2002; and U.S. Cancer Statistics
Working Group. [2010]. United States cancer statistics: 1999-2007 incidence and mortality; Web-based report.
Atlanta: U.S. Department of Health and Human Services, CDC, and National Cancer Institute.)
Age-Adjusted Cancer Death Rates,* Males by Site, United States, 1930-2007

100
Lung and bronchus
80
Rate per 100,000 Male Population
60
Stomach
Prostate
Colon and rectum
40
20
Pancreas
Leukemia
Liver
0
1930 1940 1950 1960 1970 1980 1990 1999 2007
*Per 100,000, age-adjusted to the 2000 U.S. standard population.

Note: Due to changes in ICD coding, numerator information has changed over time. Rates for cancers of the liver, lung
and bronchus, colon and rectum are affected by these coding changes.
*Age adjusted death rate for stomach cancer based on patient deaths in 2003-2007.
FIGUREÂ€7-10â•‡Age-adjusted cancer death rates for men by cancer site, United States, 1930 to
2007. (From U.S. Mortality Public Use Data Tapes 1960–1999, U.S. Mortality Volumes 1930–1959, Centers for
Disease Control and Prevention [CDC], National Center for Health Statistics, 2002; and U.S. Cancer Statistics
Working Group. [2010]. United States cancer statistics: 1999-2007 incidence and mortality; Web-based report.
Atlanta: U.S. Department of Health and Human Services, CDC, and National Cancer Institute.) Retrieved June
24, 2011 from http://apps.nccd.cdc.gov/uscs/.
In 2011, almost 7 out of 10 persons (68%) diagnosed with losses associated with cigarette smoking amount to over $301
cancer are expected to survive for the relative 5-year time frame billion annually (Rumberger etÂ€al., 2010).
after treatment. This number represents a gain from 1 in 5
(20%) in the 1930s and 1 in 3 (30%) in the 1960s. The improved Human Immunodeficiency Virus Disease (HIV)
survival rate is used to document progress in early detection Acquired immunodeficiency syndrome (AIDS) was first
and treatment. reported in the United States in June 1981. By 1987, there were
The importance of prevention should not be underesti- 50,000 reported cases of AIDS. That number reached 197,060
mated. Research suggests that “regular screening examinations by 1994, and the cumulative total through 2007 was 470,902
by a health care professional can result in the detection of … persons with AIDS reported to the CDC by state and local
cancers of the breast, colon, rectum, cervix, prostate, oral cavity, health departments (U.S. Census Bureau, 2011). The CDC esti-
and skin” at earlier stages, when treatment is more likely to be mates that even more Americans—over one million—are living
successful (ACS, 2011, p. 1). Individuals with these cancers rep- with HIV infection, and one in five of these (21%) is unaware
resent over one half of clients with recent cancer diagnoses, of of his or her status; over 600,000 have died of the disease (CDC,
whom 80% are expected to survive 5â•›years. With early detection, 2010b; CDC, 2011b).
the survival rate can increase to over 95%. Many skin cancers TableÂ€7-5 shows selected characteristics of persons living
can be prevented with protection from ultraviolet radiation in with AIDS in 1994, 2000 and from 2004, to 2007. Use the table
sunlight (both ultraviolet A and ultraviolet B rays), and cancer to answer the following questions:
from cigarette smoking and heavy alcohol use can be completely • What can you say about the rate of increase in persons living
prevented. The ACS estimates that obesity causes about 15% to with AIDS acquired from heterosexual exposure for men and
20% of cancer deaths (239,000 to 319,000 premature deaths) women?
annually, while cigarette smoking causes approximately 30% • What can you say about the numbers of persons living with
of cancer deaths (479,000 premature deaths) annually, mostly AIDS based on race or ethnicity?
from lung and other cancers, ischemic heart disease, stroke, Answers to the preceding questions are as follows:
and chronic obstructive lung disease. Health-related economic Although this table does not give rate information, you can
TABLEÂ€7-5â•…â•‡ESTIMATED PERSONS LIVING WITH ACQUIRED IMMUNODEFICIENCY SYNDROME

BY SELECTED CHARACTERISTICS: 1994, 2000, AND 2004-2007
CHARACTERISTIC 1994 2000 2004 2005 2006 2007
Total
1,2
197,060 322,242 411,089 432,029 451,837 470,902
Race/Ethnicity
White, non-Hispanic 86,417 119,172 143,338 149,107 154,770 160,010
Black, non-Hispanic 71,818 132,104 174,479 183,930 192,793 201,404
Asian/Pacific Islander 1,457 2,498 3,834 4,191 4,564 5,011
Native American/Alaska Native 668 1,073 1,462 1,563 1,632 1,698
Hispanic3 36,448 64,833 84,427 89,415 94,100 98,726
Male Adult/Adolescent Exposure Category

Male total 161,081 250,315 314,618 329,884 344,370 358,332
Men who have sex with men 94,694 143,390 186,036 196,868 207,551 218,136
Injection drug use 40,046 58,238 64,651 65,716 66,509 67,121
Men who have sex with men and 14,884 24,968 28,510 29,248 29,771 30,196
injectÂ€drugs
High-risk heterosexual contact4 7,903 20,839 32,153 34,671 37,065 39,353
Other5 3,554 2,880 3,267 3,381 3,474 3,527
Female Adult/Adolescent Exposure Category

Female total 32,702 68,015 92,443 98,101 103,447 108,756
Injection drug use 16,244 28,212 32,824 33,684 34,314 34,845
Heterosexual contact4 15,131 38,131 57,368 62,037 66,626 71,088
Other5 1,327 1,671 2,250 2,380 2,506 2,643
Child (less than 13 yrs at 3,277 3,912 4,028 4,044 4,021 3,992
diagnosis)
1
Includes persons of unknown or multiple race and of unknown sex. Because column totals were calculated independently of the values for the
subpopulations, the values in each column may not sum to the column total.
2
Persons who reported multiple racial categories or whose race was unknown are included in the total numbers.
3
Hispanics can be of any race.
4
Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
5
Includes hemophilia, blood transfusion, perinatal, and risk not reported or identified.
Data from: U.S. Census Bureau. (2012). Statistical abstract of the United States, 2012 (131st ed.). Washington, DC: U.S. Government Printing
Office. http://www.census.gov/statab/www/; and U.S. Census Bureau. (2007). Statistical abstract of the United States, 2007 (126th ed.).
Washington, DC: U.S. Government Printing Office.
see that the increase in AIDS cases from heterosexual contact Accidents and Unintentional Injuries
is Â�dramatic—from 23,034 men and women in 1994 to 110,441 In the United States, unintentional injuries are a cause of
in 2007. Women appear to be more vulnerable to contract- death, but these injuries are largely preventable (TableÂ€7-6).
ing HIV from heterosexual contact. Throughout the 1980s Considerable progress has been made in reducing deaths by
and 1990s, there were more whites than persons of other racial motor vehicle accidents by using a multiphase incremental
or ethnic groups living with AIDS, but in 2000, the number strategy. The plan included legislative, educational, and pub-
of blacks living with AIDS surpassed the number of whites, lic service efforts (see ChapterÂ€16). Legislation was passed
and this number continued to increase by an additional 52% mandating seat belt use, use of child safety seats, and the
between 2000 and 2007. The number of Hispanics living with judicious use of alcohol by drivers. Other actions included
AIDS has almost tripled since 1994. Minority groups also media public education advertisements promoting the use of
carry a heavier burden from AIDS in terms of the percentage child safety seats and discouraging alcohol use when driving.
of the total populationÂ€affected. Private agencies sponsored loaner seat programs in which
The expanded surveillance case definition of AIDS in 1993 parents who were unable to afford car seats were loaned age-
substantially increased the number of reported AIDS cases. appropriate seats.
Laboratory-initiated reporting increased from 39% of reported Drowning and fires are the other most frequent causes of
cases in 1993 to 57% of cases in 1996 (CDC, 1997b). The intro- injury-related deaths. Injuries due to fire in 2005 to 2009 were
duction of triple-drug combination antiretroviral therapy in mainly attributed to fires caused by cooking, other uninten-
1996 is thought to be largely responsible for the subsequent tional carelessness, electrical malfunctions, use of open flames,
dramatic reduction in the death rate from AIDS. HIV/AIDS smoking, and equipment misoperation and failure (U.S. Fire
dropped from the first to the second leading cause of death for Administration, 2010).
persons aged 25 to 44 in 1996, to the fifth leading cause of death
in 1998, and to the sixth leading cause of death in this age group Emerging Infectious Diseases: Viral Epidemics
in 2007 (CDC, 2010b). Additional information about HIV can Some researchers point to airborne virus–caused epidemics
be found in ChapterÂ€8. (outbreaks of infection affecting a larger number of people
TABLEÂ€7-6â•…â•‡ DEATHS AND DEATH RATES FROM ACCIDENTS BY TYPE: 1980-2007

DEATHS (NUMBER) RATE PER 100,000 POPULATION
TYPE OF ACCIDENT 1980 1990 2000 2001 2007 1980 1990 2000 2001 2007
Total 105,798 91,983 97,900 101,537 123,706 46.7 37.0 34.8 35.7 41.0
Motor vehicle traffic 53,172 46,814 43,354 43,788 43,945 23.5 18.8 15.7 15.4 14.6
Other land transport N/A N/A 1,492 1,493 1,800 N/A N/A 0.5 0.5 0.6
Other transport (water, air, and space) 2,923 1,864 1,903 4,435 1,039 N/A N/A 0.7 1.6 0.3
Accidental falls 13,294 12,313 13,322 15,019 22,631 5.9 5.0 4.8 5.3 7.5
Accidental drowning 6,043 3,979 3,482 3,281 3,443 2.7 1.6 1.3 1.2 1.1
Smoke, fire, and flames 5,822 4,175 3,377 3,309 3,286 2.6 1.7 1.2 1.2 1.1
Firearms, unintentional 1,667 1,175 776 802 613 0.7 0.5 0.3 0.3 0.2
Accidental poisoning 4,331 5,803 12,757 14,078 29,846 N/A N/A 4.6 4.9 9.9
Complications of medical & surgical care 2,282 2,669 3,059 3,021 2,597 1.0 1.1 1.1 1.1 0.9
N/A, Not available.
Effective with deaths occurring in 1999, the United States began using the Tenth Revision of the International Classification of Diseases (ICD). For
earlier years, causes of death were classified according to the revisions then in use, e.g., the Ninth Revision for 1979-1998.
Data from: U.S. National Center for Health Statistics. (2010). National vital statistics reports; Deaths, final data for 2007, 58(19), and Vital statistics
of the United States, annual; and U.S. Census Bureau. (2011). Statistical abstract of the United States, 2011 (130th ed.). Washington, D.C.: U.S.
Government Printing Office.
than would be expected, all at the same time) and pandemics HEALTH PROFILES OR STATUS AND THE LIFE CYCLE
(outbreaks affecting extremely high numbers of people, usu-
ally in many countries) as the major health threat of this cen- Certain health risks and behavior patterns are associated with
tury. Epidemics of viral diseases, such as avian influenza and selected age groups. A brief overview of health risks, morbidity,
severe acute respiratory syndrome (SARS), are particularly and mortality information especially pertinent to selected age
problematic because they are difficult to treat. SARS, a respi- groups is presented here.
ratory illness first reported in Asia in February 2003, spread
worldwide and tested the global response to an epidemiologi- Patterns of Mortality and Morbidity during
cal health crisis. Most of the U.S. cases occurred in travelers PregnancyÂ€and Infancy
returning from other parts of the world. The CDC listed only The health status of the infant cannot be separated from that of
177 reported cases and no SARS-related deaths in 2003 (CDC, the mother. Prenatal problems and problems that are present in
2003). In 2009, the H1N1 avian influenza pandemic tested the the period immediately following birth are discussed together.
level of preparedness and response both worldwide and in the The infant mortality rate, because of its sensitivity, is
United States again. The 2009 H1N1 influenza virus was first one of the most widely used statistics in evaluating the over-
detected in the U.S. in April 2009 and that same month the all improvement in health in the United States. It is also used
CDC activated its Emergency Operations Center and the WHO in making comparisons with other countries (see ChapterÂ€5).
declared the outbreak a pandemic in June 2009 (CDC, 2010c). Traditionally, the high rate of infant mortality has been viewed
By August 8 there were 477 deaths from lab-confirmed H1N1 as an indicator of unmet health needs and unfavorable envi-
influenza. In the U.S., federal, state, and local health officials ronmental conditions. The infant mortality rate has steadily
worked together to track the spread of the disease, respond to declined, dropping from 29.2 per 1000 live births in 1950 to 6.8
health professionals and the public with guidance and antivi- per 1000 live births in 2007 (U.S. Census Bureau, 2011). In 2007,
ral drugs, and develop and disseminate a vaccine by the fall 29,138 actual infant deaths occurred (MacDorman & Mathews,
of 2009, particularly targeting the population with the highest 2011). Although the infant death rate for the United States has
overall attack rate, children ages 5 to 14. Both SARS and avian improved, it is still higher than that of other industrialized
influenza are reminders that community health personnel will countries (see ChapterÂ€3).
need to be especially vigilant and quick to identify any new epi- The disparity in the death rates between minority and
demic in the future. majority populations is quite large. For white infants, the
Organizations such as the WHO and the CDC are work- mortality rate was 5.6 per 1000 live births (560 per 100,000)
ing together to monitor cases of avian influenza in Southeast compared with 13.2 per 1000 live births for black infants (U.S.
Asia and to establish procedures to contain the spread of such Census Bureau, 2011). FigureÂ€7-11 compares infant deaths by
potentially contagious diseases. Because more health care is cause of death for 1980 and 2007. Examine this graph to com-
being delivered in community health care settings rather than pare the changes in the leading causes of infant death between
in acute care hospitals, the Public Health Service updated its 1980 and 2007. Four causes account for more than 50% of
Guideline for Isolation Precautions: Preventing Transmission of all infant deaths: congenital anomalies, conditions related to
Infectious Agents in Healthcare Settings in 2007 to incorporate short gestation and low birth weight, sudden infant death syn-
recommendations that can be applied in home, ambulatory, drome, and maternal complications. Between 1980 and 2004,
and long-term care settings, and to address emerging infectious deaths due to congenital anomalies decreased but deaths due
diseases and renewed interest in multidrug-resistant organisms to short gestation and low birth weight and maternal com-
(Siegel etÂ€al., 2007). plications increased as a percentage of total infant mortality.
Cause of Death: 1980
Congenital anomalies
All other
Intrauterine Short gestation/

hypoxia and birth low birth weight
asphyxia
Placenta, cord,
and membrane Respiratory distress
complications
Accidents
Maternal complications
Perinatal period infections
Cause of Death: 2007
Congenital anomalies
(5,785)
All other
(9,024)
Diseases of the Short gestation/
circulatory system low birth weight
(624) (4,857)
Neonatal
hemorrhage (597)
Bacterial sepsis
newborn (820) Sudden infant death
syndrome (2,453)
Respiratory distress (789)
Placenta, cord, and
membrane complications
Maternal complications
(1,135)
(1,769)
Accidents (1,285)
FIGUREÂ€7-11â•‡ Causes of infant mortality: comparison of 1980 and 2007 (deaths of infants under
1â•›year old per 1000 live births; excludes deaths of nonresidents of the United States; 1980 deaths
classified according to the ninth revision of the International Classification of Diseases [ICD],
and 2007 deaths classified according to the tenth revision of the ICD). (Data from National Center
for Health Statistics. Xu, J., Kocharek, K. D., Murphy, S. L., etÂ€al. [2010]. Deaths: Final data for 2007. National
Vital Statistics Reports, 58 [19], p. 14; and National Center for Health Statistics, Vital Statistics of the United
States, annual, Monthly Vital Statistics Reports, and unpublished data.)
Changes over time in the classification of infant deaths make measles, pneumonia, and whooping cough have been virtually
it difficult to compare the percentage of deaths due to respira- eliminated in this country through immunizations. Worldwide,
tory distress, sudden infant death syndrome, or both. millions of children still die each year from vaccine-Â�preventable
Low birth weight is associated with several preventable diseases or ineffective treatment of infectious diseases (see
causes, including lack of prenatal care, maternal infection, ChapterÂ€5).
maternal smoking, maternal use of alcohol and drugs, poor
maternal nutrition, and pregnancy before the age of 18â•›years. Deaths in Childhood
Lower socioeconomic and educational levels are also often The leading causes of death in children are presented in
associated with low birth weight (see ChapterÂ€21). An expect- TableÂ€7-7. From 1977 to 1989 the significant drop in the child-
ant mother who receives no prenatal care is three times more hood death rate (23%) was attributed mostly to the mandatory
likely to give birth to a low-birth-weight infant. Poor prenatal use of motor vehicle safety restraints for young children in all
care is compounded by poverty and is one reason why Healthy 50 states and the increased use of seat belts. Since then, properly
People 2020 emphasizes improvements in prenatal care and tar- used safety seats and air bags have decreased childhood deaths.
gets high-risk groups (adolescents and poor women) for con- Nonetheless, 36% of unintentional injuries result from motor
centrated intervention. vehicle accidents (see TableÂ€7-6), which are the leading cause of
death in children in the United States. In 2008, 968,000 deaths
Patterns of Mortality and Morbidity in Childhood in children 14â•›years and younger were caused by motor vehicle
Because of public health measures, the rate of childhood deaths accidents. Almost half of children who died did not have safety
in the United States has dramatically declined since the mid- restraints, and over two thirds of motor vehicle–related child
1950s. Infectious diseases such as polio, diphtheria, scarlet fever, fatalities involved a drinking driver (CDC, 2011c).
TABLEÂ€7-7â•…â•‡ LEADING CAUSES OF DEATH IN CHILDREN: 2007 (IN THOUSANDS)

RANK CAUSE TOTAL 1-4 YEARS 5-14 YEARS
â•‡1 Unintentional injury 3,782 1,588 2,194
â•‡2 Malignant neoplasms 1,323 364 959
â•‡3 Congenital anomalies 920 546 374
â•‡4 Homicide 744 398 346
â•‡5 Diseases of heart 414 173 241
â•‡7 Suicide 184 — 184
â•‡6 Pneumonia and influenza 212 109 103
â•‡8 Chronic lower respiratory 175 57 118
â•‡9 Septicemia 152 78 74
10 Certain conditions originating in the perinatal period 92 70 22
Data from: U.S. National Center for Health Statistics. (2010). National Vital Statistics Reports (NVSR) Deaths: Final data for 2007, 58(19).
Washington, DC: U.S. Government Printing Office.
Illness in Childhood Take a moment to review the pie graph. What are the third
Infectious diseases such as recurrent tonsillitis, recurrent ear and fourth most common causes of death in this age group?
infections, mononucleosis, hepatitis, meningitis, bladder or uri- Homicide is the third leading cause of death in this age group
nary tract infections, diarrhea or colitis, rheumatic fever, and and the leading cause of death for black boys and young men.
pneumonia remain an important morbidity problem in child- The rate for black men aged 15 to 24â•›years was over ten times the
hood. In addition, in 1993 and 2001, the American Academy rate for white men in this age group in 2007, and still ten times
of Pediatrics (AAP) identified new childhood morbidities that greater when homicide rates for black and white men of all ages
should be addressed, including behavioral and mood problems, are compared (MMWR, 2011a). Race is not as important a risk
learning disabilities and other school-related problems, vio- factor, however, when socioeconomic characteristics are taken
lence, drug and alcohol use/abuse, and the behavioral effects of into account. Suicide is the fourth leading cause of death in this
media exposure (AAP, 2001). age group.
Childhood obesity is one example of morbidity that is of Are the causes of death different for men and women in
increasing concern. The number of children and adolescents this age group? FigureÂ€7-13 does not differentiate the sexes.
who are overweight was relatively stable from the 1960s to Go directly to the website for the National Center for Health
1980. However, as tracked by successive NHANES studies, the Statistics to answer this question. The data show that women
prevalence of overweight children and adolescents nearly dou- of all races have relatively lower suicide rates than do men
bled between 1980 and 1995. Results from the 2007 and 2008 (MMWR, 2011b).
NHANES (NHANES VII) indicate that 19.6% of children aged Other major health problems of this age group, such as can-
6 to 11â•›years and 18.1% of adolescents aged 12 to 19â•›years are cer and heart disease, are overshadowed by unintentional injuries,
obese—up from 15% in 1999 (FigureÂ€7-12). The CDC (2006) homicide, and suicide. However, during this period, young peo-
implicated poor diet and lack of exercise as causes, which is con- ple develop habits that have importance for health in later years.
sistent with a national trend across age groups. Lifestyle patterns related to nutrition, physical fitness and exer-
Healthy development in childhood is a primary concern. cise, cigarette smoking and drug use, safety, and sexual conduct
Developmental problems and chronic physical conditions are emerge during this period and help determine the rate of future
on the rise in this age group, and children living in poverty are chronic illness as this cohort ages. For example, substance use
at higher risk. Hearing and speech impairment, lead poison- and abuse, often initiated in young adulthood, persists until other
ing, and emotional and learning disorders are significant issues. health concerns arise. About 85% of adults who smoke started
Prevention efforts aimed at establishing healthy parenting pri- by age 21, and one in five high school students reported smok-
orities, improving environmental conditions, and promoting ing in the past month (American Lung Association, 2010). Even
healthy habits can improve the health profiles of children in all though the overall percentage of people who smoke has declined
of these problem areas. from 48% in 1965 to 23.2% of men and 19.5% of women in 2009,
these numbers are still significant (FigureÂ€7-14). Educational level
Patterns of Mortality and Morbidity in Adolescents is a predictive factor for smoking. In 2011, adults with less than
andÂ€Young Adults 12â•›years of education were almost three times as likely to smoke as
For individuals between 15 and 24â•›years of age, unintentional those with a bachelor's degree or higher (CDC, 2011d). Between
injuries, most of which involve motor vehicles, are responsible 1991 and 1993 and 2007 and 2008, binge drinking in high school
for about 47% of deaths (FigureÂ€7-13). Alcohol is involved in students decreased moderately in males but remained relatively
35% of fatal accidents (Alcohol Alert, 2010). Mortality rates constant in females, and marijuana use increased markedly in
for adolescents and young adults are rising again after declin- both male and female ninth- to twelfth-graders. In 2008, among
ing in the early 1980s, when raising the minimum drinking 12 to 17-year-olds, 14.2% of males and 15% of females reported
age resulted in fewer motor vehicle accident–related deaths. alcohol use in the previous 30â•›days, and 7.3% of males and 6%
The upward trend in mortality that began in the mid-1980s is of females reported marijuana use in the previous 30â•›days (CDC,
believed to be related in part to the increase in the speed limit 2010a). Alcohol and drug use continue to be significant problems
on rural interstate highways and inconsistent use of seat belts. and are major contributors to accidents and violence.
70
Overweight & obese, 20-74 years

60
50
40
Percentage
Overweight, not obese, 20-74 years
30
Obesity, 20-74 years
20
Obesity, 6-11 years
10
Obesity, 12-19 years

0
1960- 1963- 1966- 1971- 1976- 1988- 1999- 2001- 2003- 2005- 2007-
62 65 70 74 80 94 2000 2002 2004 2006 2008
Year
Obesity Obesity
Clarification 6–11 y/o 12–19 y/o
1963-1965 4.2 —
1966-1970 — 4.6
1971-1974 4.0 6.1
1976-1980 6.5 5.0
1988-1994 11.3 10.5
1999-2000 15.1 14.8
2001-2002 16.3 16.7
2003-2004 18.8 17.4
2005-2006 15.1 17.8
2007-2008 19.6 18.1
FIGUREÂ€7-12â•‡Overweight and obesity trends among U.S. children and adults, 1960 to 2008.
(From National Health Examination Survey and National Health and Nutrition Examination Survey; Centers
for Disease Control and Prevention, National Center for Health Statistics: Health E-stats. [2010] and Ogden,
C. L., and Carroll, M. D. [2010]. Prevalence of overweight, obesity, and extreme obesity among adults: United
States, trends 1960-1962 through 2007-2008. Retrieved June 27, 2011 from http://www.cdc.gov/nchs/data/
hestat/obesity_adult_07_08/obesity_adult_07_08.htm; and Ogden, C. L., and Carroll, M. [2010]. Prevalence of
obesity among children and adolescents: United States, trends 1963-1965 through 2007-2008. Retrieved June
27, 2011 from http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm.)
Unintended pregnancies and sexually transmitted diseases Patterns of Mortality and Morbidity in Adults
present health risks in this population. Estimates indicate that Nearly all of the major health problems faced by people
46% of high school students have engaged in sexual inter- between 25 and 65â•›years of age are preventable, totally or in
course (MMWR, 2011c). Over 80% of all teenage mothers did part, through lifestyle or environmental changes. Personal
not intend to become pregnant (MMWR, 2011d). ChapterÂ€24 responsibility for maintaining health is paramount. For exam-
addresses adolescent sexual activity, pregnancy, and their rela- ple, the dramatic decline in heart disease, strokes, and, to a
tionship to health and economic status. lesser extent, accidents in this age group since 1970 is associ-
Prevention through health education and role modeling is ated with reduced cigarette smoking, lower blood cholesterol
important for this age group. However, education alone does levels, increased control of high blood pressure, decreased alco-
not bring about the desired changes in behavior. Motivational hol consumption, increased (mandatory) seat belt use, lower
counseling and adequate support, especially for high-risk speed limits, and the availability of air bags in automobiles.
groups, is necessary to further reduce the health and social risks The public's awareness of the relationship between risk and
of alcohol and drug abuse, school failure, delinquency, violence, health has influenced social norms. Reduced public acceptance
and unwanted pregnancy, and the risk of development of future of risks related to smoking has been the impetus for establish-
chronic disease. ment of antismoking laws and creation of smoke-free work
2007: 33,982 deaths Cancer has become the leading cause of death for individ-
Heart uals 45 to 64â•›years of age as deaths from heart disease have
Cancer disease decreased (TableÂ€7-8). Although overall mortality rates for can-
cer have changed little since the mid-1950s, significant changes
have occurred in some age groups and for selected cancers.
Suicide Further changes are believed possible. For example, estimates
suggest that smoking is responsible for 30% of cancer deaths,
and another one third (such as colon cancer) are thought to
be associated with diet. Both of these cancers can be decreased
Homicide through reduction of risky behaviors and aggressive screening.
Unintentional
injuries Screening and early diagnosis of breast and cervical cancer also
have improved the survival rates of women with these cancers
(ACS, 2011).
Preventing many of the chronic diseases affecting this age
group is dependent on individual actions, including risk reduc-
All other* tion, participation in screening efforts, and prompt attention to
causes signs and symptoms to ensure early diagnosis and treatment.
All health care providers are challenged to empower individuals
*Other includes congenital malformations, deformations, and to develop or modify lifestyle patterns that maintain health and
chromosomal abnormalities; chronic lower respiratory disease;
HIV; septicemia, diabetes mellitus, influenza and pneumonia, prevent disease. Individual responsibility is not the only factor
and preumonitis due to solids and liquids. affecting health. The environment, workplace standards, socio-
FIGUREÂ€7-13â•‡ Causes of death among adolescents and young economic status, media images, educational level, and access
adults aged 15 to 24 years, 2007. (Data from Centers for Disease to information and health care are all powerful influences that
Control and Prevention, National Center for Health Statistics. [2010]. affect adult behavior and choices that support health. Healthy
Deaths among persons 15-24â•›years of age. In Health, United States, People 2020 recognizes the influence of both physical and social
2010, with chartbook on trends in the health of Americans. Washington,
environmental determinants of health on individual health
DC: U.S. Government Printing Office.)
behaviors.
60 Patterns of Mortality and Morbidity in Older Adults
Men
High school students The proportion of persons older than 65â•›years will continue
Students in grade 9-12 to increase, with the over-85 cohort showing the most rapid
50 who smoked cigarettes
on 1 or more of the 30 days growth. Individuals reaching 65â•›years of age now can expect
preceding the survey to live into their early eighties. The substantive question facing
40 these individuals, however, is not so much the question of liv-
Women ing as the question of the quality of their remaining years of life.
Percentage
Even in this age group, increasing evidence suggests that some

30 lifestyle changes can result in major health and quality-of-life
Men and women 18 years
benefits. The outcomes of the top three causes of death—heart
of age and older who ever
smoked at least 100 cigarettes disease, cancer, and stroke (TableÂ€7-9)—can still be altered. For
20
and now smoke every day or example, older smokers who quit smoking increase their life
some days expectancy, reduce the risks associated with heart disease, and
10 Mothers during pregnancy improve circulation and respiratory functioning. Eating a nutri-
Mothers with a live birth who tionally balanced diet, reducing weight, and decreasing sodium
smoked cigarettes during
intake can reduce the risk of heart disease and promote the
pregnancy
0 maintenance of elder health.
Chronic neurological, musculoskeletal, and other problems
1965
1970
1975
1980
1985
1990
1995
2000
2003
2005
2007
2009
such as arthritis and osteoporosis, visual and hearing impair-

Year ments, incontinence, digestive conditions, and dementia are all
FIGUREÂ€7-14â•‡Smoking patterns among men, women, high concerns of this age group. Because of the impact of illness on
school students, and mothers during pregnancy: United day-to-day living, disease prevention and preservation of func-
States, 1965 to 2009. (Redrawn from Centers for Disease Control tion are desirable. Pain can affect function and is often under-
and Prevention, National Centers for Health Statistics. [2010]. Cigarette
smoking among students in grades 9-12 and adults 18â•›years of age and
managed in older adults (Ebersole etÂ€al., 2008).
over, by sex, grade and age: United States, 1999-2009. In Health, United A key to physiological decline is lack of physical activity
States, 2010, with chartbook on trends in the health of Americans. (FigureÂ€7-15). A large portion of this age group (40% to 60%)
Washington, DC: U.S. Government Printing Office.) reports no participation in leisure-time physical activity. Fewer
than one third report participating in some leisure-time activ-
environments. Increased concern about drinking while driv- ity, such as walking or gardening, and fewer than 12% of men
ing has launched movements such as Mothers Against Drunk and 9% of women report participating in regular leisure-time
Drivers and has resulted in tougher regulations related to blood activities that met 2008 federal physical activity guidelines
alcohol levels, stiffer penalties for driving while intoxicated, (CDC, 2010a). Regular aerobic and muscle-strengthening phys-
and raising of the drinking age. ical activity are associated with reduced incidence of coronary
TABLEÂ€7-8â•…â•‡DEATHS AND DEATH RATES FOR THE LEADING CAUSES OF DEATH IN SPECIFIED
AGE GROUPS: UNITED STATES, 2007*
RANK CAUSE OF DEATH† NUMBER RATE
Aged 25 to 44â•›years
All causes 122,178 145.9
1 Unintentional injury 31,908 38.1
2 Malignant neoplasms (cancer) 16,751 20.0
3 Diseases of heart 15,062 18.0
4 Suicide 12,000 14.3
5 Homicide 7,810 9.3
6 Human immunodeficiency virus (HIV) disease 4,663 5.6
7 Other 33,984 —
Aged 45 to 64â•›years
All causes 471,796 616.0
1 Malignant neoplasms 153,338 200.2
2 Diseases of heart 102,961 134.4
3 Unintentional injury 32,508 42.4
4 Diabetes mellitus 17,057 22.3
5 Chronic lower respiratory tract diseases 16,930 22.1
6 Cerebrovascular diseases 16,885 22.0
7 Other 132,117 —
*Data are based on a continuous file of records received from the states. Rates are per 100,000 population in the specified group. Figures are
based on weighted data rounded to the nearest individual, so categories may not add to totals.
†
Based on the International Classification of Diseases, tenth revision (1992).
Data from: Centers for Disease Control and Prevention, National Centers for Health Statistics. (2010). Health, United States, 2010, with chartbook
on trends in the health of Americans. Washington, DC: U.S. Government Printing Office.
TABLEÂ€7-9â•…â•‡LEADING CAUSES OF DEATH 65 years Women

OF ADULTS 65 YEARS AND and over
Men
OLDER, 2007
45-64
RANK CAUSE NUMBER RATE years
All causes 1,755,567 4,633.6 18-44

1 Diseases of the heart 496,095 1,309.4 years
2 Malignant neoplasms (cancer) 389,730 1,028.6
3 Cerebrovascular diseases 115,961 306.1 0 5 10 15 20 25 30
4 Chronic lower respiratory tract 109,562 289.2 Percentage
diseases FIGUREÂ€7-15â•‡Adults participating in leisure-time aerobic and
5 Alzheimer disease 73,797 194.8 muscle-strengthening activities that meet the 2008 federal
6 Diabetes mellitus 51,528 136.0 physical activity guidelines for adults 18 years of age and over,
7 Influenza and pneumonia 45,941 121.3 by sex and age, United States, 2009. (Redrawn from Centers for
8 All other causes 472,953 — Disease Control and Prevention, National Center for Health Statistics.
[2010]. Adults engaging in leisure-time physical activity by age and sex:
Data are based on a continuous file of records received from the United States. In Health, United States, 2010, with chartbook on trends
states. Rates are per 100,000 population in the specified group. in the health of Americans. Washington, DC: U.S. Government Printing
Figures are based on weighted data rounded to the nearest individual, Office.)
so categories may not add to totals.
Centers for Disease Control and Prevention, National Centers for
Health Statistics. (2010). Health, United States, 2010, with chartbook
on trends in the health of Americans. Washington, DC: U.S.
of hypertension, management of other chronic conditions, and
Government Printing Office. aggressive screening for skin, breast, cervical, and prostate can-
cer are important health service issues. Because the rate of death
from pneumonia and influenza increases in this age group,
heart disease, hypertension, non–insulin-dependent diabetes, pneumococcal and influenza vaccination is encouraged.
colon cancer, depression, and anxiety (Ebersole etÂ€al., 2008; Life changes in this age group frequently threaten the indi-
National Institute on Aging, 2011). All of these chronic diseases vidual's functional independence. Retirement, changes in fam-
are concerns of the age group older than 65â•›years. ily and social roles, illness, disability, loss of spouse and close
Primary health services for this age group include counseling friends, and changing support networks place the individual at
for promotion and maintenance of healthy behaviors and pre- risk for bereavement, loneliness, and low self-esteem—all asso-
vention of life-limiting and life-threatening conditions. Control ciated with social isolation and depression (refer to ChapterÂ€28).
Caregiver availability and caregiver burden are issues that will American Indian
need to be addressed in the coming decades. About 6 million Health
Infant Mortality Mortality
Natality Rates
(CDC)
older persons need daily assistance, and four out of five of these (Indian Health (CDC)
Service)
live in community settings (Feder etÂ€al., 2007). As the number
State Vital
of elderly persons increases, the number of traditional family Intercensal
Estimates/
Fertility
Rates/ Registries
Survival
Rates
/
caregivers (wives, daughters, and daughters-in-law) available Bureau of Census
Evaluation
Natality
Evaluation te
s es
at n
Ra tim atio
to provide care is expected to decline. Fewer marriages, smaller Indian Affairs lity
s
E u
al al
or
ta ns Ev
ce s
family size, increased workforce participation by women, and M
ter nsu
In Ce
delayed childbearing all serve to limit the number of available Indian Census and Morbidity
family caregivers. Tribes Intercensal (CDC, National
Estimates Morbidity
Cancer
Migration (Bureau of Census)
Rates
(Immigration and Intercensal Institute)
HEALTH PROFILES OR STATUS OF POPULATIONS Naturalization
Estimates/
Census Utilization Intercensal
Rates Utilization
ATÂ€HIGH RISK Services)
Evaluation Estimates/
Census
Rates Utilization and
Evaluation Procedures
Improvement in the overall health of Americans requires spe- Demographic (CDC)
Population Information
cial attention to improvement in the health of persons who are Demographics Population 65 years
at especially high risk. Understanding the differences between (Social Security) (Health Care
Financing
the total population and these higher-risk populations is one Administration)
way to begin to address the gap in the health status and health
care services of these groups. In considering the groups included FIGUREÂ€7-16â•‡ Interrelationship among data sources for health
in this section, two caveats are important. First, data systems statistics on United States race and ethnic population. (Redrawn
from Centers for Disease Control and Prevention. [1993, June 25].
for collecting information at the national and state levels are,
Morbidity and Mortality Weekly Report, 42, 2.)
in many cases, quite limited. Second, the population subgroups
are extremely heterogeneous, which makes generalizations
about an entire cohort inappropriate unless they are reassessed
at the local level. The data presented are intended to help iden- Gathering health-related information about racial and eth-
tify broad risk groups and not to stereotype behavior of the par- nic groups is confounded by the large number of diverse data
ticular groups (see ChapterÂ€10). sources (FigureÂ€7-16). Each data source collects specific pieces
of information, some for all racial and ethnic categories, oth-
Patterns of Mortality and Morbidity in Persons ers for only white, black, and Hispanic categories. Other vari-
withÂ€LowÂ€Incomes ables correlated with health status—for example, educational
Those with low socioeconomic status include family groups or attainment or socioeconomic status—are not always collected
individuals who are unemployed, underemployed, or in low- in these surveys. This lack of data makes determining the degree
wage jobs, as well as many single-parent families who live in to which health status is influenced by social determinants and/
substandard housing and have an educational achievement rate or place of residence, versus race and ethnicity alone, more dif-
below that of the general population. ficult. Collection of racial and ethnic information has been ini-
Poverty increases health risks in many ways. The death rates tiated at various times. Continuous collection of health data has
of poor persons are approximately twice the rates of persons been carried out the longest for black and white racial groups.
above the poverty level. The incidences of disease are signifi- Most of the national data on African Americans is collected
cantly higher. Poverty also increases the risk of infant mortality, under the racial description of “black,” and these studies are
as noted earlier in this chapter. ChapterÂ€21 details the impact of reported using that designation. For the minority groups for
poverty on health status and health behaviors. which comparable information exists, the data indicate greater
Changing the health effects of income-related disparities is rates of health problems and death (TableÂ€7-10). Reducing
a challenging task. Although a difficult and time-consuming health disparities and improving the health status of minor-
endeavor, it is well worth the effort. The rewards will include ity populations is a primary goal of the Healthy People 2020
lower health costs and improved health status of the U.S. popu- national health objectives.
lation (see ChaptersÂ€3, 4, and 21).
African Americans
Patterns of Mortality and Morbidity among Minorities Many health risks of African Americans are associated with pov-
The term minority refers to a group of individuals who share erty. In 2008, 22% of blacks were below the poverty level, com-
a common ethnicity or ancestry (characteristic) and who rep- pared with 8.4% of non-Hispanic whites (U.S. Census Bureau,
resent a smaller proportion of the population than the larg- 2011). Although it is improving, life expectancy for blacks lags
est represented group. Predominant minority populations in behind that of the total population. The leading causes of death
the United States are African Americans, Hispanics, Asians, associated with chronic conditions are the same as those for the
Pacific Islanders, Native Americans, and Alaska Natives (see majority of the overall population. Heart disease, cancer, and
ChapterÂ€10). These categories, however, are oversimplifications stroke are the three leading causes of death for both blacks and
of the diversity within each racial or ethnic group. Great diver- whites; however, blacks do not live as long with these condi-
sity can be found between and among racial and ethnic groups, tions. After adjustment for normal life expectancy, only 59% of
including diversity in characteristics associated with health blacks diagnosed with cancer reached the 5-year postdiagno-
Â�status, such as lifestyle patterns, genetic influences, socioeco- sis mark compared with 69% of whites between 1999 and 2006
nomic status, and health risks. (ACS, 2011). Blacks, particularly young black men and boys,
TABLEÂ€7-10â•…â•‡RATES FOR RACIAL AND ETHNIC GROUPS FOR SELECTED

HEALTH BEHAVIORS 2004-2009
AMERICAN ASIAN OR
INDIAN OR PACIFIC BLACK WHITE
HEALTH MEASURE ALASKA NATIVE ISLANDER NON-HISPANIC HISPANIC NON-HISPANIC TOTAL
Diseases of heart death rate* (2007) 127.3 101.2 247.3 136.0 187.8 190.9
Unintentional Injury death rate* (2007) 67.3 17.2 38.0 30.4 42.9 40.0
Teen Births (as % of live births) (2007) 6.1 0.9 6.1 5.3 3.0 3.4
Infant mortality rate† (2004-2006) 8.33 4.7 13.5 5.5 5.7 6.8
Percentage low birth weight (2008) 7.4 8.2 13.4 7.0 7.1 8.2
Tuberculosis case rate* (2009) 4.3 Asian: 23.3‡ 7.6 7.0 0.9 4.3
Native Hawaiian
or other Pacific
Islander: 16.7‡
*Incidence/100,000 population.
†
Deaths/1000 live births.
‡
Asian and Native Hawaiian or Pacific Islander races first reported in 2003.
Data from Centers for Disease Control and Prevention. (2010a). Health, United States, 2010, with chartbook on trends in the health of Americans.
Washington, DC: U.S. Government Printing Office, with U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Health Statistics; and CDC. (2010d). Reported tuberculosis in the United States, 2009. Atlanta, GA: U.S. Department
of Health and Human Services, CDC.
are more likely to die from homicide and legal intervention. In Hispanics are the second poorest minority group, and their
2007 the homicide rate for black men was 37.1 compared with health status reflects the influences of poverty. This group also
5.4 for white men. For men between 15 and 24â•›years of age, the includes a small but significant migrant farm worker popula-
rates were 85.3 for blacks and 10.5 for whites (CDC, 2010a). tion, which requires special attention. Hispanics actually have less
Blacks also have higher rates of unintentional injury and diabe- access to health care and preventive health care services than do
tes. Diabetes is almost 30% more frequent among blacks; black other groups, because more of them do not have health insurance
women, especially those who are overweight, are at highest risk. (see ChapterÂ€21). Language is another barrier to obtaining care.
Both blacks and Hispanics are at greater risk of contracting As in the total population, the two leading causes of death in
AIDS and sexually transmitted diseases. Other health-related Hispanics are heart disease and cancer; however, the death rates
indicators, such as rates of low birth weight, infant mortality and associated with these diseases are higher than for non-Â�Hispanics.
morbidity, and adolescent pregnancy, also show striking dispari- Death rates for unintentional injuries, homicides, chronic liver
ties when blacks are compared with other groups in the total pop- disease and cirrhosis, and AIDS are higher than those for whites,
ulation (see ChapterÂ€24). Differences decrease dramatically for most whereas death rates for suicide, stroke, and chronic obstructive
diseases when death rates are adjusted for income level. This indi- pulmonary disease are lower than those for whites. Alcohol con-
cates that socioeconomic class, rather than race, is the primary sumption is a major health risk, especially among Hispanic ado-
contributing factor for the disparities in health status. Caregiver lescents, who report higher rates of episodic heavy drinking and
bias may also influence care and treatment options (Johnson current alcohol use (CDC, 2010a). The cultural—and therefore
etÂ€al., 2004; Moskowitz etÂ€al., 2011; Smedley etÂ€al., 2003). the health—profile of this group is diverse. For example, Mexican
Health care–seeking behaviors of the African American pop- Americans have a low rate of cerebrovascular disease, whereas
ulation are apparently different from those of the white popu- the opposite is true for Puerto Ricans living in New York City.
lation. Some of the difference is related to problems of access. Cuban Americans are high users of prenatal services, but Mexican
More African Americans than whites do not receive adequate Americans and Puerto Ricans are not.
routine and preventive health care services. Blacks make less fre-
quent visits to physicians. Black mothers are twice as likely not Asians and Pacific Islanders
to receive prenatal care until the last trimester of pregnancy, and Because health data are often collected using black and white
more African Americans receive medical care from clinics and racial categories, and because the number of Asians and Pacific
emergency rooms (Baldwin, 2003; CDC, 2010a). Changing the Islanders is relatively small, finding consistent health status
patterns of access to and delivery of health services is a major reports on this minority group is difficult. Moreover, in 2003,
challenge if the frequency and severity of complications from the CDC began reporting some types of data separately for
illness are to be reduced. Federal health care reform is intended Asians and Native Hawaiians or other Pacific Islanders. In areas
to address the disparity in services. Many states have also initi- with a significant concentration of this minority group, local
ated their own attempts to address health care access barriers studies are used to identify health status and health risks.
for uninsured and underserved populations. As with other minority groups, socioeconomic status and
degree of acculturation tend to influence the health status within
Hispanic Americans this cohort. Asians and Pacific Islanders are less likely than whites
Hispanic Americans constitute the largest and fastest-growing to have health insurance. The risk of cancer is approximately the
minority group. This group is young (median age is less than same as that for the general population but is higher in selected
26â•›years, compared with 35â•›years for the total population) and subgroups for certain types of cancer. For example, Asian and
has a high birth rate. Pacific Islanders have the highest rate of liver cancer among all
American sub-groups (ACS, 2011). For individuals who get can- Ratio of American Indian/Alaska Native Selected Age-Adjusted
cer, the risk of death is greater. The 5-year survival rate for Asians Death Rates (2002-2004) to U.S. All-Races (2003)
and Pacific Islanders is lower than that for whites (CA, 2011).
Asian and Pacific Islander immigrants are at serious risk for two Alzheimer’s Disease 0.5
infectious diseases: tuberculosis and hepatitis B. Among Southeast
Asian immigrants, the incidence of tuberculosis is 40 times higher HIV Infection 0.7
than that in the general population. Higher rates of hepatitis B
place Asian immigrants at greater risk of serious side effects, such Major Cardiovascular
Disease 1.0
as chronic liver disease, cirrhosis, and liver cancer (ACS, 2011).
Malignant Neoplasms 1.0
American Indians and Alaska Natives
Chronic Lower
American Indians and Alaska Natives (AIANs) suffer from a Respiratory Disease 1.0
variety of illnesses that can be prevented or ameliorated by early
Pneumonia and
diagnosis and treatment. Many of the health problems in this 1.5
Influenza
group are exacerbated by poverty and substance abuse stem-
ming from long-standing historical antecedents. Detailed data Suicide 1.7
have been collected for AIANs, who have much higher rates of
alcoholism and related problems such as accidents, homicides, Homicide 2.0
and suicides (FigureÂ€7-17). As a result, Native Americans are at
greater risk of early death than are members of the general pop- Unintentional Injuries 2.5
ulation. On the other hand, death rates from HIV infection and
Diabetes mellitus 2.9
Alzheimer disease are somewhat lower among AIANs.
Rates of heart disease and cancer are lower among Native Chronic liver
4.2
Americans, perhaps because these are generally diseases of older disease and cirrhosis
age; when these rates are adjusted for age, they are comparable Tuberculosis, All Forms 8.5
to those in the general population. Cirrhosis and diabetes are
two chronic conditions that affect AIANs at a higher rate than
0 1 2 3 4 5 6 7 8 9
the general population. Diabetes is so common that, in many
Ratio
tribes, 20% of members have the disease. In 2003 the AIAN
FIGUREÂ€7-17â•‡Ratio between American Indian/Alaska Native
age-adjusted death rate for diabetes was almost three times the (AIAN) age-adjusted death rates for selected causes in 2002 to
all-races rate (Sebelius etÂ€al., 2009). Native American children 2004 and death rates for the U.S. all-races population in 2003.
are also at risk for many of the health problems associated with (Redrawn from Sebelius, K., Roubideaux, Y., Church, R.M., etÂ€al. [2009].
higher levels of poverty. Trends in Indian health: 2002–2003 Edition. Rockville, MD: Indian Health
Many of the health problems of Native Americans, partic- Service.) These AIAN rates have been adjusted to compensate for mis-
ularly tuberculosis, diabetes, and pneumonia, can be reduced reporting of AIAN race on state death certificates.
or eliminated by early diagnosis and treatment. Some problems
can be reduced or eliminated by changing patterns of behav- The advent of new contagious diseases (e.g., HIV/AIDS,
ior. Public health officials, the Indian Health Service and AIAN SARS), the antigenic variations in older known contagious dis-
leaders are engaged in health projects aimed at reducing risky eases (e.g., avian influenza), and the continuing presence of
behaviors, improving lifestyle habits, and facilitating access and preventable diseases have revealed that humanity and science
provision of services for Native American populations. do not have the means to completely control or prevent infec-
tious diseases. Newly emerging and highly treatment-resistant
CONTINUING ISSUES diseases are expected to become significant issues in the near
future. Nursing and society must work in concert with environ-
The nation continues to struggle with the effects of chronic mental and medical science to prevent and cure infectious and
Â�illness, both at the human level in terms of suffering and at the chronic diseases. Using epidemiology-based research, the science
national level in terms of economic loss. Minority populations of nursing must be ready to provide strategies for disease preven-
are at greater risk, experiencing chronic illness at an earlier age tion and health promotion. Community health nurses will need
and having higher rates of early death compared with the gen- to make continuing efforts to explore factors that affect human
eral population. An important goal of Healthy People 2020 is health behaviors, lifestyles, and participation in activities that
eliminating health disparities among racial and ethnic groups. reduce diseases for populations, aggregates, and target groups.
KEY IDEAS
1. Epidemiology is the study of the health status of human 3. Epidemiology is helpful to community/public health nurses
populations. for describing the health status of a population and the fac-
2. Epidemiologists and nurse researchers use descriptive, ana- tors that contribute to its well-being, for targeting aggre-
lytic, and experimental research methods to study causative gates at risk of specific health conditions, and for evaluating
factors of illness, disability, and premature death; to describe the effectiveness of nursing interventions in populations.
the natural history of disease; to identify populations at 4. Rates and ratios are statistics used to describe births, deaths,
risk for poor health; and to determine the effectiveness of and incidences and prevalence of disease and disability in
screening, health education, and treatment measures. populations.
5. The natural history of a disease is influenced by character- 8. Community/public health nursing involves attending to the
istics of the people (host), agents (biological, chemical, and health status of multiple subpopulations as well as of the
physical), and environment that make up the epidemiologi- total population.
cal triangle. 9. Health care services and programs are aimed at three levels
6. Age, sex, race, social class, occupation, and marital status are of prevention: primary, secondary, and tertiary.
demographic characteristics frequently used when describ- 10. Understanding the multiple factors that contribute to
ing human populations. These factors contribute to varia- Â�illness, injury, and premature death is necessary but not
tions in health status, health-related behaviors, and use of adequate for improving the health status of the U.S. popu-
health care services. lation. A key challenge for community and public health
7. Much of the disparity in the health status of minority pop- nurses is to use knowledge of risk factors to shape health
ulations is linked to poverty and other social determinants policy priorities and to influence positively the health pro-
of health. file of the people they serve.
1. Obtain a copy of your local health department's annual 4. Do higher or lower rates of infectious disease exist in your
report. See whether you can identify prevalent health needs community than in your state and in the United States?
and problems in your local community. 5. As a community/public health nurse, how would you pre-
2. What are the five leading causes of death in your commu- pare a plan to reduce health problems identified in activity 3
nity? Are these mortality data similar to or different from the or 4 in this section? Whose support would you need to enroll
national mortality data? to implement such a plan? How would you go about acquir-
3. Do special cohort groups have higher rates of morbidity or ing community support for your plan?
mortality than others do in your community? If so, what
types of health problems contribute to the higher rates?

Data on health care providers with occupationally acquired HIV American Public Health Association: http://www.apha.org/
infection are published in the CDC's HIV/AIDS Surveillance Association of Schools of Public Health: http://www.asph.org/
Report. Free copies are available from the CDC National AIDS Environmental Protection Agency: http://www.epa.gov/
Clearinghouse, PO BoxÂ€6003, Rockville, MD 20849-6003; tele- National Institutes of Health: http://www.nih.gov/
phone (800) 458-5231. This report can also be downloaded U.S. Census Bureau: http://www.census.gov/
from the Internet at http://www.cdc.gov. World Health Organization: http://www.who.int/en/
The following resources are also available.
American Cancer Society: http://www.cancer.org/
American Lung Association: http://www.lungusa.org/
WEBSITE
http://evolve.elsevier.com/maurer/community/
STUDY AIDS
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SUGGESTED READINGS Human Services, Centers for Disease Control Gerstman, B. B. (2003). Epidemiology kept
and Prevention, National Center for Health simple: An introduction to classic and modern
Centers for Disease Control and Prevention. Statistics. epidemiology (2nd ed.). New York: Wiley-Liss.
(2010a). Health, United States, 2010, with Coughlin, S. S., Beauchamp, T. L., & Weed, U.S. Department of Health and Human Services.
chartbook on trends in the health of Americans. D. L. (2009). Ethics and epidemiology (2011). Healthy People 2020. Retrieved June 10,
Washington, DC: U.S. Government Printing (2ndÂ€ed.).Â€Oxford,Â€England: Oxford 2011 from http://www.healthypeople.gov/2020/
Office, with U.S. Department of Health and University Press. default.aspx.
CHAPTER
8
Communicable Diseases
Frances A. Maurer
FOCUS QUESTIONS
What methods have been used historically to safeguard Why are the concepts of epidemiology appropriate to use for
populations against communicable diseases? preventing and controlling communicable diseases?
What are the elements of a communicable disease, and how do What are the implications for the nursing process in caring
they interact? for individuals and families with communicable diseases?
How do boards of health demonstrate responsibilities for Where can nurses and clients obtain information about
controlling the spread of communicable diseases? support resources for coping with communicable diseases?
CHAPTER OUTLINE
Communicable Diseases and Control Means of Transmission
Disease Control: Biblical Times to the Present Characteristics of the Host
Early State and Federal Efforts at Disease Control Environment
Successes in Communicable Disease Control Agent-Host-Environment and Favorable Conditions
Contemporary Issues in Communicable Disease Trends in Communicable Disease
Vaccine Failure and Lapsed Immunizations Research and Research Organizations
Drug-Resistant Diseases High-Risk Populations and Health Care Workers
Tuberculosis: Difficult to Control Role of Boards of Health
Sexually Transmitted Diseases Legislative Mandate
Hepatitis Environmental Control
Human Immunodeficiency Virus Infection Reportable Diseases Oversight
Newly Emerging and Reemerging Diseases Immunizations and Vaccines: Oversight and
Influences of Modern Lifestyle and Technology Recommendations
Issues of Population Safety versus Individual Rights Protection of International Travelers
Role of the Nurse in Communicable Disease Control Nursing Care in the Control of Communicable Diseases
Epidemiology Applied to Communicable Disease Control Primary Prevention
Epidemiological Principles and Methods Prevention Related to Mode of Transmission
Communicable Disease Investigation Secondary Prevention
Causative Agent Tertiary Prevention
KEY TERMS
Agent Invasiveness Resistance
Artificial immunity Natural immunity Sources of contamination
Bioterrorism Nosocomial infections Vector
Host Pathogenicity Virulence
Infective dose Reservoirs
COMMUNICABLE DISEASES AND CONTROL infection control, microbiology, medicine, public health, and
nursing. Furthermore, the community nurse must have knowl-
Communicable diseases occur in every country, in every urban and edge of the legal system, which mandates prevention and con-
rural area, and in every neighborhood, from the very rich to the trol of communicable diseases locally, nationally, and worldwide.
very poor. Nurses who provide quality care in combating commu- Nurses must also have knowledge of effective support systems that
nicable diseases must have a basic understanding of Â�epidemiology, can be used by individuals, families, and communities.
190
CHAPTER 8â•… Communicable Diseases 191
The public health community faces new challenges. The resur- BOX 8-1â•…â•‡EARLY EFFORTS AT DISEASE
gence of old diseases, such as measles and tuberculosis (TB); the CONTROL
appearance of drug-resistant bacteria such as methicillin-resistant
Staphylococcus (MRSA) and Clostridium difficile (C. difficile); and • Fourteenth century—Physicians developed theory of communi-
the emergence of new diseases, such as severe acute respiratory cable disease process:
syndrome (SARS) and Ebola virus disease, and the persistence of • Disease spreads through contact with an infected person or article.
human immunodeficiency virus (HIV) infection and acquired • Environmental factors such as waste, garbage, and stagnant
immunodeficiency syndrome (AIDS), require health profession- water also facilitate or spread disease.
als to be alert, conscientious monitors of the public health. The • Unhealthy persons such as the weak, malnourished, or those
potential for bioterrorism, the use of disease-producing agents as with poor hygiene are at greater risk of disease.
weapons, is also a growing concern of public health agencies. • Weather conditions and a person's moral life influence the
spread of disease (Risse, 1988).
Communicable disease control involves controlling envi-
• Mid-seventeenth to eighteenth century—Plague in Venice in
ronmental elements and personal behaviors that facilitate the
1656 led to development of quarantine measures: ships quarantined,
spread of disease. The knowledge of how to control disease has
overland trade suspended, public gatherings forbidden, schools
been acquired through centuries of whimsical practice, lucky closed, streets cleaned, sick confined to pest houses. Observation
guesses, serendipitous observation, and strict scientific inquiry. of the relationship between cowpox and higher immunity to small-
The most dramatic controls have been achieved by establishing pox started efforts to use the cowpox virus to control the spread of
public hygiene measures. A brief historic review of attempts at smallpox and led to development of smallpox vaccination.
disease control provides the community health nurse with an • Nineteenth century—Role of the vector in disease transmission was
appreciation of the efforts needed to reach the level of disease still unknown. Theory of miasma developed, which blamed Â�communicable
control we have today. disease on bad air and spontaneous generation of infectious agents.
Although not completely accurate, this theory led to public health
Disease Control: Biblical Times to the Present Â�measures that worked. These measures included eliminating garbage,
Communicable diseases such as smallpox and leprosy existed refuse, and animal remains, as well as draining stagnant water.
even before the birth of Christ. Plague raged intermittently • 1800s—European cholera epidemic occurred. Physicians reexamined
throughout Europe and China during the thirteenth and four- prevailing theories and discounted slow development of putrid air and
teenth centuries, decimating the population. In the fourteenth idea that only immoral people were affected by disease. Sanitary con-
century, physicians first formulated a theory to explain the ditions helped, but did not completely control the cholera epidemic.
communicable disease process. Although it was not completely • 1900s—Swift progress was made. Microorganisms were identified
accurate, this and subsequent trial-and-error efforts helped as the cause of specific diseases (diphtheria, tuberculosis, pneu-
physicians develop sound principles for communicable disease monia, and typhoid fever) (Dowling, 1977). Jacob Henle developed
control (BoxÂ€8-1). Today, quarantine, sanitary precautions, and Â�scientific criteria to link organism to specific disease: (1) identify
travel restrictions remain methods of communicable disease organism, (2) isolate it, and (3) use the organism to generate dis-
ease. This approach remains a basic principle used by public health
control.
personnel to investigate new diseases and illnesses.
As the relationship between disease-producing microorgan-
isms and factors that are beneficial to their growth became more
apparent, control measures became more specific. Sanitary reg-
ulation of the environment and isolation of infected individuals care. In 1878 the Quarantine Act was passed, granting the fed-
became accepted strategies. These control measures were widely eral government the power to impose quarantine. In 1912, the
enforced. Streets were cleaned, the throwing of garbage into riv- Marine Hospital Service officially became the Public Health
ers and streets was discouraged, standing water was drained, Service (PHS), and states were held responsible for reporting
and infected individuals were isolated. In America, quarantine statistics to the federal government via the PHS (Miller, 2002;
laws became acceptable in the mid-1800s. Mullan, 1989).
Federal support for research assistance in communicable
Early State and Federal Efforts at Disease Control disease control led to several important actions. In 1930, the
In 1869, the first state health department was established in Ransdell Act established the National Institutes of Health (NIH),
Massachusetts; health departments in other states soon followed. which continues to be the major source of research for the PHS.
By 1901 all but five states had some type of board of health. The In 1946, the Communicable Disease Center, currently known
Massachusetts health department controlled communicable as the Centers for Disease Control and Prevention (CDC), was
diseases by regulating sanitary conditions and by building water established. The CDC's original mandate was control of infec-
and sewage systems. As boards of health developed, they began tious diseases. Over the years, however, the scope of the CDC
to realize the importance of accurate statistics for tracking and has expanded to include noninfectious diseases and environ-
controlling communicable diseases. Statistics provided a way to mental issues. The CDC is responsible for collecting morbidity
identify trends, incidence, and effective treatment. and mortality statistics on reportable infectious diseases.
Communicable disease control at the federal level was The 1970s were a decade of health reform and legislation.
almost nonexistent until the 1800s. In 1872, the Marine The needs of migrant workers were supported, and vaccines
Hospital Service, the forerunner of the Public Health Service, were made available to the poor. Funding for the NIH was
was founded by an act of Congress. At approximately the same increased, and a national effort began to decrease the incidence
time, the American Public Health Association was established. of cancer, heart attacks, and strokes. In the 1980s the important
The American Public Health Association provided a forum for role of the PHS was underscored by the advent of HIV infection.
physicians and other public health workers to set standards of The need for HIV infection prevention and education efforts,
192 CHAPTER 8â•… Communicable Diseases
the issue of confidential or anonymous testing and counseling, Immunization Initiative, resulted in massive immunizations
the need for contact tracing and notification, and the care of of young children. Unfortunately, a reduced emphasis on pub-
infected individuals in hospitals and in the community have lic health at the national level, with corresponding funding
served to emphasize the need for a public health response to cuts, diminished the impact of this early immunization effort
communicable diseases. (Jekel etÂ€al., 2007). When the public becomes complacent, some
Today public health officials face many challenges, includ- diseases resurface or new ones emerge to affect the health of
ing the need for a quick response to a bioterrorism attack (see populations.
ChapterÂ€22); the potential for rapid spread of infectious dis-
eases due to the ease of travel between countries; and the rise of CONTEMPORARY ISSUES IN COMMUNICABLE
new and drug-resistant diseases. The public health community DISEASE
must meet these challenges in spite of limited funding for pub-
lic health programs. Despite significant success in communicable disease con-
trol since the 1940s, these diseases are still among the lead-
Successes in Communicable Disease Control ing causes of death in the United States. Infectious diseases
Public health practices have initiated community protection account for 25% of all doctor visits. When considered as a
measures such as creating safer environmental conditions and group, three infectious diseases—pneumonia, influenza, and
providing treatments and vaccines as soon as they become HIV Â�infection—constituted the ninth leading cause of death
available. Water quality regulations, sewage regulations, and in the United States in 2007 (U.S. Department of Health and
food-handling regulations have decreased the incidence of Human Services [USDHHS], 2010a). The public health com-
enteric diseases. Currently, water is chlorinated, milk is pasteur- munity is especially concerned about a resurgence in the inci-
ized, preservatives are added to foods, and safe sewage plants are dence of vaccine-preventable childhood illnesses (e.g., measles),
built. Antibiotics help reduce the spread of communicable dis- TB, sexually transmitted diseases, and hepatitis and the emer-
eases (e.g., rheumatic fever, TB, syphilis) by lessening the time gence of new diseases, the most prominent of which are HIV
during which infected persons are contagious. infection, SARS, and West Nile virus infection (TableÂ€8-1). The
Vaccine development and immunization programs elim- objectives of Healthy People 2020 (USDHHS, 2010b) have tar-
inated smallpox and have dramatically decreased the inci- geted all of these Â�communicable diseases for special attention to
dence of childhood diseases such as measles, mumps, pertussis, significantly reduce their impact on the American people (refer
polio, and rubella. In 1977 a national campaign, the Childhood to the Healthy People 2020 box on page 193).
TABLEÂ€8-1â•…â•‡ FREQUENCY OF NOTIFIABLE DISEASES OVER TIME

DISEASE 1940 1950 1960 1970 1980 1990 2000 2010
AIDS 41,595* 40,758**
Chlamydia (first 702, 093 1,244,180
report 1995)
HIV 36,870**
Legionellosis 475* 1,370 1,127 3,522
Lyme disease 17,130 38,464
Measles (rubeola) 291,162 319,124 441,703 47,351 13,506 27,786 86 71++
Mumps NA NA NA 104,953 8,576 5,292 338 1,991
Pertussis 183,866 120,718 14,809 4,249 1,730 4,570 7,867 16,858
Poliomyelitis 9,804 33,300 3,190 33 9 7 0 1
Rabies, animal 7,210 7,901 3,567 3,224 6,421 4,826 6,934 5,343
Rabies, human â•›41 18 2 3 0 1 0 4
Rheumatic fever NA NA 9,022 3,227 432 108 ‡ ‡
Rubella (German measles) NA NA NA 56,552 3,904 1,125 185 5

SARS ¶
Smallpox 2,795 Last Documented case in the United States was in 1949
Syphilis 472,900 217,558 122,538 91,382 68,382 134,255 32,221 44,828
Tuberculosis 102,984 217,742 122,538 91,382 68,832 134,255 16,377 11,545
Typhoid fever 9,809 2,484 816 346 510 552 377 397
Varicella 27,382 20,482***
West Nile virus 720¶
*New emerging reportable disease.
**Combined HIV/AIDS reporting as of 2008.
***Added back to list in 2003.
‡No longer requires mandatory notification.
¶Not a reportable communicable disease at present; West Nile virus case reporting started in 2006; no current cases of SARS.
NA, Not available; SARS, severe acute respiratory syndrome.
Data from Centers for Disease Control and Prevention. (1979). Annual summary and summary of notifiable diseases—1990, 2002, 2007, 2011.
Atlanta: CDC.
HEALTHY PEOPLE 2020

Health Status Objectives
â•‡â•›1. Reduce annual incidence of AIDS cases among adolescents and adults to no more than 13 per 100,000 population (baseline: 14.4 per
100,000 in 2007).
â•‡â•›2. Reduce the number of new cases of HIV/AIDS diagnosed among adolescents and adults (developmental–no current baseline).
â•‡ â•›3. Reduce the incidence of gonorrhea:
â•›3a. Among females age 15 to 44â•›years to no more than 257 cases per 100,000 people (baseline: 285 in 2008).
3b. Among males age 15 to 44â•›years to no more than 198 cases per 100,000 people (baseline: 220 in 2009).
â•‡â•›4. Reduce the proportion of adolescents and young adults (15 to 24â•›years of age) with Chlamydia trachomatis infections:
2008 Baseline Per 100,000
Select Population All Ages; Male and Female
African American 1065.3
Native American, Alaska Native â•…465.18
Asian, Pacific Islander â•…113.68
Hispanic â•…â•›367.67
White â•…â•›141.05
â•›4a. Among females age 15 to 24 attending family planning clinics to 6.7% (baseline: 7.4% of females in 2008).
â•›4b. Among males age 24 and under enrolled in National Job Training to 6.3% (baseline: 7.0% in 2008).
â•›4c. Among all females age 15 to 44â•›years (developmental–no baseline).
â•›â•‡ 5. Eliminate sustained domestic transmission of primary and secondary syphilis to:
â•›5a. 1.4 new cases per 100,000 among females (baseline: 1.5 per 100,000 in 2008).
â•›5b. 6.8 new cases per 100,000 among males (baseline: 7.6 per 100,000 in 2008).
â•›â•‡ 6. Reduce to 9.5% the proportion of young adults with Herpes Simplex type 2 (baseline: 10.5% in 2005-2008).
â•‡â•›7. Reduce the percentage of women 15 to 44â•›years of age who have ever required treatment for Pelvic Inflammatory Disease (PID) to no more than
3.59% (baseline: 3.99% in 2006-2008).
â•‡â•›8. Reduce, eliminate, or maintain elimination of vaccine-preventable disease:
Disease 2020 Target Goal 2008 Baseline
Measles â•…â•‡â•‡30 â•‡â•›â•›115
Mumps â•…â•‡500 â•‡â•‡421
Pertussis (children under age 1 year) â•…â•›2500 â•‡2777
Haemophilus Influenzae (Hib) â•‡â•‡â•‡â•›â•›â•›0.27 per 100,000 population 0.3 per 100,000
population
Varicella (chickenpox) 100,000 582,535
â•‡â•›9. Reduce hepatitis A cases to an incidence of no more than 0.3 per 100,000 (baseline 1.0 cases per 100,000 population in 2007).
Select Population Hepatitis A 2007 Baseline per 100,000
African American 0.42
Native American, Alaska Native 0.5
Asian, Pacific Islander 1.03
Hispanic 1.44
White 0.66
â•›10. Reduce hepatitis B cases among adults 19 and older to 1.5 per 100,000 population (baseline: 2.0 per 100,000 in 2007).
â•›â•‡11. Reduce hepatitis B cases in high-risk groups:
2020 Target Goal for 2007 Baseline for
Risk Group NumberÂ€ofÂ€Cases NumberÂ€ofÂ€Cases
Injection drug users 215 285
Men who have sex with men â•‡45 â•‡62
â•›12. Reduce newly acquired hepatitis C infections to 0.2 per 100,000 (baseline: 0.3 per 100,000 in 2007).
â•›13. Reduce new cases of tuberculosis to 1.0 per 100,000 (baseline: 4.9 per 100,000 in 2005).
From U.S. Department of Health and Human Services. (2010b). Healthy People 2020. Washington, DC: Author. Retrieved May 19, 2010 from http://
www.healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf; CDC. (2010). Summary of notifiable diseases–United States 2008.
Morbidity and Mortality Weekly Report 57(54), 1-94; and Summary of notifiable diseases–United States 2007. Morbidity and Mortality Weekly
Report, 56(53), 1094.
Vaccine Failure and Lapsed Immunizations are at risk when exposed to disease. A Healthy People 2020 objec-
The resurgence of certain communicable diseases has been the tive is to have 95% of children under 6â•›years of age enrolled
result of lapses in control measures and the diminished effect of in the immunization registry. In 2008, 75% of children were
vaccines over time. enrolled (USDHHS, 2010b).
Significant progress has been made in inoculating young
Childhood Immunizations: Measles, Mumps, and Pertussis children. By 2007, 95% of school-aged children in kindergar-
Lapsed immunization efforts in the 1980s resulted in increased ten and first grade had had all the recommended vaccinations
susceptibility to certain vaccine-preventable diseases. One proof (USDHHS, 2010b). Ninety percent vaccination of suscepti-
of these lapsed immunization practices was the increase in mea- ble groups provides substantial protection against a recurrent
sles cases in the late 1980s and early 1990s. Between 1989 and epidemic. Monitoring of vaccination status for entry into
1991, some 55,000 new cases were reported. Investigations of school and daycare identifies children at risk. In Washington,
the resurgence of measles in high school and college popula- DC, for example, a review of immunization status by school
tions revealed that the vaccine did not provide lifelong immu- nurses determined that 50% of children needed one or more
nity. One to two booster doses are now recommended for vaccinations to meet the district's school entry require-
continued protection against measles. Measles outbreaks con- ment (CDC, 2003a). Stringent surveillance has increased
tinue to occur in unvaccinated children and adults. In the first the complete immunization rate to 90% of all DC students
third of 2011 there were 118 cases of measles, the highest rate (CDC, 2011c).
since 1992 (CDC 2011a). Eighty-nine percent of those measles
cases were among unvaccinated individuals and were associ- Failure to Implement Recommended Vaccinations:
ated with importation from other countries. In other words, the Pneumococcal Pneumonia and Influenza
source cases were Americans traveling overseas and/or persons Several episodes of pneumonia outbreaks in chronic care facil-
from other countries visiting this country. ities in Massachusetts, Maryland, and Oklahoma in 1995 and
As with measles, mumps outbreaks have occurred among 1996 were determined to be the result of failure to vaccinate
highly vaccinated populations. The risk of mumps has shifted at-risk populations with pneumococcal pneumonia vaccine.
from young children to older children, adolescents, and young Investigation revealed that fewer than 5% of these institutions'
adults and is usually associated with vaccine failure over time. populations were immunized. The death rate at the three insti-
The two-dose schedule of measles, mumps, and rubella vaccine tutions ranged from 20% to 28% of infected seniors (CDC,
(MMR) adopted in 1989 led to a 95% decline in the incidence of 1997a)—a preventable tragedy.
mumps (CDC, 2001a). A resurgence of mumps among adoles- Pneumococcal disease and influenza account for over 53,000
cents and young adults who had received the recommended two deaths each year (CDC, 2010b). The majority of these deaths
doses has led to the recommendation of a third dose for those at occur in people over the age of 65. Influenza immunization
high risk (CDC, 2006a; 2010a). rates are approximately 67% in this age group. Pneumococcal
vaccination rates in older adults have improved but are still
In 2009 a large outbreak of mumps occurred in New York low (61%) (USDHHS, 2010a). Nurses should make an effort
and New Jersey associated with a tradition-observant Jewish to ensure that both vaccinations are routinely administered in
community. This outbreak was traced back to a single index hospitals, nursing homes, congregate settings, and other com-
case, an 11-year-old boy who had just returned from a trip to munity settings that serve the older adult population.
the United Kingdom where a reported 7400 cases occurred
in 2009. Most of the adolescents (93%) had one dose or Drug-Resistant Diseases
two doses (85%) of the vaccine. As a result of this outbreak, One trend of special concern to public health practitioners is the
public health officials have offered a third dose of MMR in increase in drug-resistant strains of organisms that cause com-
certain schools with a substantial number of mumps cases municable diseases. After years of successful treatment, cases of
(CDC, 2010a). gonorrhea, TB, pneumonia, and syphilis are on the rise. These
increases are the result of less success with standard antibiotic
Pertussis outbreaks have occurred in undervaccinated popu- therapies. Examples of drug-resistant organisms are the following:
lations. In 2004 and 2005, 345 cases of pertussis were reported • Neisseria gonorrhoeae—resistant to fluoroquinolone; cases
among Amish preschool-age children in Delaware (CDC, spread from Hawaii and Los Angeles to all regions of the
2006a). Vaccination rates among the Amish are low, although country (CDC, 2011d)
vaccination is not prohibited by their religion. Pertussis rates • Neisseria gonorrhoeae—resistant to azithromycin in a small but
continue to rise. In 2009 there were approximately 17,000 cases growing number of cases in the United States (CDC 2011e)
(CDC, 2011b). In 2005 the CDC recommended a recondi- • Staphylococcus aureus—commonly resistant to methicillin
tioned tetanus toxoid-reduced diphtheria toxoid-acellular per- and now becoming resistant to vancomycin, the last currently
tussis vaccine (Tdap) for use among adolescents and adults. known drug treatment choice (CDC, 2006b, 2006c, 2010c)
Adolescents who have had Tdap vaccine have fewer incidences • Salmonella—a new strain, serotype Typhimurium, is resis-
of pertussis than those who have not (CDC, 2011b). tant to ampicillin, chloramphenicol, streptomycin, sulfon-
To evaluate the degree of immunization coverage, the amides, and tetracycline; strain is common in the United
National Immunization Program at the CDC established a Kingdom and has now spread to the United States (CDC,
Â�population-based immunization registry. Registries at the state 1997b: Wright etÂ€al., 2005)
and local levels track each child's immunization status. This • Shigella sonnei (gastroenteritis)—resistant to ampicillin and
information is necessary to ensure protection of the Â�population trimethoprim-sulfamethoxazole; cases found in daycare
from vaccine-preventable diseases and to identify children who centers in Kansas, Kentucky, and Missouri (CDC, 2006d)
BOX 8-2â•…â•‡GROUPS AT GREATER RISK FOR MRSA (CA-MRSA) and in fact the number and virulence of
CONTRACTING DISEASE CA-MRSA cases has alarmed public health officials (Milstone
etÂ€al., 2010).
Tuberculosis
• Individuals with human immunodeficiency virus infection Fluoroquinolone Resistant Clostridium Difficile (C. Difficile)
• Prisoners and homeless persons C. difficile bacteria is indigenous to the intestinal tract. It prolifer-
• Poor urban individuals ates after antibiotic use has reduced the number of healthy intes-
• Minorities (Native Americans and Alaska Natives, Asians, Pacific tinal bacteria that served to keep C. difficile in check. Symptoms
Islanders, African Americans, Hispanics) range from mild diarrhea to severe infections. C. difficile is the
• Health care workers most common cause of bacterial diarrhea in hospitalized patients.
Sexually Transmitted Diseases Control includes modifying antibiotic therapies, stringent clean-
• Adolescents ing of equipment and rooms, and scrupulous personal hygiene
• Young adults (Hall, 2010).
• Persons with multiple sex partners
• Persons engaging in drug-related activities Tuberculosis: Difficult to Control
• Prostitutes Nearly one third of the world's population is infected with TB.
• Minority groups (African Americans and Hispanics) It is a leading infectious cause of death worldwide, causing
more than 2 million deaths each year (CDC, 2011f). Persons
Hepatitis infected with the TB organism but without overt disease are
• Persons with poor personal hygiene or living in poor conditions asymptomatic and are not contagious to others. If infection
(overcrowded or unsanitary conditions) progresses to TB disease, individuals will have symptoms
• Persons who emigrate from areas where hepatitis B virus infection and become contagious. A person who has a compromised
is common (Africa, Asia, South America)
immune system, practices poor nutrition, lives in poverty, or
• Travelers to areas where hepatitis is endemic
has other diseases is at greater risk of progressing from TB
• Intravenous drug users
infection to TB disease (see ChapterÂ€21). People who live in
• Persons with multiple sex partners
• Alaska Natives or emigrate from countries in which TB is indigenous are at
• Health care workers greater risk of having been infected (see ChapterÂ€5). Without
prophylactic treatment for the infection, individuals have a
Human Immunodeficiency Virus Infection 5% to 10% chance of progressing to disease (CDC, 2008a).
• Persons with multiple sex partners HIV-infected individuals are at special risk. The number of
• Intravenous drug users persons with the dual diagnosis of HIV and TB has increased
• Prostitutes dramatically, with approximately 10% of all TB cases also hav-
• Minority groups (African Americans and Hispanics) ing HIV (CDC, 2008a).
• Bisexual and homosexual males The risk of acquiring TB infection or disease is relatively low
in the United States. Immigrants from countries in which TB
is indigenous are at greater risk because they are more likely to
Drug-resistant communicable diseases are a special con- have been exposed and infected in their country of origin (CDC,
cern not only because they are more complicated to treat 2011f). Although the total number of TB cases has declined,
but also because the delay in control increases the risk of the incidence among foreign-born persons as a percentage of
infection for every person, including health care workers. total cases has increased (FigureÂ€8-1). The TB case rate among
Community health nurses must be alert to screen high-risk Â�foreign-born persons in the United States is eleven times greater
groups (BoxÂ€8-2), be aware of current treatments, and be able than U.S.-born persons (CDC, 2010d). Today, public health
to identify the signs of drug-resistant infection in clients. In agencies have renewed efforts to identify and treat foreign-born
addition, community health professionals must take an active individuals. Closing the gap between TB rates among foreign-
role in educating practitioners and the public alike concerning born and native-born Americans is a national health objective
the prudent use of antimicrobial drugs to reduce the emer- and a goal of the CDC.
gence of drug-resistant strains. In the United States, effective TB treatment and case find-
ing led to dramatically fewer new cases each year by the 1980s.
Methicillin Resistant Staphylococcus Aureus (MRSA) That decline reversed as a result of lax surveillance, program
MRSA is a staph bacteria resistant to methicillin, oxacillin, funding cuts, and an upsurge of susceptible risk groups (CDC,
penicillin, amoxicillin, and sometimes to vancomycin. MRSA 1997c). Since the early 1990s, improved funding and the rein-
infections that are community located (14%) usually present stitution of tighter TB case supervision resulted in a decline in
as a skin infection. Most community-acquired infections are new cases (3.8% per year) and a sharp decline (down 11.3%)
mild, although some have become life threatening. More severe in 2009 (CDC, 2010d). One of the most effective treatment
MRSA infections (85%) occur in hospital and other health care methods is directly observed therapy. Directly observed ther-
facilities and are very serious infections (CDC, 2010c). MRSA apy involves having community health nurses or other trained
can present in surgical wounds, urinary tract infections, blood- personnel observe the ingestion of each dose of prescribed
stream infections, and pneumonia. Stringent universal pre- drug by individuals diagnosed with TB (American Journal of
cautions in intensive care units and other specialty units have Nursing, 2010; Coberly & Chaisson, 2007). Health personnel
reduced the incidence of hospital-acquired MRSA. Little prog- may observe therapy at clinic visits, during home visits, or at
ress has been made in the incidence of community-acquired the individual's work site.
20
Reported Cases (Thousands)

U.S. born
16
Foreign born
12
0
90 92 94 96 98 00 02 04 06 08 10
19 19 19 19 19 20 20 20 20 20 20
Year
The number of tuberculosis cases among foreign born persons in the United States
increased from 6262 (24% of the total number) in 1990 to 6707 (60.5% of the total number)
in 2010.
FIGUREÂ€8-1â•‡Tuberculosis cases among U.S.-born and foreign-born persons by year—United
States, 1990 to 2010. (From Centers for Disease Control and Prevention [CDC]. [2001]. Summary of
Â�
notifiable diseases—United States, various years. Morbidity and Mortality Weekly Report. Trends in
Â�tuberculosis—United States, various years. Available at http://www.cdc.gov.)
Partially as a result of lax control measures, multidrug- Individuals with untreated STDs are reservoirs, sources of
resistant TB (MDR-TB) strains developed as TB clients infection for new sexual partners. Nationwide, the estimated
became less compliant with their drug therapy. These strains reservoir of those with STDs includes 45 million (20% of the
are a public health concern because they require longer, more population) with genital herpes infection and approximately
costly treatment. MDR-TB is often fatal; the cure rate is lower, 20 million with HPV infection (CDC, 2007a, 2009b).
approximately 50-60%, even with intensive treatment and Gonorrhea rates in the United States remain the highest in
Â�follow-up (Coberly & Chaisson, 2007; CDC, 2010e). Outbreaks the developed world, with over 300,000 cases per year (CDC,
of MDR-TB have occurred in institutional settings, includ- 2010g). Drug-resistant strains of both syphilis and gonorrhea
ing prisons and nursing homes. Today a new strain causing have developed that require more prolonged and costly treat-
extensively drug-resistant TB (XDR-TB) has developed. This ment. Some STDs (e.g., herpes infection) have no cure and
organism is resistant to almost all the drugs commonly used require lifelong monitoring to control. The rise in STDs is
to treat TB. As a result, the mortality for XDR-TB is very high, related to the development of drug-resistant strains and the
nearly 70% (CDC, 2010e). Although MDR-TB and XDR-TB increased incidence of sexual activity in certain aggregates
are a serious problem worldwide (see ChapterÂ€5), they are rare within the population.
in the United States, accounting for fewer than 2% of new TB Persons at greater risk include adolescents and young adults,
cases (CDC, 2011f). However because travel between countries drug addicts, persons with multiple sex partners, and prostitutes
is common, drug-resistant TB is a real threat to this country, (Kaiser Family Foundation, 2006; Zenilman, 2007). The greatest
both economically (because of the higher cost of treatment) risk is to individuals who engage in unprotected sexual activ-
and pathologically (because of the higher death rates). In the ity. Adolescents are particularly vulnerable because they tend
United States the average cost to treat one case of MDR-TB is to ignore the consequences of unprotected sex (CDC, 2006e).
$240,000, and for XDR-TB the cost is close to $480,000 per Prostitutes who have unprotected sex have the highest risk of
person (CDC, 2009a). transmitting and acquiring an STD. Ethnic and racial minori-
ties, especially Native Americans and Alaska Natives, Asian and
Sexually Transmitted Diseases Pacific Islanders, and Hispanics, are at greater risk of STDs than
The incidence of sexually transmitted disease (STD) is esti- the general population (CDC, 2010g). Higher risk among certain
mated at more than 19 million new cases per year (CDC, 2010f). minorities may be related to other associated risk factors, such as
The three most common diseases are chlamydia, human papil- lower socioeconomic status, reduced access to health care, lim-
lomavirus (HPV) infection, and trichomoniasis. HPV infection ited health-seeking behaviors, increased risk of illicit drug use,
and trichomoniasis are not reportable communicable diseases. and residence in communities with higher prevalence rates.
Chlamydia became a reportable disease in 1995. Approximately Public health efforts to reduce STDs should stress primary
1.2 million new cases of chlamydia, 6 million new cases of HPV prevention to reduce the incidence of STDs and the long-term
infection, and 8 million trichomoniasis cases occur each year effects (e.g., chronic illness, sterility, cancer) associated with cer-
(CDC, 2009b, 2010g; Smith etÂ€al., 2010). Because most people tain STDs. New evidence suggests that some of these prevention
with STDs are asymptomatic or have mild symptoms, many are efforts have helped. STD rates are declining, especially among
untreated (CDC, 2010h). For example, up to 85% of women target population subgroups, such as adolescents, African
and 50% of men with chlamydia are asymptomatic (CDC, Americans, and Hispanics. Adolescents are becoming more
2007a). The cost of treatment is high and is compounded when responsible in their sexual behaviors, postponing the age of first
drug-resistant strains develop. The medical cost of treatment intercourse and using condoms more consistently during sexual
for STDs exceeds $16 billion each year (CDC, 2010f). activity (see ChapterÂ€24). Nonetheless, the rates are too high.
There is a vaccine against HPV that protects against both Although hepatitis B is more common, hepatitis C is emerg-
cervical cancers and genital warts caused by HPV. It is a series ing as a leading cause of chronic liver disease and cirrhosis in
of three doses and is recommended for administration to young the United States. Approximately 18,000 persons acquire HCV
girls (11â•›years and older). There is considerable debate about each year, and an estimated 2.7 to 3.9 million Americans are
the appropriate target groups and administration of HPV chronically infected with HCV (CDC, 2010j).
Â�vaccine. In 2007, the state of Texas mandated this Â�vaccine for Hepatitis-infected individuals can become carriers for life.
age-Â�appropriate girls. That ruling met with much resistance, The very young have the greatest risk of acquiring carrier status.
and Texas rescinded the mandatory requirement for HPV About 90% of infants infected with HBV at birth will become
Â�vaccination of school-aged girls. Currently only 44% of adoles- carriers, whereas the risk for young adults is far less (CDC,
cent females have had one dose and only 27% have completed 2010l). Screening pregnant women for infection and treatment
the entire three-dose series (CDC, 2010i). substantially reduces the risk of HBV transmission to infants.
No vaccine is currently available against HCV.
Hepatitis
Hepatitis A, B, C, D, and E are caused by different microorgan- Human Immunodeficiency Virus Infection
isms. Hepatitis can be transmitted by fecal-oral contamination, Worldwide, there are 33.3 million adults and children infected
sexual intercourse, and injection. Hepatitis is a reportable dis- and living with HIV and AIDS (World Health Organization
ease. The CDC reports that one in every three persons in the [WHO], 2010). The number of Americans living with HIV/AIDS
United States is infected with hepatitis A, B, or C (CDC, 2006f). has reached 1.7 million and over 617,000 people have died of
Hepatitis A and hepatitis B are the two most common forms the disease in the United States (Avert, 2011; CDC, 2011g). HIV
of hepatitis. Hepatitis A virus (HAV) is transmitted by the fecal- infection was the second leading cause of death among persons
oral route, and thus nonhygienic living conditions place peo- aged 25 to 44â•›years in 1995 but had dropped to the sixth cause of
ple at risk. Sanitary control measures reduce the spread of HAV. death by 2007 (USDHHS, 2010a). HIV/AIDS is the third leading
Some HAV outbreaks have been traced to infected food han- cause of death for African Americans in this age group. HIV pre-
dlers serving the public (e.g., in restaurants). In 2003, over 555 vention efforts and the widespread use of antiretroviral therapies
people in seven states contracted HAV as a result of eating at a have had an impact on the progression of HIV infection to AIDS.
single Mexican restaurant in Pennsylvania (CDC, 2003b). Starting in 1996, the incidence of AIDS began to decline. At the
Prior to 2004, HAV was the most common form of Â�hepatitis. same time, the prevalence or number of people living with AIDS
Since the introduction of HAV vaccine, cases of HAV have increased because of more effective treatment.
drastically declined. For example, in 2009 an outbreak in Â�western Most states have now implemented HIV surveillance reports
Illinois and eastern Iowa was confined to only 32 persons (Daniel, and as a result, the prevalence estimates of HIV cases are more
2009). HAV vaccine is currently recommended for all children reliable. Nonetheless, these HIV surveillance reports may not
1year of age or older and for at-risk populations such as travelers reflect the true number of HIV-positive persons because many
to HAV-endemic countries or geographic areas of high concen- people do not want to know their HIV status and are not tested,
tration in the United States (CDC, 2007b). while others use widely available home testing kits and do not
Hepatitis B virus (HBV) and hepatitis C virus (HCV) are share their HIV status with at-risk intimate partners. An esti-
passed from one person to another in blood and body fluids mated 21% of HIV-infected persons are unaware of their HIV
through sexual relations and shared needles, toothbrushes, and status (CDC, 2010m).
razors. Groups at particular risk include those with multiple Because AIDS-related care is long term and extensive, the
sex partners, intravenous drug users, travelers to and emigrants cost of treatment is high. The lifetime costs of treatment for one
from HBV-endemic countries, health care workers and others person with HIV or AIDS is now more than $400,000 (Vann,
exposed to blood and blood products in their work (e.g., police 2009). Although no cure for AIDS is available, recently estab-
and institutional staff), hemophiliacs, and men who engage lished drug protocols have increased the time people survive
in homosexual intercourse. The CDC estimates that approxi- with the disease, which has also increased the cost of care.
mately 38,000 people are infected with HBV each year and Because AIDS is a disease that weakens the individual's body
the number of persons living with chronic HBV infection is defense system, people with AIDS experience many different
between 800,000 to 1.4 million (CDC, 2010j). HBV vaccination symptoms or conditions. For diagnostic purposes, the CDC has
of infants and adolescents has dramatically reduced the num- developed a listing of conditions that are diagnostic of AIDS.
ber of new cases in persons under 19â•›years of age (down 75%), This list is found in Website Resource 8A. AÂ€Â�significant
and the number of new cases is expected to continue to decline number of communicable diseases are among these, including
in these age groups. In 2009 the reported case rate for hepa- candidiasis, herpes infection, TB, and pneumonia. The diag-
titis B was 1.12 per 100,000, a drop of 50% since 2005 (CDC, nostic categories for AIDS are similar for children but include
2007c, 2011b). HBV vaccine is recommended for all children conditions commonly seen in HIV-infected children (CDC,
and adults, with particular emphasis on at-risk adults. 2008b).
Infection with HBV and other blood-borne pathogens is an The groups at special risk for acquiring HIV infection are
occupational risk for health care workers. Health professionals similar to those at risk for HBV infection. Most diagnosed AIDS
are at much greater risk of acquiring work-related HBV than clients are men (75%) and homosexual or bisexual (53%). Since
of acquiring work-related HIV/AIDS. Even so, only 26 cases of 2004 the growth in newly diagnosed AIDS cases is occurring
work-related HBV transmission were reported in 2008 (CDC, among those risk groups (men and men who engage in sexual
2010k). Scrupulous adherence to universal precautions greatly activity with other men) (TableÂ€8-2). The rate of HIV/AIDS
reduces the risk to health care workers. Likewise, homosexual is six times higher among African Americans and three times
men who employ safer sex practices have also reduced their risk. higher among Hispanics than among whites and other racial
TABLEÂ€8-2â•…â•‡ESTIMATED NEW CASES OF Timely access to care is important. Many HIV-infected

HIV/AIDS AMONG PERSONS persons are not identified until they are diagnosed with
AGED 13 YEARS OR OLDER AIDS. To ensure that HIV-infected persons benefit from the
latest antiretroviral treatment, early diagnosis is crucial. HIV
BY SEX AND EXPOSURE
counseling and testing programs in health care settings must
CATEGORY, 2009
improve the process of identifying of persons at risk as well
2009 as counseling and screening efforts. People frequently have
PERCENTAGE a number of STDs at the same time. For example, studies
EXPOSURE CHANGE FROM indicate that people with chlamydia, gonorrhea, or syphi-
CATEGORY NUMBER PERCENTAGE 2004-2009 lis are at increased risk of HIV (CDC, 2010f). Screening for
Men other STDs should be part of the protocol for any screening
MSM1 41,303 â•‡53 + 9.5 programs.
IDU2 â•‡5,859 â•‡7.5 + 3.5
MSM-IDU â•‡2,765 â•‡3.5 â•…+.1 Newly Emerging and Reemerging Diseases
Heterosexual â•‡8,513 â•…11 â•…â•‡-1 A significant number of health problems have raised pub-
Other* â•…206 â•….3 â•… -.1 lic concern in recent years. Some of these are newly emerg-
Total 58,640 â•…75 â•‡ + 5 ing illnesses and some are preexisting problems that surge in
Women incidence from time to time. A few examples are given in the
IDU â•‡3,502 â•‡4.5 â•‡-1.5 following sections.
Heterosexual 15,446 â•…20 â•… -2
Norwalk-like Virus Infection
Other* 186 â•….2 â•… -.3
Total 19,134 24.6 â•‡-4.4 Periodic outbreaks of gastroenteritis caused by Norwalk-like
Overall Total 77,774 100 viruses (NLVs) or Noroviruses have occurred over the years.
The CDC estimates approximately 21 million cases occur every
*Risk not reported or identified. year in the United States (CDC, 2011h). The latest outbreaks
1
Men who have sex with men.
have occurred on cruise ships and in other areas (FigureÂ€8-2).
2
Injecting drug users.
Data from Centers for Disease Control and Prevention. (2006). Racial/ These viruses are transmitted through contaminated food and
ethnic disparities in Diagnoses of HIV/AIDS—33 states, 2001-2004. water and account for the vast majority of cases of nonbacte-
Morbidity & Mortality Weekly Report, 55(05), 121-125; and Diagnoses rial gastroenteritis (CDC, 2011h). NLVs are highly infectious.
of HIV infection and AIDS in the United States and dependent areas, In addition to the usual sources of contamination (vehicles of
2009. HIV Surveillance Report, 21, 19-24. transmission), in epidemic situations person-to-person con-
tact, droplets, and contaminated environmental objects such as
and Â�ethnic groups (CDC, 2010m). Starting in 1991, there has doorknobs, utensils, and bed linens can transmit the viruses.
been an 80% decline in perinatally acquired HIV/AIDS. Only Control of NLV is a two-part process. Primary prevention
57 babies were born HIV positive in 2003 and none in 2009 efforts reduce the risk of initial contamination by ensuring safe
(USDHHS, 2006; CDC, 2011g). The decline in HIV-positive food and water (see page 224). Preventing subsequent person-to-
babies is attributed to the successful attempt to identify poten-
tially infected pregnant women and the use of antiretroviral Vacation settings
mediations to reduce perinatal transmission. Adolescent (13- to (includes cruise ships)
Restaurants,
19-year-old) AIDS cases doubled between 1988 and 1995 and 20.5%
parties, events
have remained constant since then. While the rate among ado- 31.1%
lescents is only a third of the rate among 19 to 44-year-olds,
those teens must cope with HIV for the rest of their lives. AIDS
prevention strategies must be geared toward all who engage in
risky behaviors, because an effective vaccine remains elusive.
A long time delay exists between HIV infection and the devel-
opment of AIDS; in fact, the average latency period is 10â•›years Schools and
(CDC, 2008c). Because of this time delay, aggregates among the communities
more recently determined high-risk groups, for example sexu- 13%
ally active adolescents and homosexual men, are often unaware
of or dismiss their danger. After years of steadily decreasing
numbers, a second-wave epidemic is emerging among young
men who engage in homosexual activity (CDC, 2006g). Because
many of their compatriots do not have noticeable symptoms,
ignoring the problem is easy for both adolescents and young
Nursing homes
homosexual men. These new cases of HIV-positive individu- 35.4%
als will result in an increasing number of AIDS cases in these
FIGUREÂ€8-2â•‡Settings for 660 outbreaks of Norwalk-like viruses
groups as late as 10 to 15â•›years from now and may be respon- reported to the Centers for Disease Control and Prevention (CDC),
sible for the increase seen in TableÂ€8-2. Public education cam- 1994 to 2006. (Data from CDC. [2011]. Updated norovirus outbreak man-
paigns should be directed toward increasing awareness in these agement and disease prevention guidelines. Morbidity and Mortality
risk groups. Weekly Report, Recommendations and Reports, 60â•›[RR-03], 1-15.)
person transmission of NLV via fecal-oral and airborne routes, 20

especially in institutional settings, is important. Prevention
requires frequent hand-washing with soap and water, use of
masks by personnel who clean contaminated areas, careful han- 15
dling of bed linens, and cleaning of surfaces with a germicidal
product (e.g., 10% household bleach). Cruise ships or camps
10
may be shut down to be cleaned.
Nancy A. is a nurse who is assigned to do communicable

5
disease investigation at the CDC in Atlanta. In October,
Nancy and other team members were assigned to investi-
gate an outbreak of acute gastroenteritis (AGE) on a cruise 0
ship. The ship was on a 7-day cruise of the Caribbean, with
ia
la
la
i)
io
ia
te
ol
n
el
el
br
er
ac
si
2318 passengers and 988 crew members. The ship returned
-C
on
ig
Vi
st
r
ob
Sh
Ye
(E
Li
lm
to port, and the CDC team proceeded to board and investi-
yl
in
Sa
ph
ox
am
gate the problem.
at
ig
C
Sh
The team used personal interviews and written question-
naires to gather information. They found that during the FIGUREÂ€8-3â•‡ Food-borne incidence 2010 (per 100,000 population).
voyage, 2% of the crew and 260 (12%) of the passengers (Data from CDC. [2011]. Vital signs: Incidence and trends of infection with
pathogens transmitted commonly through food–FoodBorne Diseases Active
reported illness to the ship health personnel. The question- Surveillance Network, 10 U.S. sites 1996-2010. Morbidity and Mortality
naire that was distributed revealed that 21% of the crew Weekly Report, 60[22], 749-755.)
and passengers met the criteria for AGE. Fecal samples
demonstrated the presence of Norovirus. The team recom-
mended, and ship personnel completed, a thorough clean- Control of food-borne illnesses requires better control of
ing and disinfecting before new passengers were allowed food products including:
to board. • Increased detection and outbreak surveillance
The ship sailed the same day after the cleaning effort. New • Institution of cleaner slaughter mechanisms
cases of AGE emerged among the second set of passengers • Microbial food testing
and crew. The ship returned to port early. The CDC team • Improved inspection of food processing plants
recommended a more aggressive cleaning and sanitation • Increased consumer education related to proper food
strategy. This work was completed in 1â•›week. The ship was preparation
cleared to resume cruises. No new cases of AGE emerged on
the subsequent cruise (CDC, 2002a). Lyme Disease
Lyme disease is the most common vector-borne disease in the
Food-borne Infections United States. The vector (carrier of infection) is a tick infested
Food-borne infections are a serious problem. There are at least with a spirochete. The infected ticks are carried by deer and
1000 outbreaks and an estimated 48 million illnesses each year rodents. Between 1995 and 2009 the number of cases of Lyme
(CDC, 2011i). Symptoms are generally mild to severe diarrhea. disease tripled to over 38,000 (FigureÂ€8-4). Ninety-five per-
Other serious complications such as hemorrhagic colitis, septi- cent of cases are in the northeastern United States, Wisconsin,
cemia, meningitis, and kidney failure are less common. Children and Minnesota (CDC, 2011j). Efforts to prevent Lyme disease
5â•›years old and under have the highest incidence of food-borne emphasize the following:
illness but senior adults (60 and older) and those with compro- • Reduction of the tick population
mised immune systems are at highest risk of hospitalization and • Avoidance of tick-infested habitats
death from food-borne infections. • Use of insect repellents
Food-borne illnesses are tracked through the Foodborne • Prompt removal of attached ticks
Diseases Active Surveillance Network (FoodNet). FigureÂ€8-3 A vaccine, LYMErix, was licensed in 1998 but was removed
shows the incidence of the most common food-borne illnesses from the market in 2002 because of insufficient demand (CDC,
for 2010 tracked through FoodNet. Salmonella is the most com- 2011k). Insect control remains the primary method of control-
mon of the food-borne infections, causing approximately 1.2 ling Lyme disease.
million illnesses each year (Scallan etÂ€al., 2011).
West Nile Virus Infection
West Nile virus (WNV) has become an increasing problem in
Between July 2009 and April 2010, 272 cases of Salmonella
the United States, spreading over a wide geographic area and
Montevideo were reported in 44 states and the District of
infecting more people each year. By 2002, WNV was consid-
Columbia. Epidemiological investigation involved interview-
ered an epidemic. Because of this, the CDC provides surveil-
ing patients in order to attempt to identify the food source.
lance, even though WNV is not on the list of diseases for which
Some patients reported eating an Italian-style meat and/or
reporting is mandatory.
purchasing meat from a national warehouse chain the week
WNV is a vector-borne virus spread by infected mosquitoes.
before they became ill. The outbreak was eventually traced
The virus has been found in wild birds, chickens, horses, dogs, and
to a salami product, which resulted in the voluntary recall of
squirrels, as well as humans. The incidence of WNV has dropped
approximately 1.3 million pounds of salami (CDC, 2010n).
by over 68% since 2006. There were only 1021cases reported
45,000
40,000
Confirmed cases
35,000 Probable cases
30,000
25,000
Cases
20,000
15,000
10,000
5,000
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
FIGUREÂ€8-4â•‡ Numbers of cases of Lyme disease, by year—United States, 1995 to 2009. (Redrawn
from Centers for Disease Control and Prevention [CDC]. [2002]. Lyme disease—United States, 2000. Morbidity
and Mortality Weekly Report, 51[2], 29-31; and CDC [2003, 2004, 2005, 2006, 2007, 2008, 2009]. Summary
of notifiable diseases—United States [selected years]. Morbidity and Mortality Weekly Report, 50â•›[53], 1-108;
51[53], 1-84; 52â•›[54], 1-85; 53â•›[53], 1-79; 54â•›[53], 2-92; 55[53], 1-94; 56[53], 1-94; 57[54], 1-94; 58[53], 1-100.)
inÂ€2010 (CDC, 2011l). WNV started in the New England area and Although few people have been infected with avian flu, it is of
has spread to most states (FigureÂ€8-5). WNV infection is serious concern because of its potential to affect large populations. In
because 35% of people with the infection develop meningoen- 2004, 17 people in Thailand developed influenza after exposure
cephalitis. Public health surveillance of the number of dead birds to infected poultry. About 60% of people infected with avian
and an aggressive mosquito-control program are the primary flu have died (CDC, 2010o). Public health officials are con-
methods used to reduce risk to the population. cerned because this strain is closely related to the influenza virus
responsible for the epidemic that killed millions of people during
Avian Influenza World War I (Kay, 2005). As a result, the WHO, CDC, and health
Since 2003 there have been numerous outbreaks of avian flu departments in many countries employ vigilant surveillance
(bird flu) among poultry in many Asian countries (CDC, 2006h, to control infected poultry and prevent the spread to humans.
2010o). Cross-species transmission of the virus has occurred. There have been no cases of avian flu in the United States.
West Nile virus (WNV) neuroinvasive disease incidence

reported to ArboNET, by state, United States, 2010
Per 100,000 Population*

0.00
0.01–0.24
0.25–0.49
0.50–0.99
1.00
*Scales are different for state and county incidence maps
FIGUREÂ€8-5â•‡Areas reporting West Nile virus (WNV) activity—United States, 2010. (Redrawn from
Centers for Disease Control and Prevention. [2011]. West Nile virus human neuroinvasive disease incidence in
the United States. Division of Vector-Borne Infectious Diseases. Retrieved from http://www.cdc.gov/ncidod/
dvbid/westnile/Mapsincidence/surv&contro110IncidebyState.htm.)
INFLUENCES OF MODERN LIFESTYLE Carolina, and yellow fever in various states are other exam-
ANDÂ€TECHNOLOGY ples of diseases brought in from abroad (CDC, 2002b,
2003e, 2010q).
Some current trends in communicable diseases can be attrib- World commerce increases the possibility of tÂ�ransporting
uted to modernization and new technology. Industrialization infected products from one country to another. The live-Â�
and the crowding of a large number of people into the rel- animal market has been a source of infection and is the rea-
atively small space of a city provide fertile ground for an son many countries have strict animal quarantine standards.
increase in certain diseases. Crowding threatens sanitary and Even so, monkeys, reptiles, and birds shipped between coun-
other environmental conditions. In hard economic times, tries have been identified as sources of illness. Monkeypox
more families are forced to move in with relatives, which pro- outbreaks in the United States have been traced to U.S.-
duces more crowded conditions, or they move to housing that raised prairie dogs and Gambian giant rats imported from
is affordable but frequently less safe, with environmental haz- Ghana via Texas (CDC, 2003f). All of the infected animals
ards and more crime. eventually ended up with a single distributor in Illinois. In
Daycare arrangements and facilities for children have 2008 a shipment of rescued animals (cats and dogs) from
increased as rising numbers of mothers (or primary caregivers) Iraq contained one animal that was subsequently found to
enter the workforce. Approximately 7 million children under have rabies. None of the animals had documented rabies vac-
the age of five are now in daycare (Laughlin, 2010). These chil- cinations (CDC, 2008d).
dren are at greater risk of enteric infections (hepatitis A, cryp- Several disease outbreaks have been associated with food
tosporidiosis), respiratory tract infections, and middle ear shipments. The United States has strict guidelines for food
infections. Infected children, in turn, are infecting other house- shipped into this country, but lapses and outright disregard
hold members. of these standards occur. For example, raw meat infected with
The greater mobility of individuals and groups has facili- roundworms was the source of recent trichinellosis (CDC,
tated the transmission of diseases that would not otherwise 2003g). The contaminated meat products were manufactured
cross natural boundaries, such as oceans or mountains. Each in the United States, Egypt, Vietnam, and Yugoslavia. In 2007,
year, more and more people travel between countries. The pet food ingredients imported from China were linked to
spread of HIV infection can be traced to international and the death and severe illness of many household pets, and the
intracountry travel. For example, within Africa, cases of HIV United States Food and Drug Administration issued a warning
infection are heavily concentrated along travel routes (rivers about potential poisonous additives in toothpaste imported
and roads) from one country to another. HIV infection has also from China (China rejects U.S. alert on toothpaste, 2007). In
been traced to transoceanic travel as travelers infected elsewhere 2011 the Food and Drug Administration (FDA) found dried
return to their home countries. The spread of the SARS epi- lychee from China contained salmonella (FDA, 2011). In
demic is another example. 2010 there was a voluntary recall of 822 pounds of prosciutto
imported from Canada because of contamination with listeria
(U.S. Department of Agriculture, 2010).
In February 2003, China notified the WHO that a SARS of
Even modern medical interventions increase the possibility
unknown origin was present in six different regions in the
of rapidly transmitting communicable diseases. Hickman cath-
country, having started in approximately November 2002.
eters threaded into the jugular vein to provide easy access for
In February 2003, a man who had traveled to China was
drug administration and diagnostic procedures, central venous
hospitalized in Vietnam with similar symptoms. Health
pressure catheters, and other intravenous lines provide a route
care providers at the Vietnamese hospital also developed
for infectious organisms. Intubation devices, intracranial pres-
the same illness. The man initially treated in Vietnam was
sure monitors, and respiratory nebulizers are all sources of
transferred to a hospital in Hong Kong, where he died. By
Â�nosocomial infections. Because the United States does not have
that time, Hong Kong had a cluster of similar cases linked
a stringent reporting system it is difficult to determine just how
to another traveler to China. By mid-March 2003, the WHO
many deaths are associated with Â�hospital-acquired infections.
had reports of 264 individuals from 11 countries with sus-
The CDC estimates that hospital-Â�associated infections are the
pected or probable SARS (CDC, 2003c). By mid-June 2003
cause of about 99,000 deaths per year (Pollack, 2010).
a total of 8465 SARS cases were identified in 29 countries,
One new disease, legionellosis, is reported under the
with a 9.5% mortality rate.
National Notifiable Disease Surveillance System (NNDSS).
Legionellosis flourishes as a result of new technology, with
Examples of traveler-related illness episodes in the the causative organism thriving in damp, moist areas such as
United States include 75 cases of SARS in 2003, cholera heating and air conditioning ventilation systems. Legionellosis
in California, a new form of leishmaniasis among troops was first identified during an epidemiological investiga-
returning from the Persian Gulf conflict, and 1125 cases tion of an outbreak of illness among veterans attending an
of dengue fever in 2006 to 2008 (CDC, 1994, 2003d, 2004, American Legion Convention in the early 1980s. Periodic
2010p). Fifty-seven percent of the cases of measles in the outbreaks have occurred ever since, although careful mainte-
United States are brought in from other countries (CDC, nance of ventilation systems reduces the probability of infec-
2011m). Almost all cases of malaria (1484 in 2009) have tion. In 2008 an outbreak of legionellosis among patients at
been brought in from Africa, Asia, and Central America an Arizona hospital was traced to bronchoscopy equipment
(CDC, 2011n). Plague in New York City, pertussis in North (CDC, 2009c).
ISSUES OF POPULATION SAFETY VERSUS public health practitioners prefer to enroll the client in the
INDIVIDUAL RIGHTS treatment regimen by using education, encouragement,
and careful monitoring of compliance. If these measures
Throughout history, governments and public health officials fail, however, individuals may be restrained in hospitals or
have struggled with the problem of balancing individual rights institutions for a course of therapy until they can no longer
with the right of the community to be protected from infec- infect others and the disease is contained (see the Ethics in
tion. As a general rule, the safety of populations has taken pre- Practice box).
cedence over individual rights. To reduce the risk of exposure in The problem of HIV-infected persons who continue
populations, individual rights have been curtailed or revoked. risky behaviors is more difficult. How would one go about
For example: monitoring what people are doing in their private lives?
• People with leprosy were forced to wear bells to warn Should one even try? Health care workers have been strug-
others of their passing or were quarantined in separate gling with this dilemma for quite some time. HIV/AIDS has
communities. no cure. If one were to confine these clients, for how long
• Cities required individuals to dispose of their sewage in would one do so? For life? At the present time, only a few
approved privies. AIDS clients have been confined against their will because
• People who polluted water sources were imprisoned. of their refusal to protect others against infection. In some
• Plague victims were isolated in their homes or removed to cases, individuals with HIV infection or AIDS have been
central infected houses. criminally prosecuted for knowingly placing others at risk,
• During epidemics, the names of infected individuals were either through unprotected sex or deliberate injury such as
published. biting or scratching.
Similar strategies were used in other epidemics, including Many individuals in the public health sector have argued
the measles epidemics early in the twentieth century. Failure to for some time that HIV/AIDS should not be singled out for
comply with regulations was punishable by civil penalties such special treatment and that public health supersedes the indi-
as fines or by more drastic measures such as imprisonment or vidual's right of privacy. New recommendations from the
execution (Risse, 1988). For example: CDC recommend testing of all patients age 13 to 64 in health-
• During World War I, prostitutes were confined in central care settings and repeat testing annually for high-risk groups.
locations and treated to reduce the spread of venereal disease HIV testing is also recommended for all pregnant women and
epidemics. for newborns whose mothers' HIV status is unknown (CDC,
• The first widespread immunization program mandated that 2006i).
children be vaccinated against typhoid (Risse, 1988). Most state health departments do targeted testing of high-
• In the 1914 and 1919 polio epidemics, physicians and nurses risk groups. Routine testing in health care settings is sporadic.
made house-to-house searches to identify all infected Most state health departments do HIV testing of pregnant
persons. Infected children were removed to hospitals, women, 17 states screen newborns, and 6 states screen the
and the remaining family members were quarantined until general population age 13 to 64 (Kaiser Family Foundation,
they became noninfectious. Parents were unable to leave 2009).
their homes to bury their child if the child died in the
hospital.
Today the issue of individual rights versus community pro- ROLE OF THE NURSE IN COMMUNICABLE DISEASE
tection is an ongoing concern. Workplace safety is one impor- CONTROL
tant issue. Carriers of hepatitis A are restricted from certain
jobs, such as food handling. The CDC recommends that HIV- Historically, nursing has been an integral part of disease con-
infected health care workers be selectively assigned to duties so trol. Individuals with communicable diseases have always
as not to place other health care workers or clients at risk. The needed reliable nursing care. Initially, nursing was provided
CDC recommends that persons at risk for HIV infection not by members of religious orders, who were often the only help
give blood and that they change risky sexual and intravenous available during epidemics. In 1883, communicable disease
drug practices. This issue is especially pertinent today in light nursing was based primarily on the premise of preventing the
of the potential use of infectious disease agents as bioweapons spread of disease through cleanliness and fresh air. Aronson
(see ChapterÂ€22). (1978, p. 15) recalls the safety precautions for nurses making
An important area in which individual rights clash with pub- home visits:
lic safety involves the right of people to continue to knowingly
Before leaving the client's house, the nurse was required to
place others at risk. Two salient contemporary examples of this
wash her hands with carbolic soap and rinse her mouth with
problem are the following:
a fresh potassium permanganate solution. It was very impor-
• What should be done with a client with TB who refuses to
tant for the nurseâ•›.â•›.â•›.â•›to do the disinfection becauseâ•›.â•›.â•›.â•›people
follow the treatment regimen?
were very slow to learn.
• What should be done with an HIV-infected individual who
continues to share needles or engage in unprotected sex after In addition to caring for the sick, teaching hygiene to fami-
diagnosis? lies was a major responsibility of community nurses and is
Many states have laws to enforce treatment or isola- still a primary focus in the current control of communicable
tion of persons with known communicable diseases. Most diseases today.
ETHICS IN PRACTICE
Tension between Individual and Societal Rights Gail A. DeLuca Havens, PhD, RN
Codes of ethics can be thought of as moral codes. Moral commitments Paolo agrees, reluctantly, to cooperate in therapy. He asks how long
“to adhere to the ideals and moral norms of the profession,” such as it will take to be cured. Kay knows that the response to therapy var-
maintaining competency in practice, are expressed in the American ies, but most persons can be cured within 9â•›months (CDC, 2003b). Kay
Nurses Association (ANA) Code of Ethics for Nurses (2001, p. 5) and explains that 6â•›months of medication has been prescribed to cure his
are made by individuals when they become nurses. The fundamental tuberculosis. Before Kay leaves, Paolo takes his first dose of medication,
concept underlying the Code of Ethics for Nurses is respect for persons. and they establish a schedule for his observed daily self-Â�administration.
Certain principles growing out of this concept guide nurses' decision Paolo's treatment continues as planned over the next several months.
making. These include fostering self-determination, doing good, avoid- He gains strength and eventually finds a job. Returning to work requires
ing harm, being truthful, respecting privileged information, keeping that his medication regimen be modified. Paolo has no trouble adapting
promises, and treating people fairly. In their moral decision-making hier- it to his more demanding schedule. Several weeks pass with this new
archy, Beauchamp and Childress (2001) refer to principles and rules as arrangement until, one evening, Paolo does not appear. Kay leaves a
action guides. Principles are the more global and basic conceptions that message for him to call her, but does not hear from him. When Paolo
justify the rules. fails to appear again the following evening, Kay returns to the shel-
When ethical principles are being considered, it is important to ter. Eventually, Kay learns that Paolo has not been complying with his
remember that individuals are interdependent members of a commu- prescribed medication regimen. He does not deny it and tells Kay that
nity. The nurse will encounter situations in which the tension between because he has been taking medication for more than 3â•›months and
individual liberty and the need to preserve the health and well-being feels better, he believes that he is cured of his tuberculosis and no lon-
of the community creates an ethical dilemma in practice. For instance, ger needs therapy.
the nurse promises, as expressed by the principle of fidelity in the ANA How should Kay respond? Should she respect Paolo's right to self-
Code, to maintain client confidentiality. However, such a promise is not determination by not interfering with the decisions he has made? What
absolute when innocent parties are in direct jeopardy (e.g., threatened if Paolo were to be harmed by this noninterference? What if others were
with being killed) (ANA, 2001). This particular kind of dilemma is made to be harmed? Does Kay's obligation to Paolo to maintain confidential-
even more troublesome for the nurse who is attempting to deal with two ity remain even when his behavior might compromise the health and
opposing or contradictory promises. For example, the implicit promise well-being of others? Under what circumstances might a nurse place
of the nurse to maintain client confidentiality, as expressed in the ANA the health and well-being of members of a community before those of
Code, may contradict the nurse's obligation to obey a law that requires an individual client?
reporting a particular situation (ANA, 2001). The nurse also has an ethi- In this situation, because Paolo is an adult who is responsible for
cal responsibility to respect the client and promote self-determination. his own health, Kay could simply disregard the fact that Paolo has
Consider the following situation. not been adhering to his prescribed medication regimen. However,
Kay is a community health nurse who has been employed by a home she would not be helping Paolo to protect himself or others. Another
health agency for more than 10â•›years. Several of her clients live in a strategy that Kay might employ would be to engage Paolo in problem
homeless shelter and have been referred to her agency for follow- solving to further explore his reasons for not complying with the med-
up tuberculosis treatment after hospital discharge. Today she is mak- ication regimen. Uncovering reasons for noncompliance often results
ing her first visit to Paolo, a 33-year-old Hispanic man discharged in identifying ways to avoid it. One of the strategies recommended
after treatment in the hospital for acute, infectious tuberculosis. Kay for directly observed therapy is for the nurse to adopt a nonjudg-
explains that her agency, along with the city's health department, mental attitude toward clients, acknowledging that individuals often
helps persons with tuberculosis continue to take their medication as will not be 100% compliant with medication regimens. Kay could
prescribed until they are cured. Kay asks Paolo how he is feeling this acknowledge that, because Paolo is feeling better, it is understand-
morning. He replies that he is tired; he did not sleep well this first night able that he is not taking his medication as prescribed. However, she
in a place not familiar to him. After she completes Paolo's admission also ought to remind him that he places himself at great risk for get-
history and physical examination, Kay tells him that she, or a nurse ting very sick again and developing drug-resistant tuberculosis by not
substituting for her, will be visiting Paolo daily for 2â•›weeks to observe following his medication regimen. This course of action might also
him taking his medication and then twice weekly for at least 6â•›months. be an opportunity to foster Paolo's self-determination, to maintain
Paolo protests that he is not a child and that he can be depended on the confidential nature of his care, and to strengthen the client-nurse
to take his medication as prescribed. Kay explains that the current relationship.
standard of care is that everyone in the community being treated for However, adopting this strategy does jeopardize Paolo's health and
tuberculosis receive directly observed medication therapy. It will help the health of the people with whom Paolo comes in contact. Kay does
him remember to continue to take medication as prescribed, particu- not know whether Paolo's tuberculosis is infectious. Kay initiates tuber-
larly when he begins to feel better. Stopping the medication makes the culosis screening for the people with whom Paolo has been in contact
treatment he received in the hospital ineffective. When medication is and creates an opportunity for Paolo to have his tuberculosis reevalu-
stopped, often the tuberculosis becomes infectious again. In addition, ated. This action ought to diminish the potential for harm from active
not completing treatment increases the likelihood that he will develop tuberculosis to Paolo and to others with whom he has been in contact.
a type of tuberculosis that is resistant to medication therapy (Centers Because Kay's authority has been delegated to her by the health depart-
for Disease Control and Prevention [CDC], 2003a). He could be very ill ment, she can communicate with the health department without legally
again. The city has an obligation to protect its residents from becom- violating confidentiality. Kay is aware that many states require quaran-
ing infected with tuberculosis. Kay tells Paolo that she will be commu- tine of individuals who do not successfully complete a medication regi-
nicating with health department personnel because they are the ones men for tuberculosis. To protect the public, a community health nurse
who referred him to her. can recommend that formal action be taken to ensure that a person
Continued
ETHICS IN PRACTICE—CONT'D
Â�
complies with treatment. In this instance, quarantine means that indi- References
viduals can be hospitalized or incarcerated for treatment of tuberculosis American Nurses Association. 2001. Code of ethics for nurses with
against their will. interpretive statements. Washington, DC: Author.
As a third strategy, Kay can follow the established protocol to Â�initiate Beauchamp, T. L., & Childress, J. F. 2001. Principles of biomedical Â�ethics
quarantine, reporting Paolo's lack of compliance with medication ther- (5th ed.). New York: Oxford University Press.
apy to the appropriate people. However, this breaches the confidential Centers for Disease Control and Prevention. (2003a, June 20). Treatment
nature of the client–nurse relationship and compromises the trust and of tuberculosis: American Thoracic Society, CDC, and Infectious
mutual respect that have been established between Paolo and Kay. The Disease Society of America. Morbidity and Mortality Weekly Report,
ANA Code (2001) alerts nurses to the reality of suspending individual Recommendations and Reports, 52â•›(RR-11), 1-80. Retrieved May 22,
rights but warns that this ought to "be considered a serious deviation 2007 from http://www.cdc.gov/mmwr/PDF/rr/rr5211.pdf.
from the standard of care" (p. 9). Usually a nurse does not select the Centers for Disease Control and Prevention. (2003b). Treatment of drug-
third alternative until the second alternative has proven ineffective.Â€How susceptible tuberculosis disease in persons not infected with HIV.
might Paolo be affected by this experience? How might Kay be affected (Fact sheet). Retrieved May 22, 2007 from http://www.cdc.gov/tb/
by this experience? Which alternative would you choose? pubs/tbfactsheets/treatmentHIVnegative.htm.
Nurses have developed a new specialty—infection Â�control.

the dairy to cease selling raw milk products. The team rec-
Most of the time, infection control nurses are employed in
ommended that dairy workers increase their hand-washing,
hospitals or in large institutional settings. These nurses are
replace some of their equipment and utensils, and improve
concerned primarily with protecting staff and clients from
the cleaning Â�procedure in the dairy. No additional cases of
communicable and infectious organisms by developing and
Salmonella infection appeared (CDC, 2003h).
monitoring infectious control practices and educating staff
and clients.
Community health nurses play a major role in Â�contact EPIDEMIOLOGY APPLIED TO COMMUNICABLE
investigation for reportable communicable diseases. Sometimes DISEASE CONTROL
other health personnel may also be engaged in contact inves-
tigation. Community health nurses interview infected persons Epidemiology began as the study of communicable diseases
to help identify contacts placed at risk by exposure to infected affecting large populations (see ChapterÂ€7). Although the scope
individuals. Community nurses also perform home visits to of epidemiology has expanded to include noncommunicable
monitor persons under treatment and ensure compliance with diseases and other health-related issues, epidemiological prin-
the accepted treatment protocol (e.g., the TB observed therapy ciples are still the backbone of communicable disease control.
strategy). Nurses employed in special settings may also engage
in epidemiological investigations of new diseases or outbreaks Epidemiological Principles and Methods
of recognized illnesses, for example, Hantavirus disease in the Preventing communicable diseases begins with Â� knowledge
Southwest and food poisoning outbreaks such as a Salmonella- about the links in the chain of infection. The relationships and
caused episode in four states that resulted from the consump- interactions among the infectious agent (causative microor-
tion of unpasteurized milk. ChapterÂ€7 provides additional ganism), the host (human or animal incubating the agent),
information about epidemiological investigation. and the environment, that is, the components of the epidemi-
ological triangle, are important. Communicable disease con-
trol depends on discovering the weak link in the triangle and
Bridget Smith, a nurse with the Ohio Department of Health,
developing measures that attack and reduce or eliminate that
was assigned to a team investigating the suspected food poi-
threat. Control efforts include prevention activities and efforts
soning and hospitalization of two children. The children were
to reduce the seriousness of an illness as measured by the sever-
diagnosed with Salmonella enterica infection. The cause was
ity, the length of illness, the cost of treatment, the short- and
suspected to be raw (unpasteurized) milk. The milk came
long-term effects, and the risk of death.
from a popular dairy and restaurant. During the next 45â•›days,
the health department received reports on 94 other potential Communicable Disease Investigation
cases. As the number of potential cases increased, the depart-
In accordance with epidemiological principles, communica-
ment issued a regional public health alert. The health team
ble disease investigation involves five steps: identifying the dis-
performed case finding by screening the dairy workers, inter-
ease, isolating the causative agent, determining the method of
viewing customers of the restaurant, and obtaining spec-
transmission, establishing the susceptibility of the populations
imens (food and stool) for analysis. The team verified that
at risk, and estimating the impact on the population. With this
a total of 62 people had illness consistent with Salmonella
knowledge, public health officials can plan an effective interven-
infection (40 customers and family members and 16 dairy
tion program. The community health nurse contributes to the
workers). Testing of the food samples uncovered Salmonella
investigation effort at every level. The nurse in direct client care
in the raw milk, cream, and butter purchased by customers.
may be the first to identify the onset of a communicable disease,
Four barn workers had positive test results. The barn work-
to determine new victims and their relationship to known vic-
ers milked the cows, bottled the milk, and made ice cream.
tims (contact cases), and to discover patterns in the spread of
The health department reviewed the findings and ordered
the communicable disease. The role of the community health
nurse has broadened beyond direct care. Nurses are currently

involved with other health care professionals in population- Object or
focused investigation and intervention program design. vector
Causative Agent
Factors associated with the agents causing infectious diseases
CT
CO
include pathogenicity, infective dose, physical characteristics,
RE
NT
organism specificity, and antigenic variations. Pathogenicity,
DI
AC
or seriousness, encompasses invasiveness and virulence, terms
IN
T
used to assess the strength of the agent in victims. Highly virulent
(stronger) organisms cause greater morbidity and mortality. For
example, some influenza viruses are more virulent than others.
Although influenza A and B are similar, the symptoms of influ- DIRECT CONTACT
Agents* Human**
enza A are usually more severe, last longer, and require more fre-
quent hospitalization than the symptoms of influenza B (Bridges
etÂ€al., 2003). The degree of invasiveness (spread) is important, *Number of agents **Defense mechanisms
because highly invasive organisms have an opportunity to affect Characteristics of agents Immunity
more body systems. For example, the bacterium causing gonor- Pathogenicity Personal characteristics
rhea is usually confined to the genitourinary region. However, FIGUREÂ€8-6â•‡Transmission of communicable disease.
the spirochete that causes syphilis invades many different tissues,
including the brain, which results in more diverse symptoms.
The amount of agent needed to produce illness (infective Characteristics of the Host
dose) varies. Some agents are highly infectious; others are less Individuals possess defense mechanisms to combat or impede
so. For example, a disease such as chickenpox is highly infec- transmission of communicable disease agents. These defense
tious. Many people become infected even when exposed to rela- mechanisms include tears, skin, mucus, saliva, and the cilia
tively small amounts of chickenpox virus. Agents that are less (hairs) in the nose. Nose hair, for example, traps organisms
infectious, such as TB, require host exposure to larger numbers transmitted by breathing and reduces an agent's chance of
of TB bacilli for longer periods for transmission of disease. reaching a vulnerable body site. Even when defense mecha-
Transmission ability is also influenced by the agent's host nisms are compromised, health care professionals can assist in
requirements (agent specificity) and its ability to vary its genetic reducing the chance of infection. For example, Staphylococcus
structure (mutate). Some agents are highly particular about bacteria enter the body through a break in the skin barrier. Even
hosts. For example, the smallpox virus can infect only humans. when a wound breaks the skin barrier, good aseptic technique
Agents that are limited in the hosts they can infect are consid- will reduce the risk of staphylococcal infection.
ered highly specific. Immunity, either natural or artificially created, is another
The ability of some agents to alter their genetic structure also host characteristic useful in combating communicable disease.
poses problems for control efforts, because the resistance (abil- The immune system can halt symptoms by stopping the infec-
ity to resist a medication) of different strains may make treat- tion process before symptoms develop. Immunity is one exam-
ment less effective. For example, many variants of the organism ple of primary prevention. Natural immunity occurs when
causing gonorrhea are resistant to penicillin. In recent years, the individual has been infected with the disease and develops
Staphylococcus aureus infection has become difficult to treat immunity because of the body's antigen-antibody response to
because some strains are resistant to methicillin and other drugs the infection. Before the advent of vaccines, mothers deliber-
(CDC, 2006b, 2006c). ately exposed their children to others with mumps or measles,
purposely infecting them, because it was widely believed at the
Means of Transmission time that the illness would be less serious in young children
The frequency of transmission of an infectious disease depends than in those infected as adolescents or adults.
on the opportunities present for organism transport from its Artificial immunity is developed through vaccination rather
source to a new host. Transmission can occur through direct than through exposure to a communicable disease. Artificial
or indirect contact (FigureÂ€8-6). Direct contact includes physi- immunity can be active or passive. Active immunity is a result of
cal contact with an infected individual, animal, or other carrier, vaccination with live, killed, or attenuated organisms or a toxoid
or with large droplets (greater than 5µm) that travel very short of the agent. Live vaccines usually produce immunity that lasts
distances (less than 1m). Indirect contact involves passive trans- for long periods but may not be advisable for certain individu-
mission by something other than the source, usually an object als. For example, pregnant women and immunocompromised
that has been in direct contact with the source (e.g., contami- individuals should not be vaccinated with live antigen (e.g.,
nated water, air, dust, dressings, instruments, body secretions, polio vaccine). With the shorter-acting vaccines using toxoid
small droplets traveling longer distances, vectors). For exam- or attenuated, absorbed, and killed toxins (e.g., tetanus toxoid),
ple, Salmonella bacteria can be transmitted directly (through boosters are needed to keep antibody levels high enough to be
person-to-person contact by the oral-fecal route) or indirectly effective. Most people can use these vaccines.
(by way of food contaminated with infected feces). Knowledge Passive immunity can also be used to prevent infection. This
about transmission methods allows community health nurses type of immunity is derived from either antitoxins or antibodies
to reduce the risk of transmission to communities through (immunoglobulins), such as those transmitted from a mother
health education and assurance of good aseptic technique. to a fetus. This immunization is temporary and will have to
be repeated with each exposure. Immunoglobulin should not changes in the population. Variations in disease frequency can
be given with live vaccines of measles, mumps, or rubella because be examined to identify regular trends and episodic occurrences
the expected antibody response is decreased when the two are (Merrill & Timmreck, 2006). Regular trends include expected
given together. seasonal and yearly variations. For example, hay fever occurs
during the fall and spring seasons, and upper respiratory tract
Environment infections are common in the winter. An episodic occurrence
Altering the environment to reduce conditions that favor the is a sudden change in the rate of transmission or an epidemic.
spread of infectious agents is a very effective means of commu- For example, a large number of community residents may sud-
nicable disease control. Temperature, humidity, radiation, pres- denly contract food poisoning, or a countrywide measles epi-
sure, and ventilation can all be used to decrease the transmission demic may occur.
of infectious diseases. For example, organisms that thrive in Trends can also be observed over longer periods. At the
heat can be exposed to cold, those that grow best in humidity beginning of this chapter, a historic review provided evidence
can be controlled in a climate with little humidity, and so on. of change in the characteristics, spread, and treatment of com-
Crowding, famine, and the mobility of people increase the municable diseases over centuries. A more detailed examina-
possibility of spreading infections. Crowding is a problem tion of U.S. data shows a clear picture of communicable disease
because it provides agents with many potential victims rather trends since the 1950s (see TableÂ€8-1). As public health mea-
than only a few. In a famine, humans are weakened by poor sures become more effective in controlling certain communi-
nutrition and other health problems and are less able to resist an cable diseases, other diseases, new diseases, or mutant strains of
infectious disease. A starving population has many more suscep- known diseases become more prominent.
tible hosts than would be the case with a well-nourished popu-
lation. Finally, mobility increases the likelihood that agents are Research and Research Organizations
carried to other environments. The most obvious way to com- The first methodic studies of communicable disease were con-
bat such a spread is quarantine. Countries routinely close bor- ducted in 1913. In these studies, scientists explored the effects
ders when threatened by severe communicable diseases. During of water quality and pollution, and the resulting information
the 1950s, the primary method of reducing the spread of polio helped in the design of community interventions to control
was home quarantine. SARS is a recent example of an infectious the spread of disease through contaminated water. Surveys
disease leading to a closed-border quarantine. and contact investigation strategies were refined. Several orga-
nizations are committed to researching the characteristics and
Agent-Host-Environment and Favorable Conditions transmission patterns of communicable diseases. The two most
A basic knowledge of the impact of environment, host, agent, important research centers devoted to the study of the incidence
and the interrelated features in disease transmission is essen- of communicable diseases, treatment for diseases, and trends in
tial for community health nurses. Nurses must have the skill to diseases are the CDC and the WHO.
assess households and communities for favorable environments, The U.S. CDC, based in Atlanta, receives reports from local
susceptible hosts, and likelihood of viable agents. In addition, and state health departments and publishes a yearly summary
nurses must have the expertise to advise families and communi- of communicable diseases in the Morbidity and Mortality Weekly
ties regarding the strategies necessary to make the environment Report. Whenever an unusual outbreak of disease occurs, the
less habitable, reduce host susceptibility, and reduce or eliminate CDC sends scientific teams to the location of the outbreak to
the agent source. In some instances, interventions can be directed assist local authorities. The CDC is equipped with modern
at only one factor; in others, all three may be altered to improve computer and telecommunication technologies to track data
community resistance to infection. For example, needles contam- and coordinate monitoring efforts.
inated with HIV-infected blood can transmit HIV. A weak bleach
solution will kill the virus, altering the environment and reducing
the risk to a potential host (FigureÂ€8-7). HIV can also be trans-
mitted by sexual contact with an HIV-infected person. Using
barrier method precautions during sexual contact (dental dam, Infected
condoms, or nonoxynol-9 spermicidal jelly) will contain or kill needle
the virus. Diseases that are spread through contaminated water
or food are controlled by boiling or treating the water (chlorina-
tion) and by storing, preparing, and serving foods using sanitary ion
lut
techniques. For example, meats, poultry, vegetables, and fruits are h so
ac
inspected for infestation and approved for use only when they are Ble
free from contaminants and safe for human consumption.
Trends in Communicable Disease

The study of diseases over time provides valuable information
for public health planners. Trends are studied so that commu- HIV Condoms
nity health needs can be anticipated and intervention Â�strategies Human
virus
preplanned. Trends are also useful in examining the impact
of intervention programs. If programs are effective and effi- FIGUREÂ€8-7â•‡ Breaking the chain of infection in human immuno-
cient, they can be used again and again with modifications that deficiency virus infection (HIV) and acquired immunodeficiency
consider physical, psychological, sociological, and economic syndrome (AIDS).
The WHO supervises research into communicable diseases Â�

infectious organisms. Hepatitis B and HIV infection can both be
worldwide (see ChapterÂ€5). The WHO monitored the smallpox transmitted when health care workers are exposed to blood, semen,
epidemic and vaccination efforts; in fact, smallpox eradication or vaginal secretions. The resurgence of TB and other drug-resis-
is credited to the coordinated efforts of the WHO (Barquet & tant infections creates another occupational hazard. Time delays
Domingo, 1997). The WHO is currently coordinating world- during diagnosis or until treatment is effective place health care
wide immunization efforts. workers at risk. Correct and consistent infection control measures
The WHO adapts solutions from one part of the world for use are absolutely necessary to provide optimal protection in both
in similar situations in other areas. Researchers continue to study inpatient and community settings. Community health nurses
interventions in health care, adapting successful interventions to should be especially vigilant to maintain safe technique during
different cultures and discarding unsuccessful ones. For example, home and clinic interactions. The Occupational Safety and Health
vasectomy as a birth control measure is acceptable in some cultures Administration (OSHA) standards issued in 2001 require that
but unacceptable in others. The WHO's goal is to make health ser- safer injection devices be adopted and that records be kept of all
vices available in every country and dramatically reduce the rates sharp injuries. Implementation involves the use of needle-shielding
of communicable diseases. Community health nurses are an inte- or needle-free syringes in all situations (CDC, 2006j).
gral part of the WHO's intervention and research initiatives. Health
practitioners, many of them nurses working on site, are able to pro- ROLE OF BOARDS OF HEALTH
vide accurate, realistic, reliable data to assist this mighty effort.
Legislative Mandate
High-Risk Populations and Health Care Workers Local boards of health are charged with maintaining the health
High-risk populations need special attention, from prevention of the community. Boards provide direct services to individuals,
through treatment and recovery. Donnelly and colleagues (2010) gather data from these individuals and families, collate the data,
call these individuals compromised hosts, individuals who have report the data to state and local agencies, and maintain records
one or more defects in the body's natural defense mechanisms. for research purposes. Local boards carry out the legislative
These defects in defense are significant enough that the individual mandates of both the state and federal governments. The costs
is rendered predisposed to severe, often life-threatening infection. for carrying out the mandates are usually shared by all three lev-
The age, sex, genetic makeup, and general well-being of the els of government. The CDC offers financial assistance for many
host can contribute to or decrease the resistance to infectious programs aimed at control of infectious diseases.
diseases. Generally infants, young children, and older adults
(especially those who are undernourished or have a chronic Environmental Control
illness) have a lower resistance to infection. The severity of The primary responsibility for environmental oversight and
illness in these groups is also greater. Preschool children are at prevention of associated health problems rests with the health
special risk because they spend a lot of time in groups and do department. Jekel and colleagues (2007) list some of the respon-
not have fully developed immune systems. Many older adults sibilities related to water, food, and sewage controls. The water
have diminished immunity from underlying medical problems supply is protected by chlorinating and fluoridating munici-
or an impaired nutritional status. Older adults' skin is fragile pal water supplies, testing private and public drinking water
and easily broken, and they may have been exposed for longer for contaminants, regulating the digging of wells, and limiting
periods to environmental hazards. Consequently, the risks for or restricting construction in watershed districts. The health
urinary tract infections, infectious diarrhea, and upper respira- department protects food supplies through surveillance of res-
tory tract infections such as TB and pneumonia are increased. taurants, grocery stores, and markets. These departments check
Community health nurses who understand these factors can for proper food storage, preparation, and service and monitor
develop nursing strategies to increase resistance and generate the health of persons serving and preparing the food. If any
more efficient defense mechanisms in clients at particular risk. food processing or packaging plants are within the jurisdiction,
Immunosuppressed clients are also at risk for contracting these are scrutinized as well. Sewage disposal and treatment are
communicable diseases. People undergoing immunosuppressive controlled. Public swimming pools and beaches are inspected
therapy after bone marrow or organ transplantation or therapy frequently to ascertain the safety of water and facilities. Most
for acute lymphocytic leukemia risk infection from multiple local boards of health either have direct control or work closely
organisms. Other conditions that may cause a defect in the cel- with the public agency that mandates construction codes for
lular immunity of a person are Hodgkin disease and HIV infec- public and private buildings.
tion. Cancerous conditions such as acute leukemia, myeloma,
hairy cell leukemia, and brain tumors predispose clients to Reportable Diseases Oversight
reduced resistance to diseases. Clients with spinal cord injuries The CDC tracks national statistics for and trends in commu-
are susceptible to urinary tract infections and skin infections. nicable diseases through the NNDSS, which maintains regu-
Intravenous drug abusers are at risk because drug abuse can lar surveillance of all disease for which reporting is mandatory,
directly cause infection. An infected needle left by one person as well as other diseases of interest or concern (BoxÂ€8-3). For
and shared by another will transmit infection. There may be example, reporting is not mandatory for either SARS or mon-
indirect causes for the increase of infections in intravenous drug keypox, but both are monitored and tracked by the CDC. The
abusers as well. Many drug abusers are poorly nourished, live CDC also issues guidelines and recommendations on the pre-
in substandard conditions with poor sanitation, and are more vention and treatment of specific diseases. An excellent source
often exposed to others who carry communicable diseases. for this Â�information is the Morbidity and Mortality Weekly Report
Health care workers are considered a risk group because published by the CDC. This publication is a valuable resource
their work environment places them in proximity to numerous for community health nurses because it provides information on
BOXÂ€8-3â•‡ â•…NATIONALLY NOTIFIABLE INFECTIOUS DISEASES—UNITED STATES, 2009

• Anthrax • Measles
• Arboviral neuroinvasive and nonneuroinvasive diseases • Meningococcal disease
• California serogroup virus disease • Mumps
• Eastern equine encephalitis virus disease • Novel influenza A virus infections
• Powassan virus disease • Pertussis
• St. Louis encephalitis virus disease • Plague
• West Nile virus disease • Poliomyelitis, paralytic
• Western equine encephalitis virus disease • Poliovirus infection, nonparalytic
• Botulism • Psittacosis
• Food-borne • Q fever*
• Infant • Acute
• Botulism, other (wound and unspecified) • Chronic
• Brucellosis • Rabies
• Chancroid • Animal
• Chlamydia trachomatis, infections • Human
• Cholera • Rocky Mountain spotted fever
• Coccidioidomycosis • Rubella
• Cryptosporidiosis • Rubella, congenital syndrome
• Cyclosporiasis • Salmonellosis
• Diphtheria • Severe acute respiratory syndromeassociated coronavirus (SARS-CoV)
• Ehrlichiosis/Anaplasmosis disease ‡
• Ehrlichia chaffeensis • Shiga toxinproducing Escherichia coli (STEC)
• Ehrlichia ewingii • Shigellosis
• Anaplasma phagocytophilum • Smallpox§
• Anaplasma undetermined • Streptococcal disease, invasive, group A
• Giardiasis* • Streptococcal toxic shock syndrome
• Gonorrhea • Streptococcus pneumoniae, drug resistant, all ages, invasive
• Haemophilus influenzae, invasive disease* disease
• Hansen's disease (leprosy) • Streptococcus pneumoniae, invasive disease non drug resistant in
• Hantavirus pulmonary syndrome children younger than 5 years
• Hemolytic uremic syndrome, post-diarrheal • Syphilis
• Hepatitis, viral, acute • Syphilis, congenital
• Hepatitis A, acute • Tetanus
• Hepatitis B, acute • Toxic shock syndrome (other than streptococcal)
• Hepatitis B virus, perinatal infection • Trichinellosis
• Hepatitis C, acute • Tuberculosis
• Hepatitis, viral, chronic • Tularemia*
• Chronic hepatitis B • Typhoid fever
• Hepatitis C virus infection (past or present) • Vancomycin-intermediate Staphylococcus aureus (VISA)
• Human immunodeficiency virus (HIV) infection** infection*
• Influenza-associated pediatric mortality • Vancomycin-resistant Staphylococcus aureus (VRSA) infection*
• Legionellosis • Varicella (morbidity)
• Listeriosis • Varicella (mortality)
• Lyme disease • Vibriosis †
• Malaria • Yellow fever
*New to list since 1997.
**AIDS has been reclassified as HIV stage III.
†New to list in 2007.
‡New to list since 2003.
§Added back to list since 2003.
From Centers for Disease Control and Prevention. (2011). Summary of notifiable diseases United States, 2009. Morbidity and Mortality Weekly
Report, 58(53), 1-100.
specific diseases and public health problems and supplies epi- Â�

pertussis report form showing the type of information filed with
demiological data on reportable diseases, as well as other com- the CDC. The state health departments issue reporting directions
municable diseases and public health concerns such as HPV and treatment recommendations to local health departments
infection and adolescent homicide. and those departments gather information about communica-
State public health departments have the legal responsibil- ble diseases from health care providers in their regions.
ity for controlling communicable diseases and reporting notifi- Direct diagnosis and treatment, counseling, contact trac-
able communicable diseases to the CDC. Most of the reporting ing, and follow-up are done by local health departments.
to the CDC is done electronically. Website Resource 8B is a Community health nurses perform many of these services.
In addition to collecting information on all notifiable com- Protection of International Travelers

municable diseases, states may investigate other health concerns Local boards of health serve the public by acting as a conduit
at their discretion. Throughout the United States, approximately of information on health-related matters for international trav-
90 diseases are reportable through the health department sur- elers. These boards provide information on country-specific
veillance systems. Surveillance data help the CDC and individual immunization requirements and strategies to protect a trav-
states decide which health concerns should have priority. eler's health while in another country. The Office of Overseas
Many communicable diseases show seasonal fluctuations Travel at the CDC supplies most of the travel-related informa-
or uneven geographic distributions or higher incidences in tion to local and state units; for example, information on water
selected risk groups; others have cycles during which they and food safety, sanitary conditions, sanctions or penalties for
are more or less severe. Surveillance data reveal these trends. illegal drug use, and necessary steps to ensure travelers that
Appropriate strategies can then be planned to prevent or reduce they are in compliance with the laws regulating legal medica-
the impact of these diseases. Surveillance also assists in identify- tion use in foreign countries. In most countries, travelers must
ing the most effective control methods. For example, the CDC carry documentation on prescription drugs. Community health
was able to identify a resurgence of measles among adoles- nurses in local health departments can assist travelers in collect-
cents and young adults. Researchers found that the combined ing information pertinent to their travel plans.
measles-mumps-rubella vaccine was less long-acting than was
previously thought. New immunization standards were developed NURSING CARE IN THE CONTROL OF
to include a booster dose around age 11 or 12â•›years. COMMUNICABLE DISEASES
Immunizations and Vaccines: Oversight Community health nurses may focus their energies on popula-
andÂ€Recommendations tion groups or on individuals and their family members. In either
Immunization is the most effective primary prevention method case, their ultimate goal is the same: protecting populations from
for controlling communicable diseases in populations. Vaccines the spread of communicable diseases. To be effective, commu-
are not presently available for all communicable diseases. nity health nurses must be familiar with basic information about
Immunization is important not only for children, but also for communicable diseases, including causative organisms, incuba-
older adults, the chronically ill, and other individuals who are tion period, mode of transmission, symptoms, protective mea-
at increased risk (e.g., health care workers). FiguresÂ€8-8 and 8-9 sures, and the necessary treatments. This information is critical
provide lists of recommended immunizations for young chil- to planning care aimed at preventing transmission of infectious
dren and adults. Website Resource 8C provides a recom- diseases or ameliorating the symptoms of persons who have
mended immunization schedule for children age 7 through acquired a disease. Basic information about a number of specific
18â•›years. Website Resource 8D provides a guide to vaccines diseases is given in TableÂ€8-3. The diseases are arranged accord-
indicated for adults based on medical and other conditions and ing to five general routes of infection: respiratory, integumentary,
Website Resource 8E is a guide to contraindications and gastrointestinal, serum, and sexually transmitted. Some diseases
Â�precautions to vaccine administration. can be transmitted through more than one route. For example,
State and local health departments provide immunization HIV infection and hepatitis are discussed under blood-borne
clinics and free immunizations to selected populations and over- diseases, but both are also transmitted through sexual contact,
see vaccine distribution and safety. Local health departments and hepatitis can be transmitted through the fecal-oral (gastro-
have the responsibility to report specific vaccine-related infor- intestinal) route as well. TableÂ€8-3 presents only a brief overview
mation to the U.S. Department of Health and Human Services of selected communicable diseases. For more complete infor-
in compliance with the National Childhood Vaccine Injury Act. mation, refer to the Heymann text, Control of Communicable
All health care providers who administer a vaccine must record Diseases Manual (2008), published by the American Public
the serial number of the vial, the name of the company, and Health Association.
any adverse reactions to the vaccine. Website Resource 8F
provides a sample state vaccine report form. If the vaccine is Primary Prevention
privately purchased, the report goes through the local board of The major thrust of community health agencies in controlling
health to the U.S. Food and Drug Administration; if it is pub- communicable diseases is primary prevention. Community
licly purchased, reporting is done directly to the CDC. health nurses play a vital role in eliminating or reducing the
In the early 1980s a significant number of severe reactions spread of disease by providing immunizations, prophylactic
to the pertussis vaccine (e.g., psychomotor limitations, paraly- measures, and health education. Health teaching efforts are
sis) generated concern that parents were not receiving adequate geared toward risk reduction (e.g., increasing public awareness
information about the risks associated with vaccines. As a result, of risky behavior, eliminating or reducing the risk of personal
in 1986, Congress passed the National Childhood Vaccine Injury behaviors, and providing information for caregivers on meth-
Act, or Child Injury Act. This law requires that a parent's signa- ods to isolate and destroy bacterial or viral agents and on self-
ture be obtained before a child is immunized to testify that the protection techniques).
parent has been informed of the risks associated with adminis-
tration of the vaccine and establishes (1) a reporting system for Immunizations
tracking all vaccine doses and (2) a fund to assist children with Vaccines are the most effective way to control contagious dis-
adverse reactions to the vaccine. To receive compensation for eases. Immunizations are available for chickenpox, measles,
vaccine reactions, the affected person must have an injury of at mumps, rubella, diphtheria, pertussis, tetanus, polio, influ-
least 6â•›months' duration and at least $1000 in expenses directly enza, and hepatitis A and B. Research continues on the devel-
related to the injury. opment of vaccines for HIV, herpes virus, and cytomegalovirus.
Recommended immunization schedule for persons aged 0 through 6 years—United States, 2012 (for those who fall behind or start late, see the catch-up
schedule)
1 2 4 6 9 12 15 18 19–23 2–3 4–6
Vaccine Age Birth month months months months months months months months months years years
Range of
Hepatitis B1 Hep B HepB HepB recommended
ages for all
children
Rotavirus2 RV RV RV2
Diphtheria, tetanus, pertussis3
DTaP DTaP DTaP see footnote3 DTaP DTaP
Haemophilus influenzae type b 4
Hib Hib Hib 4
Hib Range of
recommended
Pneumococcal5 PCV PCV PCV PCV PPSV ages for certain
high-risk
Inactivated poliovirus6 IPV IPV IPV IPV groups
Influenza7 Influenza (Yearly)

Measles, mumps, rubella8 MMR see footnote8 MMR
Range of
Varicella9 Varicella see footnote9 Varicella recommended
ages for all
children and
Hepatitis A 10
Dose 1 10
HepA Series certain high-
risk groups
Meningococcal11 MCV4 — see footnote 11
This schedule includes recommendations in effect as of December 23, 2011. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated
and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory
Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm Clinically significant adverse events that
follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).
1. Hepatitis B (HepB) vaccine. (Minimum age: birth) 7. Influenza vaccines. (Minimum age: 6 months for trivalent inactiveted influenza
At birth: vaccine [TIV]; 2 years for live, attenuated influenza vaccine [LAIV])
• Administer monovalent HepB vaccine to all newborns before hospital discharge. • For most healthy children aged 2 years and older, either LAIV or TIV may be
• For infants born to hepatitis B surface antigen (HBsAg)–positive mothers, used. However, LAIV should not be administered to some children, including
administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) 1) children with asthma, 2) children 2 through 4 years who had wheezing in
within 12 hours of birth. These infants should be tested for HBsAg and antibody the past 12 months, or 3) children who have any other underlying medical
to HBsAg (anti-HBs) 1 to 2 months after completion of at least 3 doses of the conditions that predispose them to influenza complications. For all other
HepB series, at age 9 through 18 months (generally at the next well-child visit). contraindications to use of LAIV, see MMWR 2010;59(No. RR-8), available at
• If mother’s HBsAg status is unknown, within 12 hours of birth administer http://www.cdc.gov/mmwr/pdf/rr/rr5908.pdf.
HepB vaccine for infants weighing ≥2,000 grams, and HepB vaccine plus • For children aged 6 months through 8 years:
HBIG for infants weighing <2,000 grams. Determine mother’s HBsAg status — For the 2011–12 season, administer 2 doses (separated by at least
as soon as possible and, if she is HBsAg-positive, administer HBIG for 4 weeks) to those who did not receive at least 1 dose of the 2010–11
infants weighing ≥2,000 grams (no later than age 1 week). vaccine. Those who received at least 1 dose of the 2010–11 vaccine
Doses after the birth dose: require 1 dose for the 2011–12 season.
• The second dose should be administered at age 1 to 2 months. Monovalent — For the 2012–13 season, follow dosing guidelines in the 2012 ACIP
HepB vaccine should be used for doses administered before age 6 weeks. influenza vaccine recommendations.
• Administration of a total of 4 doses of HepB vaccine is permissible when a 8. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months)
combination vaccine containing HepB is administered after the birth dose. • The second dose may be administered before age 4 years, provided at least
• Infants who did not receive a birth dose should receive 3 doses of a HepB- 4 weeks have elapsed since the first does.
containing vaccine starting as soon as feasible. • Administer MMR vaccine to infants aged 6 through 11 months who are
• The minimum interval between dose 1 and dose 2 is 4 weeks, and between traveling internationally. These children should be revaccinated with 2 doses
dose 2 and 3 is 8 weeks. The final (third or fourth) dose in the HepB vaccine of MMR vaccine, the first at ages 12 through 15 months and at least 4 weeks
series should be administered no earlier than age 24 weeks and at least 16 after the previous dose, and the second at ages 4 through 6 years.
weeks after the first dose. 9. Varicella (VAR) vaccine. (Minimum age: 12 months)
2. Rotavirus (RV) vaccines. (Minimum age: 6 weeks for both RV-1 [Rotarix] and • The second dose may be administered before age 4 years, provided at least
RV-5 [Rota Teq]) 3 months have elapsed since the first dose .
• The maximum age for the first dose in the series is 14 weeks, 6 days; and • For children aged 12 months through 12 years, the recommended minimum
8 months, 0 days for the final dose in the series. Vaccination should not be interval between doses is 3 months. However, if the second dose was
initiated for infants aged 15 weeks, 0 days or older. administered at least 4 weeks after the first dose, it can be accepted as valid.
• If RV-1 (Rotarix) is administered at ages 2 and 4 months, a dose at 6 months 10. Hepatitis A (HepA) vaccine. (Minimum age: 12 months)
is not indicated. • Administer the second (final) dose 6 to18 months after the first.
3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. • Unvaccinated children 24 months and older at high risk should be
(Minimum age: 6 weeks) vaccinated. See MMWR 2006;55(No. RR-7), available at http://www.cdc.gov/
• The fourth dose may be administered as early as age 12 months, provided at mmwr/pdf/rr/rr5507.pdf.
least 6 months have elapsed since the third dose. • A 2-dose HepA vaccine series is recommended for anyone aged 24 months
4. Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks) and older, previously unvaccinated, for whom immunity against hepatitis A
• If PRP-OMP (PedvaxHIB or Comvax [HepB-Hib]) is administered at ages 2 virus infection is desired.
and 4 months, a dose at age 6 months is not indicated. 11. Meningococcal conjugate vaccines, quadrivalent (MCV4). (Minimum age: 9
• Hiberix should only be used for the booster (final) dose in children aged 12 months for Menactra [MCV4-D], 2 years for Menveo [MCV4-CRM])
months through 4 years. • For children aged 9 through 23 months 1) with persistent complement
5. Pneumococcal vaccines. (Minimum age: 6 weeks for pneumococcal conjugate component deficiency; 2) who are residents of or travelers to countries with
vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPSV]) hyperendemic or epidemic disease; or 3) who are present during outbreaks
• Administer 1 dose of PCV to all healthy children aged 24 through 59 months caused by a vaccine serogroup, administer 2 primary doses of MCV4-D,
who are not completely vaccinated for their age. ideally at ages 9 months and 12 months or at least 8 weeks apart.
• For children who have received an age-appropriate series of 7-valent • For children aged 24 months and older with 1) persistent complement
PCV (PCV7), a single supplemental dose of 13-valent PCV (PCV13) is component deficiency who have not been previously vaccinated; or 2)
recommended for: anatomic/functional asplenia, administer 2 primary doses of either MCV4 at
— All children aged 14 through 59 months least 8 weeks apart.
— Children aged 60 through 71 months with underlying medical conditions. • For children with anatomic/functional asplenia, if MCV4-D (Menactra) is
• Administer PPSV at least 8 weeks after last dose of PCV to children aged 2 used, administer at a minimum age of 2 years and at least 4 weeks after
years or older with certain underlying medical conditions, including a cochlear completion of all PCV doses.
implant. See MMWR 2010:59(No. RR-11), available at http://www.cdc.gov/ • See MMWR 2011;60:72–6, available at http://www.cdc.gov/mmwr/pdf/wk/
mmwr/pdf/rr/rr5911.pdf. mm6003. pdf, and Vaccines for Children Program resolution No.
6. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) 6/11-1, available at http://www. cdc.gov/vaccines/programs/vfc/downloads/
• If 4 or more doses are administered before age 4 years, an additional dose resolutions/06-11mening-mcv.pdf, and MMWR 2011;60:1391–2, available
should be administered at age 4 through 6 years. at http://www.cdc.gov/mmwr/pdf/wk/mm6040. pdf, for further guidance,
• The final dose in the series should be administered on or after the fourth including revaccination guidelines.
birthday and at least 6 months after the previous dose.
This schedule is approved by the Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/recs/acip),
the American Academy of Pediatrics (http://www.aap.org), and the American Academy of Family Physicians (http://www.aafp.org).
Department of Health and Human Services • Centers for Disease Control and Prevention
FIGUREÂ€8-8â•‡Recommended child and adolescent immunization schedule by vaccine and age

through age six years, 2011. (From Centers for Disease Control and Prevention. [2011]. Recommended
immunization schedule for persons aged 0 through 6â•›years—United States, 2011. Retrieved from http://www.
cdc.gov/vaccines/recs/acip.)
Recommended Adult Immunization Schedule—United States - 2012

Note: These recommendations must be read with the footnotes that follow
containing number of doses, intervals between doses, and other important information.
Recommended adult immunization schedule, by vaccine and age group1
VACCINE AGE GROUP 19-21 years 22-26 years 27-49 years 50-59 years 60-64 years 65 years
Influenza 2 1 dose annually
Tetanus, diphtheria, pertussis (Td/Tdap) 3,* Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs Td/Tdap 3
Varicella 4,* 2 Doses
Human papillomavirus (HPV) Female 5,* 3 doses
Human papillomavirus (HPV) Male 5,* 3 doses
Zoster 6 1 dose
Measles, mumps, rubella (MMR) 7,* 1 or 2 doses 1 dose
Pneumococcal (polysaccharide) 8,9 1 or 2 doses 1 dose
Meningococcal 10,* 1 or more doses
Hepatitis A 11,* 2 doses
Hepatitis B 12,* 3 doses
*Covered by the Vaccine Injury Compensation Program
For all persons in this category who Recommended if some other risk Tdap recommended for 65 if contact No recommendation
meet the age requirements and who factor is present (e.g., on the basis with 12 month old child. Either Td or
lack documentation of vaccination of medical, occupational, lifestyle, or Tdap can be used if no infant contact
or have no evidence of previous other indications)
infection
Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.
vaers.hhs.gov or by telephone, 800-822-7967.
Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the
U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.
Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at www.cdc.gov/vaccines or from the CDC-INFO Contact
Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 8:00 a.m. - 8:00 p.m. Eastern Time, Monday - Friday, excluding holidays.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
FIGUREÂ€8-9â•‡Recommended adult immunization schedule, by vaccine and age group. (From

Centers for Disease Control and Prevention. [2011]. Recommended adult immunizations schedule—United
States, October 2011. Retrieved from http://www.cdc.gov/vaccines.)
Rabies Â�vaccine is only selectively available to persons at high risk Older adults need a tailored immunization program. By age
because of costs and side effects. Although a TB vaccine is avail- 65, most older Americans have developed an immunity to mea-
able, it is not in common use in the United States because the sles (rubeola) and diphtheria, but they need to maintain their
rate of infection has been low and the vaccine is only moderately polio, tetanus, influenza, hepatitis, and pneumococcal vaccine
effective. In conjunction with the Healthy People 2020 objectives, protection. Approximately 49% of tetanus cases occur in per-
community health nurses should strive to increase immuniza- sons over the age of 50â•›years (CDC, 2011o). Community health
tion rates among all designated target groups by providing edu- nurses need to check for outdated or nonexistent immuniza-
cation on the need for immunization, identifying and targeting tions in older adults and other at-risk groups. Influenza vac-
risk groups, and improving access to immunization through cines are modified each year to accommodate new strains.
public and privately financed efforts. The national coverage Unless older and chronically ill persons are revaccinated
rates exceed 90% for school-aged children (USDHHS, 2010b). yearly, they may not be protected from the most recent form
The most significant progress has been made in Haemophilus of influenza.
influenzae type b and hepatitis B vaccinations. All clients should be well informed of the risks associated
Community health nurses educate parents of children as with each vaccine they receive. Every health care provider who
well as susceptible adults about the importance of immuniza- administers immunizations should be aware of the responsibil-
tions and supply immunizations through clinic facilities (see the ity to provide this information to the client or, in the case of
Healthy People 2020 box on page 223). When reviewing individ- children, to the parents.
ual records, nurses should be especially diligent to ensure that Nurses should screen clients before administering the
vaccinations for all clients are up to date. Antibody titers can vaccine. The person's health status should be assessed. The
identify clients whose antibody levels have waned. Revaccination individual should be asked if he or she has been ill recently
is often necessary for individuals with low Â�antibody titers. or under a physician's care; if he or she has had previous
Text continued on Page 222
TABLEÂ€8-3â•…â•‡COMMUNICABLE DISEASES, COMMUNITY HEALTH CONCERNS,

AND TREATMENT (COMPILED BY JENNIFER KLIPHOUSE*)
DISEASE COMPLICATIONS AND
(CAUSATIVE MODE OF COMMUNITY HEALTH TREATMENT OR
AGENT) SYMPTOMS TRANSMISSION CONCERNS NURSING MANAGEMENT
Respiratory Route
Chickenpox (Varicella Prodromal: low-grade fever, Very contagious, person- Seasonal with increased Isolation at home until lesions
zoster virus) headache, listlessness. to-person direct contact incidence in late winter and are crusted over.
2nd: pruritic rash which has with respiratory early spring. Supportive: rest, relief of
three phases; macular, secretions or contact Older adults and itching and prevention of
papular, and vesicular, which with airborne respiratory immunocompromised bacterial skin infection
scab and crust over. droplets. may develop shingles, (clean and dry skin, short
Rash usually on scalp and trunk Indirect contact via soiled herpes zoster, with virus nails or mitts to prevent
(where most concentrated) articles infected from reactivation. A shingles scratching, calamine
can generalize to entire body lesions or discharge vaccine has been developed lotion, tepid oatmeal
and mucous membranes from skin lesions, vesicle for people over the age baths, antihistamines),
such as the mouth with discharges, or nasal or of 60 who have not had antipyretics (non-aspirin
appearance as shallow white pharyngeal secretions. shingles. due to the association with
ulcers. Incubation period: Complications: secondary Reye syndrome).
Fetal effects: rare congenital 10-21â•›days. bacterial infections of Antivirals are considered for
symptoms (Congenital Communicable: 1-2â•›days skin caused by itching and the immunocompromised
Varicella Syndrome, with before and until lesions scratching. and those at risk for
infection during first are crusted over, about Others: encephalitis, severe disease to decrease
20Â€weeks of gestation), 5â•›days. pneumonia, death. symptoms.
low birth weight, extremity Prevention: Vaccine either
atrophy, scarring of skin, Varicella live attenuated
eye and neurological vaccine or Herpes
abnormalities. Zoster vaccine (for those
over 60).
Vaccine contraindicated for
immunosuppressed, those
who are pregnant,
and recent blood product
recipients.
Diphtheria Flu-like symptoms with sore Person-to-person Asymptomatic carrier state Hospitalization, antitoxin
(Corynebacterium throat, fever, swelling direct contact with possible; should be treated (immediately on diagnosis),
diphtheriae) of cervical lymph nodes airborne respiratory with antibiotics. antibiotics. Isolation (until
anaerobic gram and larynx with potential droplets or rarely with Complications: respiratory two negative throat cultures
positive bacillus respiratory distress. indirect contact with obstruction, suffocation or 24â•›hours after antibiotics
Characterized by formation of contaminated articles. (especially in children under completed).
gray asymmetrical tenacious Incubation period: 2-5â•›days. 5â•›years). With toxin release Respiratory support; oxygen,
membrane on tonsils and Communicable: variable, in the blood: myocarditis, humidification.
pharyngeal walls. as long as 4â•›weeks neuritis. Prevention: Vaccine
without antibiotics. immunization. Contacts of
diphtheria should receive
prophylactic antibiotics.
Meningococcal Sudden onset flu-like Direct contact with Increased risk seen with close Hospitalization, antibiotics,
meningitis symptoms; fever, headache, respiratory droplets (e.g., and prolonged contact (e.g., droplet precautions.
(Neisseria stiff neck, nausea, vomiting, kissing, coughing). first-year college students Prevention: Vaccine
meningitides) photophobia, lethargy. Incubation period: living in dormitories, immunization. Close
(bacteria) Rapid progression of disease 2-10â•›days military recruits) and in contacts of disease should
may be fatal with multiorgan Communicable until live travel to areas with high receive prophylactic
failure. bacteria no longer meningococcal disease. antibiotics and booster if
present in discharge Medical emergency, early inadequately immunized.
droplets, usually 24â•›hours diagnosis and treatment Reduce overcrowded living
after antibiotic treatment is essential to prevent conditions if possible.
started. complications.
Complications: Permanent
hearing loss, neurological
damage, loss of phalanges
or limbs, death.
TABLEÂ€8-3â•…â•‡COMMUNICABLE DISEASES, COMMUNITY HEALTH CONCERNS, AND TREATMENT

(COMPILED BY JENNIFER KLIPHOUSE*)—CONT'D
Pertussis or 1st: catarrhal stage: symptoms Direct contact with Incidence has increased Respiratory isolation,
whooping cough of upper respiratory infection. respiratory secretions or gradually since the 1980s. antibiotics, hospitalization
(Bordetella 2nd: paroxysmal stage: rarely by indirect contact Infants younger than 1year with oxygen, humidification,
pertussis) (bacteria) numerous rapid coughs with contaminated are most severely affected fluids, nasotracheal
followed by high-pitched articles. with asphyxia possible. suctioning.
inspiratory "whoop." Incubation period: Usually Complications: otitis media, Prevention: Vaccine
Vomiting, small scleral and 7-10â•›days. secondary bacterial immunization. Close
conjunctival hemorrhages Communicable: very pneumonia, seizures, contacts of pertussis
caused by severe coughing. contagious from early encephalopathy, death. should receive antibiotic
catarrhal stage to prophylaxis.
2â•›weeks after onset.
Rubella and German Prodromal: low-grade fever, Direct or indirect Mild self-limiting disease Isolation at home until rash
measles (rubella malaise, sore throat, coryza, contact with large except to fetus. disappears.
virus, rubivirus) cough. respiratory droplets To prevent congenital rubella Supportive: rest, fluids, cool
“three day measles” 2nd: fine red maculopapular or nasopharyngeal syndrome, women of mist vaporizer, analgesics
rash begins on face and secretions. childbearing years should (avoid aspirin due to the
scalp with spread down Transmission to fetus be immunized before association with Reye
to body and limbs lasting during active maternal pregnancy and delay syndrome).
1-3â•›days. Occipital lymph infection. Infants with pregnancy for 4â•›weeks after Prevention: Vaccine
node enlargement, arthralgia, congenital rubella immunization. Alternately, immunization. Pregnant
arthritis. syndrome may shed virus women can be vaccinated women should avoid contact
Fetal infection: congenital from body secretions for immediately after delivery. with persons with rubella.
rubella syndrome most up to a year.
common in first trimester Incubation period:
exposure; deafness (most 14-23â•›days.
common symptom), Communicable: 7â•›days
cataracts, heart defects, before to 5-7â•›days
microcephaly, mental after rash appears.
retardation, spontaneous Moderately contagious.
abortion, premature delivery,
fetal death.
Rubeola and measles Prodromal: cold-like symptoms, Person-to-person direct Complications: diarrhea, Isolation at home until 5â•›days
(rubeola virus) cough, and high fever or airborne contact otitis media, pneumonia, after rash disappears.
(paramyxovirus) (103-105°F), malaise. with large respiratory encephalitis. In hospital respiratory
“red or hard Conjunctivitis, photophobia. droplets. Measles during pregnancy isolation.
measles” “9â•›day Koplik spots in the mouth Incubation period: can cause miscarriage, Supportive: rest, fluids, tepid
measles” (bluish-white and very fine) 7-14â•›days. premature labor and low- baths, cool mist vaporizer.
that disappear with rash Communicable: 4â•›days birth-weight infant. Comfort by dimming the
onset. before to 4â•›days after Generally MMR vaccine lights, washing eyes
2nd: red maculopapular rash rash. Highly contagious. is contraindicated in with warm saline water.
begins in hairline with face Permanent immunity is immunosuppression, Analgesics (avoid aspirin
down distribution covering acquired after disease. however, persons who due to the association with
most of the body lasting are HIV positive and Reye syndrome).
5-6â•›days. asymptomatic or mildly Prevention: Vaccine
symptomatic should be immunization. Avoid
considered for the vaccine vaccination during
because the illness could pregnancy and delay
be fatal. pregnancy for 4â•›weeks after
vaccination.
Immunoglobulin given within
6â•›days after exposure to
lessen effects of disease.
Live vaccine 72â•›hrs
postexposure may prevent
illness.
(Continued)

Mumps (mumps virus) Prodromal: low-grade fever, Airborne or person-to- Complications: sensorineural Isolation, no less than 9â•›days
(paramyxovirus) headache, anorexia, myalgia. person direct contact deafness, meningitis, after beginning of swelling,
2nd: pain and swelling of with saliva and encephalitis. until swelling subsides.
parotid or other salivary respiratory droplets. Orchitis after puberty, but Supportive: rest until swelling
glands (unilateral or More commonly a sterility is rare. subsides. Cool or warm
bilateral), earache, pain with childhood disease. Potential for spontaneous compresses, warm salt
chewing. Incubation period: abortion if woman is water gargles, fluids, soft
14-18â•›days. infected in early pregnancy. bland diet, avoid citrus
Communicable: 7â•›days fruits to decrease pain.
before to 9â•›days after the Analgesics (avoid aspirin
onset of symptoms. due to the association with
Permanent immunity is Reye syndrome).
usually acquired after Prevention: Vaccine
contracting the disease. immunization. (delay
pregnancy for 1â•›month after
vaccination).
Tuberculosis (TB) Latent TB: no symptoms; Inhalation of respiratory Latent TB can become active Persons infected (without
(Mycobacterium immune system keeps TB droplets containing with weakened immune active disease) are treated
tuberculosis) infection inactive with no bacteria. system. Risk factors for prophylactically with
spread to others. Positive Communicable: until after active TB include poverty, antitubercular medications.
skin test, normal chest x-ray 2-4â•›weeks of effective poor health, immigrant Multiple drug therapy,
and sputum culture. treatment for active TB status, HIV positive status, isolation, rest, respiratory
TB disease: low-grade fever, disease. the very young and old age. supportive care for persons
weight loss, listlessness, Globally, the emergence of with active disease. In
night sweats, respiratory extensively drug resistant hospital respiratory isolation
congestion, cough, and multidrug resistant in negative pressure room.
hemoptysis. Positive skin TB is a concern, especially Prevention: Better living
test, may have abnormal for those with weakened conditions, proper nutrition,
chest x-ray and/or sputum immune systems. and positive health
culture. Complications: pulmonary practices (cover nose and
Sites other than the lungs may tissue damage and necrosis, mouth when coughing).
be infected (extrapulmonary respiratory failure. Bacille Calmette-Gurin
TB disease); if so, symptoms vaccine (BCG) given in some
will be specific to the site other countries.
(e.g., meninges, joints,
bladder, lymphatic system).
Influenza (influenza Respiratory symptoms such Inhalation of respiratory Very infectious, most common Supportive: rest, liquids,
virus) “flu” as runny or stuffy nose, dry droplet spread from nose in the fall and winter oxygen as needed,
cough, sore throat. and mouth. Less often months. analgesics, antipyretics,
May be accompanied by spread via contact with People age 65 and older, (avoid aspirin due to the
headache, fever (usually soiled surface and then those with chronic medical association with Reye
high), body aches, fatigue. touching nose or mouth. conditions, young children syndrome).
Symptoms usually last Incubation period: 1-4â•›days. and pregnant women Antivirals given within 2â•›days
2-3â•›days but energy depletion Communicable: day are most likely to have of illness can decrease
may linger. before symptoms and complications of the flu. duration of illness.
extends for 1â•›week after Complications: pneumonia, Prevention: Good health
symptoms. dehydration, bronchitis, habits, rest, proper diet,
sinus and ear infections, hand hygiene.
myocarditis, death. Yearly influenza vaccination
(especially high-risk patients
and health care workers
of high-risk patients).
Pneumococcal vaccination
is also recommended.

Mononucleosis Fever, fatigue, enlarged lymph Direct contact with oral Usually self-limiting disease Supportive: maintain adequate
(Epstein-Barr virus) nodes (especially posterior secretions. and resolves in several rest, prevent fatigue, fluids,
"kissing disease" cervical nodes), sore throat, Common disease of weeks. Often associated warm saline gargles,
malaise. At times enlarged older children and with strep infections thus a analgesics, antipyretics, (avoid
liver and spleen. adolescents. throat culture may also be aspirin due to the association
Incubation period: performed. with Reye syndrome).
4-6â•›weeks. Complications: potential for Avoid activity that may cause
splenic rupture. blunt abdominal trauma and
splenic rupture.
Prevention: avoid transfer of
saliva with someone who
is currently or was recently
infected with the disease.
Haemophilus- Causes disease almost Spread by respiratory Factors that increase Hospitalization, isolation and
Influenzae type exclusively in children droplet infection and exposure and Hib disease antibiotics, analgesics,
b (Hib) (bacterial younger than 5â•›years. discharges from nose include children in close respiratory support as needed.
infection) S/S: lower respiratory tract and throat during the contact, large household If disease is diagnosed in a
infection, malaise and infectious period. size/crowding, daycare daycare setting, all parents
fever. Hib can affect many Incubation period: less attendance, school-aged should be notified of
organ systems and may be than 10â•›days. siblings. Factors that exposure, informed of risk,
rapidly fatal without prompt Communicable: varies, increase susceptibility and advised regarding signs
treatment. may persist as long as to Hib include low and symptoms of illness.
organism is present in socioeconomic status, To prevent the spread of
the nose and throat. chronic disease states. disease, the antibiotic
Complications: meningitis, rifampin may be
hearing loss, pneumonia, recommended for household
cellulitis, epiglottitis, septic and daycare contacts not
arthritis, death. immunized for Haemophilus.
Prevention: vaccine
immunization.
Erythema infectiosum Mild viral illness begins with a Communicable by Community outbreaks are Usually a mild disease.
(fifth disease) mild cold then three stages respiratory droplet common, most frequently Symptomatic treatment.
(parvovirus B19) of skin eruptions: infection (e.g., sharing in the winter and spring. Affected children do not have to
1st: "slapped cheek" drinking cups or The highest incidence is be excluded from child care or
appearance. utensils). seen in school-age children school because children are
2nd: maculopapular rash on the Incubation period: between 5 and 15â•›years. unlikely to be contagious after
trunk and extremities, which 4-20â•›days. Complications: rare risk of the rash has become manifest.
becomes mesh-like and lacy; Communicable: most fetal injury and fetal loss to Prevention: hand-washing.
may itch. infectious before rash nonimmune pregnant women. Do not share eating utenÂ�
3rd: periodic rash fading with presents. May cause serious illness sils. Avoid exposure, if
eruptions (recurs with heat, in immunocompromised possible, if high risk,
exposure to sun) may appear and persons with sickle cell e.g., immunosuppressed,
for weeks to months. anemia. pregnant, anemic.
Scarlet fever (Group 1st: characterized by high fever, Spread by respiratory Symptomatic contacts are Antibiotics.
A streptococci) nausea, vomiting, pharyngitis droplets or direct contact cultured. Supportive: warm saline
(red or edematous with with infected secretions, Complications: otitis gargles, cool mist vaporizer.
purulent exudate), "strawberry rarely by indirect contact media, rheumatic fever, Encourage fluids, soft diet.
tongue" (whitish coating with through objects. glomerulonephritis. Sucking on candy may
red, swollen papillae). Incubation period: 1-3â•›days. relieve discomfort of sore
2nd: rash with sandpaper feel Communicable: 10-21â•›days throat.
most often seen on neck before and during clinical Prevention: hand-washing.
and chest; dark red skin illness or until 1â•›day after Keep drinking glasses and
creases. Rash blanches with antibiotic therapy begins. utensils separate from
pressure. Skin desquamation others.
(especially tips of fingers/
toes) after fever subsides.
(Continued)

Severe Acute Variable S/S. Person-to-person direct Most cases of SARS have Isolation (negative pressure
Respiratory Prodromal: High fever, chills, contact with respiratory occurred among travelers room in hospital),
Syndrome (SARS) headache, malaise. secretions. Potential and health care workers antibiotics, antivirals,
(coronavirus) Respiratory disease, from spread by indirect in areas of the world steroids.
Rare–no cases in mild to severe symptoms: contact with objects affected by SARS. Supportive: respiratory
United States cough, dyspnea, hypoxemia, contaminated with Persons with SARS should support, hydration.
pneumonia, respiratory infectious droplets. limit out-of-home contacts Prevention: respiratory and
distress syndrome, death. Incubation period: for 10â•›days after symptoms contact precautions (hand-
2-10â•›days. are gone. washing, avoid sharing
Communicable: unknown, Close contacts to SARS eating utensils, towels,
however, is most likely should monitor for bedding, etc. with SARS
infectious when S/S are symptoms, if present, patient).
present. limitÂ€public activities
andÂ€seek medical
evaluation.
Integumentary Route
Impetigo (group A Skin blisters usually found in Direct contact with lesions Any break in the skin may Topical antibiotics after
streptococcal or the corners of the mouth near or secretions. Scratching allow bacterial entry. Most removal of crusts by
staphylococcal the edge of nose. spreads the disease to common in hot, humid washing lesions with warm,
bacteria) Blisters break and form yellow other areas of the body. climates and summer soapy water (cover affected
crusts that resolve with little Indirect contact with months, which disrupt the areas to prevent spread).
or no scarring; blisters may secretions via towels, normal flora of skin. Wash all clothing and linens
be itchy, and scratching may clothing, and linens that Most problematic in children. in hot water.
occur. have touched infected Infected children should Oral antibiotics in severe
skin. be kept home until not cases.
Incubation period: 1-3â•›days. contagious (usually Prevention: Keep skin clean.
Communicable: very 24â•›hours after treatment Educate on hand-washing
contagious as long as has begun). and use of separate towels
lesions are present. Complications: cellulitis; and washcloths.
Acute glomerulonephritis
in preschool-age
children.
Pediculosis (parasitic Lice and eggs (nits) may be Direct or indirect transfer Nuisance disease. Lice are treated with
lice) present in scalp hair or pubic of adult lice or nits Occurs without regard to medicated pediculicide
hair or on the body. (eggs) via body contact socioeconomic status but shampoos or topical
Itching and other signs of or contact with personal seen more in overcrowding medication, isolate for
skin irritation, such as pin- items that are infected where sanitation and 24â•›hrs after treatment.
sized blood spots, a rash, with the parasites. hygiene are poor. Nits (eggs) should be removed
or swollen glands, may be Head lice—live 2â•›days Complications: sores caused from scalp hair with a fine-
present. without a blood meal. by scratching. toothed comb.
Body lice—live 1â•›week To prevent re-infestation
without a blood meal. with lice: wash and dry
Pubic lice—live 2â•›days all affected garments
without a blood meal. (clothing, linens, towels)
Communicable as long as on hot settings, dry clean
eggs or lice viable. or remove from body blood
contact, vacuum floors and
furniture, wash combs and
brushes.
Prevention: educate not to
borrow combs, hats, and
so forth. Bathing, clean
clothes, and hand-washing
to prevent transfer of
eggs.

Scabies (parasitic Skin rash (small raised red Direct person-to-person High incidence seen in cases Topical scabicide application
mite) bumps), itching that is most contact or possible of overcrowding and among from the chin down
intense at night. transmission on clothing household contacts where as directed; a second
Mite burrows, just below the and bed linens. there is frequent skin-to- treatment may be necessary
skin, appear as gray or white Incubations: No previous skin contact. after 1â•›week.
tracts; may be especially exposure 2-6â•›weeks, Sexual partners and persons Bedding and clothing used
evident in skin folds on wrists, previous exposure with prolonged direct skin- by an infested person must
finger webs, belt line, elbows, 1-4â•›days before onset of to-skin contact with infested be thoroughly cleaned or
knees, armpits, and genitals. symptoms. person should be treated. removed from body contact
Communicable: as long as Complications: sores caused by for at least 3â•›days.
eggs or mites are alive. scratching, which may become Prevention: educate to change
Mites do not live more infected. Symptoms may clothing daily; launder with
than 2-3â•›days away from persist for several weeks after hot water and dryer.
the human body. the mites have been killed.
Tetanus (lockjaw) Descending, progressive Wound contamination by Neonatal tetanus (more Hospitalization, antitoxins,
(Clostridium tetani) pattern of tonic muscle soil or dust containing common in undeveloped sedatives, muscle relaxants,
(bacteria) spasms. The first sign is Clostridium tetani countries) is caused by antibiotics, wound
jaw stiffness (lock jaw) bacteria from animal and contamination of umbilical debridement.
followed by stiffness of the human feces. cord of an infant born to Minimize environmental
neck, difficulty swallowing, Incubation period: usually unimmunized mother. stimuli to decrease spasms.
rigid respiratory muscles, 10â•›days. Complications: spasms may Maintain patent airway and
generalized body stiffness, interfere with ventilation adequate ventilation.
tonic spasms of skeletal and cause fractures of the Prevention: vaccine
muscles and opisthotonos. spine and long bones, as immunization.
well as death. Tetanus immune globulin
Prognosis is improved with or tetanus antitoxin with
early identification and unclean, major wounds and
treatment, recovery may uncertain immunization
take several months. status.
Gastrointestinal Route
Poliomyelitis Three patterns of infection are Direct contact of virus Crowded living conditions Isolation with enteric
possible: with the mouth, and poor sanitation promote precautions.
1. Asymptomatic. predominately spread spread. Supportive: rest, respiratory
2. Nonparalytic: flu-like through the feces (fecal- Complications: permanent support as needed.
symptoms, muscle oral transmission). paralysis; disability and Physical therapy, positioning
weakness and stiffness. Humans are the only deformities. or range of motion to
3. Paralytic: paralysis that natural host and Postpolio syndrome with prevent contractures.
may affect any muscle reservoir of the virus. symptoms of fatigue, muscle Prevention: vaccine
group, including limbs and Incubation period: 7-14â•›days. pain, weakness, or paralysis immunization. Sanitation
respiratory muscles. Communicable: 7-10â•›days may be experienced to prevent fecal-oral
before and after onset of 30-40â•›years after the initial transmission.
symptoms. paralytic polio infection.
Salmonellosis Sudden onset of acute Direct via person-to- Infections more frequent in warm Fluids and enteric isolation.
(bacteria) gastroenteritis with person oral-fecal contact weather (summer months). Antibiotics for severe
abdominal cramps, diarrhea, or indirectly by ingestion Uncooked eggs, poultry, raw symptoms.
nausea, fever, and sometimes of food contaminated milk, and meats are usual Prevention: hand-washing
vomiting and dehydration. with feces containing sources that harbor bacteria. after toileting and touching
Stools may be loose for days- Salmonella. Some pets and reptiles (e.g., pets, before food preparation
months after acute episode. Incubation period: turtles, iguanas) may harbor and eating. Exclude persons
6-72â•›hours. infection. who are infected from food
Communicable: during Complications: dehydration, handling. Refrigerate foods;
the entire period of infection can spread to wrap fresh meats in plastic
infection (may be as long bloodstream and cause to avoid blood contamination
as several months after death in people with of other foods; discard
symptoms disappear). weakened immune systems, cracked or dirty eggs. Cook
older adults, and infants. foods thoroughly.
(Continued)

Shigellosis (bacteria) Stomach cramps, diarrhea (may Direct person-to-person Infants and children who are Supportive: fluids, antibiotics
aka bacillary contain mucus, blood), fever, by fecal-oral route or not potty trained are more for severe symptoms,
dysentery nausea, and dehydration. indirect transfer to the often infected because of enteric precautions, fluid
Usually resolves in 5-7â•›days. mouth by contaminated poor hygiene. replacement.
foods, toys, or Seasonal, more common in Prevention: hand-washing,
contaminated water. warm weather. careful personal hygiene,
Incubation period: usually Complications: High fever and dispose of diapers properly;
1-3â•›days. seizures in children under exclude those infected from
Communicable: as long 2â•›years of age with severe food handling.
as organism is present infection. Developing country
in stools; may be one precautions: drink only bottled
month or more. water. Eat cooked, hot foods
and peel fruits yourself.
Pinworms (intestinal Perianal itching. With heavy Transmitted via ingestion Infestation in school and Treat with prescription
worms) infection, loss of appetite of eggs of the worms, daycare settings is common. or over-the-counter
and difficulty sleeping. either directly via It is not necessary to screen anthelmintic medications
hands and fingernails asymptomatic children, but in two-step treatment with
or indirectly through children should be examined second treatment 2â•›weeks
transfer of eggs to food, if symptoms occur. after first. Shower and
water or articles (such as Diagnosis: cellophane tape change underwear every
toys) to the mouth. application to anal area morning; wash night clothes
Communicable: pinworm early in the morning to and sheets after treatments.
eggs can live up to confirm egg deposits. Discourage anal itching to
2â•›weeks on objects. prevent reinfection.
Prevention: teach hygiene
to prevent fecal-oral
transmission.
Rotavirus Vomiting, watery diarrhea, Direct fecal-oral Leading cause of severe Self-limiting disease in
fever, abdominal pain. transmission or indirect diarrheal disease in infants healthy persons.
transmission by ingestion and young children leading Supportive: fluids, enteric
of contaminated water, to hospitalization. precautions.
food, and respiratory Children with diarrhea should Prevention: vaccine
droplets. Incubation be excluded from daycare immunization,
period: 1-3â•›days until symptom free. hand-washing.
Communicable: Very Complications: Severe
contagious. 2â•›days prior dehydration can cause
to 10â•›days after onset of death.
symptoms.
Toxoplasmosis Most persons have no Most commonly by Toxoplasmosis screening may Usually self-limited;
(Toxoplasma gondii) symptoms or only mild ingestion of food and be done for those at risk of treatment not needed
(parasite) symptoms (enlarged lymph water contaminated serious disease; pregnant with healthy, nonpregnant
nodes, muscle aches and by the feces of cats women and those with a persons. Pregnant and
pains). or ingestion of the weakened immune system. immunosuppressed
Fetal infection: may result parasite via uncooked Complications: individuals are treated with
in spontaneous abortion, or undercooked meat. immunosuppressed antiinfective drugs.
stillbirth, or varied Transplacental infection and AIDS patients may Prevention: wear gloves while
complications after birth. when the mother has a develop life-threatening gardening. Wash hands
primary infection. disseminated visceral after outdoor activities,
Immunosuppression may disease (encephalitis, care of cat litter box, and
reactivate a prior infection. myocarditis, etc.) contact with raw meat.
Incubation 5-23â•›days. Complications of fetal Cook all meats thoroughly
Communicable: Not infection include blindness, and wash all surfaces that
directly between encephalitis, hydrocephalus, have contact with raw meat.
humans, transplacental and mental retardation. Daily disposal of cat litter
transmission possible. and feces.

Hepatitis A (hepatitis Rapid onset of symptoms; Person-to-person by fecal- Very contagious and spreads Self-limiting disease. Enteric
A virus)—"viral or nausea, vomiting, abdominal oral route and can be rapidly. High risk in daycare precautions. Supportive
infectious hepatitis" cramps, anorexia, malaise, transmitted during oral centers, international travel care.
jaundice, dark-colored urine, sexual activity. to endemic countries, Prevention: good hand-
and clay-colored stools. May Also spread by ingestion among illicit and injecting washing and screening
be asymptomatic. of contaminated food, drug users and men who of food handlers. Vaccine
milk, undercooked have sex with men. immunization. Immune
shellfish, and water. Outbreaks have been linked serum globulin when
Incubation period: time of to ingestion of seafood from exposure has been
exposure to symptom polluted water. identified.
onset: 15-50â•›days (28â•›day Complications: rarely, acute Prevention with travel to
average). Communicable liver failure. developing countries: drink
last half incubation to only bottled water. Eat
few days after jaundice cooked, hot foods and peel
onset. fruits yourself.
Serum Route
Hepatitis B (HBV) General gastrointestinal Exposure to infected body Health care workers, persons Symptomatic treatment of
(hepatitis B virus) symptoms or no symptoms. fluids, parenteral or with multiple sex partners, acute hepatitis (e.g., rest,
(serum hepatitis) Liver deterioration, if present, mucosal (e.g., via wounds, injection drug users, nutrition, fluids).
is noted by markedly intravenous drug use) and infants of infected mothers, Prevention: Vaccine
enlarged and tender liver, by intimate sexual contact household contacts of immunization. Condoms
dark urine, light or gray stool, with contaminated infected persons and during sexual intercourse
jaundiced eyes. human secretions (semen, hemodialysis patients are at may decrease risk of
HBV infection can be self- cervical secretions, increased risk of disease. infection.
limited or chronic. Acute saliva). Chronic carriers can transmit Hepatitis B immune globulin
infection usually runs In health care workers disease to others. and vaccine postexposure
a 3-4â•›week course but exposure to infected blood The greatest risk for acquiring for the unvaccinated.
symptoms may last up to is often via accidental chronic carrier status is the Chronic carriers of HBV
6â•›months. needle puncture. very young (90% of infants must not share razors,
Can be passed from infected with HBV at birth toothbrushes, or any objects
mother to newborn at will be carriers). contaminated with blood.
birth. Incubation period: Complications: chronic Treatment: interferon with
1-6â•›months. hepatitis, cirrhosis, liver chronic infection is 25-50%
Communicable: 1 to cancer, death. successful.
2â•›months before and
after symptoms or if
chronic carrier.
Human Initial infection: Asymptomatic Contact with infected Increased risk of HIV with Antiretroviral treatment to
immunodeficiency or nonspecific symptoms body secretions (semen other sexually transmitted slow the decline of immune
virus (HIV) (decreased appetite, weight or vaginal secretions diseases. system function. Treatment
loss, fever, night sweats, during sexual intercourse; At risk: injection or for altered immune system
diarrhea, tiredness, swollen parenteral exposure of intravenous drug users, depends on specific
lymph nodes). blood and blood products; multiple sexual partners, presenting opportunistic
2nd: symptoms of immune perinatal or transplacental unprotected sex with illness or disease.
compromise; opportunistic transmission; breast milk). someone at risk for Prevention: education about
infections and cancers that Incubation period: a few HIV, infants born to HIV safe sexual and personal
allow for the diagnosis of days to a few weeks mothers. Persons positive habits. Condoms to decrease
AIDS ( see Website after initial infection. for HIV infection may be risk of exposure. Do not
Resource 8A). Death. Potentially 1-15â•›years asymptomatic for years and share needles, syringes or
or more before AIDS may unknowingly engage injection equipment. Needle-
diagnosis. in risky behavior, putting exchange programs. Blood
Communicable: After others at risk. product testing. Immediate
onset of HIV infection. antiretroviral treatment
Lifetime infectiousness postexposure. Efforts at
related to viral load. vaccine development continue.
(Continued)

Sexually Transmitted Route
Herpes (herpes S/S: 2-12â•›days after exposure Direct contact with oral Virus stays dormant in body Incurable. Antivirals are
simplex virus; or may be no symptoms. and genital secretions. and successive eruptions given to control symptoms
HSV-1; HSV-2) aka Prodromal S/S: burning or Mother-to-infant occur commonly as a result and suppress recurrent
genital herpes and "prickly" sensation. transmission at birth. of stress or other illnesses. episodes.
herpes simplex 2nd: clusters of small blisters Both HSV-1 and HSV-2 Recurrence tends to become Symptomatic: Sitz bath,
that rupture and cause viruses can cause oral less severe and less analgesics, antipyretics.
painful ulcers. and genital herpes. frequent over the years and Pouring water on
Symptoms may include fever, HSV-1 is most commonly in some, stops recurring. perineum while voiding
painful intercourse, painful an infection of the mouthComplications: Uncommon may decrease pain with
urination, and swollen and and lips, "fever blisters",but include encephalitis, urination. Keep lesions
tender groin glands. "cold sores". meningitis. clean and dry (e.g., well-
Fetal effects: abortion, preterm Incubation period: Transmission can occur during ventilated clothing).
labor. Birth canal exposure— 1-26â•›days. asymptomatic periods when Prevention: avoid touching
blindness, brain damage, or Communicable: most lesions are not present. active blisters. Hand-
death. contagious 2-7â•›weeks washing. Sexual
after sores are present. abstinence. Condom
use can decrease risk
of infection. Cesarean
section birth for maternal
prodromal symptoms or
active herpes to prevent
neonatal herpes.
Cytomegalovirus Usually asymptomatic. If Transmitted through Virus remains in body for Most healthy people have
(CMV) symptomatic, resembles mucosal contact with life. Immunosuppressed no symptoms. Those
mononucleosis (fever, sore infected body fluid individuals are at risk for with serious infection
throat, fatigue, swollen (semen and vaginal reactivation of latent virus are treated with antiviral
glands). secretions, blood, breast and frequent infectious medications.
Fetal effects: Usually none milk, urine, feces, episodes. Prevention: hand-washing,
but may include temporary respiratory secretions) Transmission is so common personal hygiene, do not
enlarged liver and spleen, and organ transplant or that 60% of children in share eating utensils or
jaundice, death. placental transmission. daycare centers have CMV drinks.
Permanent symptoms in Incubation: 3-12â•›weeks. in urine or saliva (usually
newborns may not be Communicable: Many spread by not washing
evident at birth but usually months and can be hands).
present within first years of episodic for several
life; low IQ, developmental years.
and motor disabilities,
hearing and vision
impairment, chronic liver
impairment.
Genital warts Soft, pink-gray warts with Direct contact with Complications: most serious No cure. Most infections
or human "cauliflower appearance" in infected person; complication is the link resolve without treatment.
papillomavirus and around sex organs, which primarily sexually between the disease and Remove or destroy
(HPV) may or may not be painful, transmitted. malignancies of the cervix symptomatic warts:
may or may not be visible. Rarely passed to infants and genital tract. cryotherapy, laser therapy,
Warts may also be present in through the birth canal. Regular pap screening is electrocautery, surgical
the anus and mouth. Incubation: Usually recommended. removal, topical or
Infants may develop respiratory 1-3â•›months after contact Can block opening to the injected agents.
symptoms as a result of but may be longer. vagina, urethra, rectum, or Prevention: abstain from
infection in the throat and Communicable: during throat. sexual contact, use
mouth acquired during acute and persistent condoms to decrease
vaginal delivery. infection. risk of infection. Vaccine
immunization.

Gonorrhea (Neisseria Frequently asymptomatic. Primarily sexual contact. Incidence is most prevalent in Antimicrobials. Contact
gonorrhoeae) Infection of endocervical, Mother to infant via young adults (15-35â•›yrs). isolation.
(bacteria) vaginal, urethral, pharynx, or passage through birth Complications: Women—pelvic Antibiotics appropriate
rectum sites. canal. inflammatory disease (PID), to treat chlamydia (if
Symptomatic infection: Incubation period: Usually ectopic pregnancy, premature appropriate) are prescribed
Women—pain, purulent greenish 1-14â•›days after sexual delivery, sterility. Men— as many people are
vaginal discharge, pain in contact. epididymitis, infertility. coinfected with both
the genital and pelvic areas, Communicable: Treatment Rare complications: arthritis, simultaneously.
dysuria. Abnormal vaginal ends infectability within sepsis, meningitis, Sex partners should be
bleeding after intercourse hours, if untreated endocarditis. referred for evaluation,
and between periods. communicable for test, and treatment.
Men—acute purulent white, months. Educate to avoid sexual
yellow, or green intercourse until therapy is
discharge from the anterior completed.
urethra, dysuria, urinary Prevention: abstain from
frequency. sexual activity. Use
Pharynx—sore throat. condoms to decrease risk of
Rectum—mucus discharge, infection.
intense irritation.
Infants born during an
active case may contract
conjunctivitis (ophthalmia
neonatorum).
Chlamydia Frequently asymptomatic. Primarily sexual contact Complications: women— Antibiotics.
(Chlamydia Symptomatic infection: (vaginal, anal, or oral pelvic inflammatory Evaluate, test, and treat
trachomatis) urethritis, dysuria. sex) but infections can disease, ectopic sexual partners.
(bacteria) Women—abnormal vaginal occur in other areas of pregnancy, premature Chlamydia and gonorrhea
discharge, inflammation of the body if contact is delivery, infertility. Men— coinfection frequently
cervix, bleeding between made with the bacteria. epididymitis, sterility. Reiter occurs, presumptive
periods. Transmission to neonate syndrome. treatment of
Men—abnormal discharge by passage through the Annual screening of sexually bothÂ€infections is
from penis, burning on birth canal. active women age 25 and appropriate.
urination. Incubation: 1-3â•›weeks younger and women with Instruct to abstain from
Infant effects as a result of Communicable: Unknown, high-risk sexual behaviors is sexual intercourse until
vaginal delivery: mucous presume infectious when recommended. All pregnant treatment is completed.
membrane infection of the present. women should be tested for Prevention: abstinence
eyes (conjunctivitis) and chlamydia. from sexual contact, use
respiratory tract (pneumonia). condoms to decrease risk of
infection.
Health and sex education.
Syphilis (Treponema Disease stages if left Primary transmission Incidence is increasing, Parenteral penicillin; if
pallidum) (bacteria) untreated. occurs via contact with especially among young individual is allergic to
Primary stage: chancre sore mucocutaneous syphilis adults. penicillin, other antibiotics
at site of infection (genital, lesions during vaginal, Complications: blindness, are given.
rectum, lips); usually anal, or oral sex. brain damage, dementia, Prevention: abstinence from
painless with contagious Mother-to-fetus paralysis, heart disease, sexual activity, use of
fluid. transmission during death. condoms can decrease the
Secondary stage: occurs pregnancy. risk.
4-6â•›weeks later; may have Incubation period: Health and sex education.
fever, sore throat, body rash approximately 3â•›weeks.
(especially soles of feet
and palms of hands), sores
(mucous patches that are
highly infectious), inflamed
eyes, patchy hair loss.
(Continued)

Latent stage: signs and Communicable: infectious
symptoms disappear but to others in the primary
infection remains in the body. and secondary stages,
Tertiary stage: destruction of rare after first year of
body organs (brain, skeleton, infection.
heart, and large blood
vessels).
Fetal infection, "congenital
syphilis": abortion, stillbirth,
skeletal deformities, organ
defects.
Vector Route
West Nile virus Frequently asymptomatic. Bite from an infected Most infections are mild and Supportive: hospitalization,
Mild infection: fever, fatigue, mosquito. clinically unapparent. Peak intravenous fluids, respiratory
nausea and vomiting, Rarely spread occurrence in late summer support, prevention of
anorexia, headache, myalgia, via intrauterine to early fall. Complications: secondary infections.
rash, lymphadenopathy. transmission, blood permanent neurological Prevention: avoid mosquito
Severe infection: encephalitis, transfusion, or organ effects, death. bites via repellant use, wear
meningitis, weakness, high transplantation. Dead birds, a virus reservoir long sleeves and pants and
fever, change in level of Incubation period: that mosquitoes feed on, socks when outside, avoid
consciousness, seizure. 3-14â•›days. may be a sign of the virus in outside hours from dusk to
Communicable: No direct an area. dawn.
human transmission Eliminate and drain standing
except blood transfusion water, which is where
or in utero. mosquitoes breed.
Lyme disease Erythema migrans or bull's eye Bite of tick that became Peak occurrence: Late spring Treatment: antibiotics.
(Borrelia rash at site of tick bite, fever, infected after feeding on and summer months. Prevention: reduce exposure
burgdorferi) malaise, headache, muscle deer affected with the Major risk factors include to tick bites; avoid walking
(spirochete) aches, and arthralgia. spirochete. spending time outdoors, in tall grass and brush, wear
Incubation period: usually geography where Lyme long-sleeved shirts and
7-10â•›days. disease is endemic, and pants and socks, use tick
Communicable: no person- season. repellant, carefully examine
to-person transmission. Complications: skin for ticks.
rheumatological,
neurological, and cardiac
disorders.
*The author acknowledges the contribution of Gayle Hofland for her work in the previous edition of the book.
Data from: Heymann, D. L. (Ed.), (2008). Control of communicable diseases manual (19th ed.). Washington, DC: American Public Health
Association; and Atkinson, W., Wolfe, C., & Hamborsky, J. (Eds.), (2011). Epidemiology and prevention of vaccine-preventable diseases.
Washington, DC: U.S. Department of Health and Human Services, Public Health Foundation.
Â�
reactions to medications or foods; and, if female, if she might ously with any live vaccine administration or at least 30â•›days
be pregnant. In many situations, immunizations should not after vaccination.
be given or should be delayed. These circumstances include Community health nurses must provide health teach-
the following: ing at the time of immunization. The nurse should encour-
• If any child experiences seizures after an initial dose of a age the client to remain on site for at least 15 to 20 minutes
vaccine series (e.g., diphtheria-pertussis-tetanus), the child after vaccine administration to ensure that no reaction occurs.
should not receive the additional doses in the series. Epinephrine should be kept available so that it can be admin-
• Immunizations probably should not be given to clients with istered to reduce the effects of a reaction, if any.
chronic renal disease, because in such clients the ability to Documentation is very important. Every client should be
clear medication from the body is compromised. given a written record of the immunizations she or he has
• Tuberculin test results may be incorrect if the test is given received, when these were administered, and possible reactions.
shortly (less than 1â•›month) after a live-virus vaccine is admin- Clinic or organization records must be compreÂ�hensive to com-
istered. Tuberculin testing should be performed simultane- ply with the National Vaccine Injury CompenÂ�sation Act.
HEALTHY PEOPLE 2020 Sanitation

Community health nurses must be aware of the sanitary con-
Objectives for Primary Prevention: Immunization
ditions of the environment in which they and their clients live,
1. Increase immunization levels as follows: work, and play. Some homes do not have running water or ade-
Achieve immunization coverage of at least 90% among children quate sewage disposal; community health nurses may practice in
19Â€to 35â•›months of age. neighborhoods in which this is considered normal. Community
Immunization 2008 Baseline
health nurses may be called into neighborhoods during a disas-
ter when sanitation services have been suspended temporarily.
4 doses diphtheria-tetanus-pertussis (DTaP) 85%
For example, during riots and after hurricanes, entire neigh-
3 doses Haemophilus influenzae type b (Hib) 57% in 2009
borhoods may be without adequate, safe sanitation resources.
1 dose measles-mumps-rubella (MMR) 92%
When no adequate source of safe water and no methods of safe
3 doses hepatitis B (HB) 94%
waste disposal or safe food preparation and storage are avail-
3 doses polio 94%
1 dose varicella (chickenpox) 91%
able, extra precautions become necessary.
4 doses pneumococcal conjugate vaccine (PCV) 80% Employment
2 doses Hepatitis A 40%
Nurses have an additional need to be aware of health codes
2. Maintain immunization coverage at 95% for children in kindergar- in employment situations. States and the federal government
ten (baseline: 94 to 96% in 2007-2008). have established employment regulations that attempt to safe-
3. Increase the rate of immunization coverage to 90% among adults guard workers, and knowledge of the regulations affecting
65â•›years of age or older and high-risk institutionalized adults 18 or local employers is important. Nurses must play an integral role
older. in educational, research, and practice efforts to develop and
2020 Target 2008 enforce these regulations.
Goal Baseline Health care workers themselves may be at risk. Nurses, phy-
Immunization Adults Adults sicians, police officers, firefighters, paramedics, ambulance per-
Noninstitutionalized Adults 65 Years of Age or Older sonnel, morticians, and persons in other similar professions are
Influenza vaccine 90% 67% at risk for most communicable diseases, including TB, tetanus,
Pneumococcal vaccine 90% 60% typhoid, hepatitis B, HIV infection, and diphtheria. Many agen-
cies require employees to receive immunizations and specialized
High-Risk Adults 18 or Older education to protect them from communicable diseases. OSHA
Influenza vaccine 90% 62% has directed that employees be provided with safety measures to
Pneumococcal vaccine 90% 66% help protect them from blood-borne pathogens. OSHA requires
that employers provide health workers with yearly in-service
4. Increase the proportion of young children and adolescents who
education on infectious disease control and eliminate or mini-
receive all vaccines that have been recommended for universal
mize occupational exposure to blood-borne pathogens (OSHA,
administration for at least 5â•›years (Baseline 68% of children and
adolescents have received 4 DTaP, 3 polio, 1 MMR, 3 Hib, 4 PCV
2011). An increasing number of health care facilities are offer-
inÂ€2008). ing HBV vaccine at no cost to their employees.
5. Increase to 95% the proportion of children who participate in fully
Travel
operational population-based immunization registries (baseline:
75% of children under 6â•›years of age in 2008). Community health nurses are frequently called on to advise cli-
6. Increase to 50% the proportion of providers who have systemati- ents traveling to other countries about protection from infec-
cally measured the vaccination coverage levels among children in tious diseases. Nurses should remind clients about differences
their practice populations (baseline: 40% of public and 33% of pri- in climate, hygiene, food preparation, water purity, and sewage
vate providers in 2009). management. Simple practices such as eating only fruits or veg-
etables that can be peeled and using bottled water for drinking
and brushing the teeth are effective preventive measures. Caution
People 2020: Washington, DC: Author. Available at http://www.
HealthyPeople.gov. about diseases that are endemic to the region and Â�disease-specific
safety precautions should be provided to travelers.
Information on mandatory immunizations is available from
local health departments and the CDC. Community nurses
should remind travelers to allow enough time to receive all the
Prophylactic Measures necessary immunizations (6â•›months may be needed). Many
Prophylactic measures are aimed at reducing the risk of illness in immunizations cannot be given together, and some (e.g., for
persons who have already been exposed to a communicable dis- hepatitis) require a series of inoculations over a set time to pro-
ease. Chemoprophylactic actions include administration of vac- vide maximal protection.
cines, vaccine booster doses, or other medication. Prophylactic
measures are not available for all communicable diseases. Community Support Programs and Services
Community health nurses should know for which diseases risk- Nurses play an integral role in planning and implementing
reduction medication is available so that they can direct persons community support programs and services to improve the
who have been exposed to the appropriate treatment. Website health of the nation. Many of the Healthy People 2020 Â�objectives
Resource 8G provides selected prophylactic recommenda- can be addressed through primary prevention efforts. Nurses
tions for specific communicable diseases. are involved in devising prevention programs aimed at improving
environmental conditions and reducing the spread of commu- Respiratory Route

nicable diseases. Community health nurses also participate in For diseases spread by the respiratory route, action should be
specific strategies to decrease the incidence of HIV infection, geared toward reducing the risk of contact with droplets to
STDs, and other infectious diseases (see the Healthy People eliminate spread. In light of the risk that pneumonia, TB, and
2020Â€box on this page). Nurses can educate the community other respiratory conditions pose to persons who are exposed,
on the importance of being tested for HIV and HBV; they can containing respiratory secretions is vital. Affected persons
instruct individuals and families on methods of preventing and should be instructed to sneeze and cough into tissues and dis-
transmitting STDs; they can enlighten communities on the pose of them in a receptacle. Although most pathogens die
importance of immunizations for children, adults, and older when exposed to heat, light, and air, frequent hand-washing will
adults; and they can take part in community efforts to improve further reduce the threat of passing viable organisms from the
sanitation measures. hand to other persons.
Prevention Related to Mode of Transmission Integumentary Route

Health education on preventive measures can be taught to fam- Reducing the spread of parasites to uninfected persons depends
ily members and significant others who are at risk or are in direct on personal hygiene habits. Hats, combs, brushes, and other
contact with infected persons. Community health nurses can personal items should never be shared. Parasitic spread is espe-
tailor general precautions to the specific route of transmission. cially difficult to control in children; hence, the recurring out-
breaks of head lice in elementary schools. Scrupulous bathing
and hand-washing with hot water and soap reduce the potential
HEALTHY PEOPLE 2020 transfer of eggs, viruses, and bacteria. When close personal con-
Objectives to Reduce Risk for STDs and HIV/AIDS tact encourages spread, sexual contact should be avoided with
the infected individual until he or she is free of parasites.
Education and Counseling Clothing and bed linens should be washed in hot water.
1. Increase to 43.2% the proportion of elementary, middle, and senior Sharing clothing and bedding with infected individuals should
high schools that provide school health education on unintended be avoided. Sealing infected linens or personal items in plastic
pregnancy, HIV/AIDS, and STDs (baseline: 39.3% in 2006).
bags for 2â•›weeks can also kill mites and lice.
2. Increase the proportion of college and university students who
receive information from their institution on each of the priority Gastrointestinal Route
health risk behavior areas: unintentional injury, violence, suicide,
tobacco use and addiction, alcohol and illicit drug use, unintended Prevention of gastrointestinal diseases is geared toward reducing
pregnancy, HIV/AIDS and STDs, unhealthy dietary patterns, and the chance of transferring pathological organisms to the mouth
inadequate physical activity (baseline: developmental–no baseline). and digestive tract. Meticulous hand-washing after toileting or
3. Increase to 90% the proportion of elementary, middle, and senior changing infant diapers and before working with food products
high schools that provide comprehensive education to prevent is imperative. Fingernails should be kept short and the area under
alcohol and drug use (baseline 81.7% of schools in 2006). the nails cleaned regularly to eliminate this potential reservoir.
For organisms that thrive in stool, isolation and careful disposal
Behavior Change of infected stool and clean bathroom facilities are important.
1. Reduce to 20.4% the proportion of adolescents who have been Proper storage and refrigeration of foods, as well as effective
offered, sold, or given an illegal drug on school property (baseline food preparation and handling, are crucial. Fastidious clean-
22.7% of students grades 9-12 were offered, sold, or given illegal ing of equipment used in food preparation is essential in both
drugs in 2009). homes and institutions. Chemical treatment of the water sup-
2. Increase to 38% the population of sexually active females who use ply, proper disposal of garbage, and sanitation of sewage com-
condoms (baseline 34.5% of sexually active unmarried women [15- pletes the efforts at reducing pathogenic organisms.
44â•›years] used a condom at last intercourse in 2006-2008).
3. Increase to 60.7% the population of sexually active unmar- Serum Route
ried males who use condoms (baseline 52.2% of sexually active
For blood-borne diseases, efforts are directed toward reduc-
unmarried males [15-44â•›years] used condom at last intercourse in
ing the risk of exposure to infected blood and blood products.
2006-2008).
Infected persons should be monitored for adequate control of
Screening Programs body secretions, including blood and semen. Sexual contact
1. Increase to 95% the proportion of substance abuse treatment facil- increases the opportunity for exposure to contaminated blood,
ities that offer HIV and AIDS education, counseling, and support and such contact should be discontinued or barrier protection
(includes HIV screening) (baseline: 54.4% in 2008). used. Needle-exchange programs are aimed at reducing the
2. Increase to 44.1% the proportion of sexually active females risk of infection among users of illicit intravenous drugs. Users
24â•›years of age or younger and enrolled in commercial health are given sterile needles in exchange for used ones. Needle-
insurance plans who are screened for genital Chlamydia infec- exchange programs are controversial because some fear they
tions during the measurement year (baseline: 40.1% of females will encourage the use of illicit drugs. Currently, there are 146
[16-20â•›years] were screened in 2008). needle-exchange programs in the United States. In 2002 those
3. Increase to 16.9% the proportion of adolescents and adults who programs exchanged 24.9 million syringes (CDC, 2005). The
have been tested for HIV in the past 12â•›months (baseline 15.4% number exchanged is an indicator of the extent of injected drug
[age 15–44â•›years] in 2006-2008). use in this country. Although needle-exchange programs are
From U.S. Department of Health and Human Services. (2010). Healthy controversial, they seem to be effective in reducing the spread
People 2020: Washington, DC: Author. Available at www.HealthyPeople.gov. of HIV, HBV, and HBC infections (Villarreal & Fogg, 2006).
Most intravenous drug users (over 70%) are infected with one Meticulous screening of the blood supply is important to reduce
or more of these diseases within 5â•›years of initiating drug use risk to clients who must be transfused or maintained on blood
(Baciewicz, 2005; National Institute on Drug Abuse, 2006). A products. Efforts to improve the safety of the blood supply con-
2005 study in New York found the incidence of HIV infection tinue. One measure of success is the reduction in hepatitis B virus
decreased 40% and the incidence of HBC decreased 30% dur- and HIV infections among individuals who must receive blood or
ing a 10-year period in which needle exchange was available blood products. Vaccination for hepatitis B is recommended for all
to intravenous drug users (DesJarlais etÂ€al., 2005). Prevention risk groups, including clients who must receive blood products on
efforts have now expanded to include the following: a long-term basis as well as health care personnel, first responders,
• Vaccination against HBV and police officials. Community health nurses should be careful to
• Treatment for substance abuse identify every individual at risk and encourage immunization.
• Tailored HIV prevention counseling and testing Health care workers must practice universal precautions
• Prevention of sexual transmission through education and at all times. Working outside the hospital setting should not
provision of barrier birth control supplies lull community health nurses into being less vigilant in using
• Additional health care services tailored to the needs of intra- appropriate precautions. BoxÂ€8-4 provides a useful guide for
venous users teaching home safety precautions to clients and their families.
BOXÂ€8-4â•…â•‡ GUIDELINES FOR INFECTION CONTROL IN THE HOME

Personal Cleanliness—Personal Articles 2. Household members should not share used towels and washcloths.
1. Hand-washing is the single most important infection control method. Other members can safely use them after they have been laundered.
Hand-washing after using toilet facilities or after contact with body
fluids is important. Wash hands with soap and water or antimicrobial Preventing Cross-Infection
foam or gel. 1. Wear gloves when handling body fluids, linens, or other objects contami-
2. Do not share equipment potentially contaminated with body secre- nated with body fluids. (People with exudative lesions or weeping derma-
tions, such as thermometers, razors, or toothbrushes. titis should refrain from caring for the client until the condition resolves.)
2. Disposable gowns or aprons may be worn to protect clothing from
Kitchen and Bathrooms becoming soiled with body fluids.
1. Eating utensils used by all household members must be washed with 3. Caregivers with a cold or influenza should wear a mask when in close
hot water and soap. personal contact with a person with acquired immunodeficiency syn-
2. Kitchen counters should be cleaned with scouring powder or weak drome (AIDS) to protect the client, because clients with AIDS are
bleach solution (1:9 solution or 10% bleach and 90% water). highly susceptible to opportunistic infections.
3. Refrigerators should be cleaned regularly with soap and water to 4. Ensure good ventilation in the living quarters.
control molds.
Trash Disposal
4. Kitchen floor should be mopped weekly or more often, if necessary.
1. Body wastes such as urine, feces, and blood should be flushed down
Dispose of mop water by pouring down toilet and disinfecting toilet
the toilet.
with bleach solution.
2. Discard dressings, diapers, incontinent pads, or any materials soiled
5. Toilet, bathtub, shower, and bathroom floor should be cleaned with
with body fluids and secretions in a plastic bag. Pour in a 1:9 bleach-
a freshly prepared bleach solution. If the client spills urine or has
water solution until soiled contents are soaked. Place sealed bag into
watery diarrhea that splashes onto the toilet seat, the seat must
another plastic bag, seal again, and place in regular trash.
be wiped off after each spill and then cleaned with the bleach
3. Sharps should be discarded in a special sharps container provided
solution.
by the home care agency. Transport container back to agency for dis-
6. Clean sponges used to wash floors or clean up body fluid spills by
posal when container is three-fourths full. If no sharps container is
soaking them for 5 minutes in a bleach solution. When at all possible,
available, use a metal coffee can or a puncture-proof plastic con-
use paper towels rather than sponges, because they can be disposed
tainer to discard needles and sharps. When container is three-fourths
of and do not harbor germs.
full, pour 1:9 bleach-water solution over sharps material. Seal con-
Food Preparation tainer, double-bag in plastic trash bags, and discard in the trash.*†
1. Wash hands thoroughly before food preparation. Sexual Practices
2. Do not lick fingers or mixing spoon while cooking. 1. When recommended, precautions must be taken to prevent the shar-
3. Avoid unpasteurized milk to reduce risk of Salmonella exposure; thor- ing of body secretions; therefore, information about safe sex prac-
oughly wash uncooked chicken; do not use cracked eggs. tices should be provided to the client and family members. Pamphlets
and counseling are available.
Laundry and Linens
1. Clothing or linen soiled with body fluids should be stored separately in Pets
a plastic bag and should be washed separately in a washing machine 1. Clean birdcages wearing gloves and mask, because birds can spread
using hot water, detergent, and bleach. Liquid Lysol can be used for psittacosis.
colored laundry. (Wear disposable gloves when touching the soiled 2. Clean cat litter boxes wearing gloves and mask to prevent toxoplasmosis.
clothes or linen.) Linens not soiled by body fluids may be handled in 3. Change water in tropical fish tanks wearing gloves and mask to pre-
the usual manner without special precautions. vent Mycobacterium infection.
*Do not place with recyclables.
†
If allowed by state law.
Adapted from Rhinehart, E., & Friedman, M. M. (1999). Infection control in home care. Gaithersburg, MD: Aspen; and Trotter, J. (1992). Guidelines for
people with AIDS living in the community. Unpublished.
Sexually Transmitted Route HEALTHY PEOPLE 2020

For sexually transmitted diseases, precautions essentially involve Objectives for Secondary Prevention for
reducing sexually risky behavior. Methods include abstaining
Communicable Diseases
from sexual intercourse, reducing the number of sex partners,
using barrier contraception during intercourse and foreplay, and â•›1. Increase the number of admissions to substance abuse treatment
avoiding sexual activity with infected persons who have not been for injection drug users to 279,706 (baseline: 254,278 in 2006).
treated or have not completed treatment. Community health 2. Increase to 93% the proportion of all tuberculosis clients who are
nurses should concentrate their public education efforts on these eligible to complete therapy (baseline: 83.8% in 2006).
areas and aim their efforts at populations at special risk. 3. Increase to at least 79% the treatment completion rate of con-
The majority of HIV-positive individuals acquired the infec- tacts to sputum smear-positive cases who are diagnosed with
tion through sexual activity (CDC, 2006f). After considerable latent tuberculosis infection (LTBI) and started treatment (base-
progress was made in reducing the spread of HIV in the homo- line: 68.1% in 2007).
sexual population, evidence suggests that the effort has stalled. From U.S. Department of Health and Human Services. (2010). Healthy
Consistent use of condoms can prevent approximately one half People 2020: Washington, DC: Author. Available at http://www.
of all sexually transmitted HIV infections and reduce the inci- HealthyPeople.gov.
dence of other STDs as well.
Targeting adolescents and women, the two fastest-Â�growing
risk groups, is vital. Approximately 40% of U.S. adolescents on Ellis Island between 1890 and 1920. More than 20 Â�million
engage in unprotected sexual intercourse (CDC, 2010r; see people were evaluated by the Marine Hospital Service for
Â�
ChapterÂ€24). The spread of HIV infection in adolescents is pri- signs and symptoms of disease. Persons who were found to be
marily through heterosexual activity, not intravenous drug use. infected with a communicable disease (typhus, cholera, plague,
When planning programs for adolescents, community health smallpox, or yellow fever) were denied entry into the United
nurses should try to provide a reality-based experience by States until they were no longer infected.
encouraging clients to delay sexual activity and to act respon- Screening for communicable diseases involves interviews,
sibly when engaging in such activity and by providing access to physical assessment, procurement of laboratory samples, and
or information on resources for condoms. Teenaged speakers diagnostic testing. Screening programs for communicable dis-
who are infected with HIV are a powerful tool for communi- eases are most often cost effective when the screening proce-
cating the realities of ignoring the problem and should be used dure is relatively quick and inexpensive and the communicable
whenever possible. disease is highly infectious or has the potential to inflict seri-
Heterosexual women are another group at increased risk for ous harm on the population. Screening may be done as part of
STDs and HIV infection. Only 20% to 25% of sexually active employment (e.g., TB, hepatitis) or school enrollment (e.g., col-
American women have male partners who use condoms, and lege requirements for a measles titer). More frequently, screen-
even in these cases, such use is sporadic (USDHHS, 2006). ing is targeted at special risk groups; for example, studies show
Socioeconomic status impacts condom use; poor women that people often have more than one STD at a time (CDC,
are less likely to have male partners who use condoms. For 2010g). Nurse practitioners, community health nurses, and oth-
women who are reluctant to insist on condom use or whose ers who provide care should be aware of the need to screen for
partners refuse to wear condoms, there is a condom designed other STDs at the time a person seeks treatment for an STD
especially for women that is recommended for both contra- (e.g., gonorrhea, chlamydia, syphilis). All TB clients should
ceptive use and STD prevention. Nurses can provide women be screened for HIV infection, and all HIV clients should be
with information on the availability and use of condoms for screened for TB.
women, which are an effective method of barrier protection For most communicable diseases, screening is done for
(CDC, 2010r). both public protection and early treatment. Because HIV
infection has no cure, screening programs are more con-
Secondary Prevention troversial. Opponents argue against screening because, once
The second level of prevention includes measures directed at identified, infected individuals may be discriminated against
early detection of disease to provide early treatment, ensure in employment opportunities, health insurance plans, and
treatment effectiveness, and minimize the spread of disease other areas. Proponents argue that much is to be gained by
within the population (see the Healthy People 2020 box on this early identification of HIV infection. HIV screening is done
page). Secondary prevention activities include antibiotic drug for the following reasons:
therapy, contact tracing, and follow-up of persons who are • To promote behavior changes
infected or exposed. The community health nurse's role in sec- • To provide entry into clinical care
ondary prevention includes identification of cases (screening • To provide information for partner notification and
and case finding); confirmation of illness; administration or education
observation of administration of medication; and provision of • To protect the blood supply
education, oversight, and support of caregivers. • To protect the fetuses of HIV-positive women
Screening increases population protection by reducing the
Screening Programs risk to close contacts. Although HIV screening will not facilitate
Screening programs are designed to evaluate a large number of a cure, it does allow HIV-infected individuals the opportunity to
people for possible infection. Early detection can reduce com- seek supportive care earlier and thus increase their quality of life.
plications and diminish further transmission of disease in a The CDC suggests that hospitals and clinics with a large number
community. One early example is the screening of immigrants of HIV and AIDS cases should routinely test for infection.
HIV/AIDS screening is still voluntary and confidential and after learning of their HIV-positive status. Individuals newly
should include a pretest and posttest counseling session. Clients diagnosed with HIV infection should be referred for counseling
who test positive are referred for further services, but all cli- and support services.
ents are counseled about risky behaviors and safer sex practices. Case Finding and Contact Tracing. The purpose of case finding
Resources for counseling and teaching clients with HIV or AIDS is to identify every case of disease and to provide swift treatment
are available by calling the special toll-free PHS telephone num- for new cases. Community health nurses often function as case
ber listed in Community Resources for Practice at the end of finders. Searching for potential cases begins by identifying indi-
the chapter. viduals with the most intimate contact (level I) and proceeds to
Mandatory versus Voluntary Screening for Human those with less close contact (levels II and III) (FigureÂ€8-10). For
Immunodeficiency Virus. In 1999 the Institute of Medicine rec- most communicable diseases, if no cases are discovered among
ommended voluntary HIV testing of all pregnant women. In the level I contacts, proceeding to level II is unnecessary. For
response to this recommendation, the CDC developed screen- example, when screening schoolchildren for cases of head lice,
ing guidelines for all populations, including pregnant women the nurse would first screen the grade in which the contact case
(CDC, 2001b, 2001c). The CDC (2006j) recommendations for was found and any grades that contain family members of that
HIV screening were listed previously in this chapter on page 202. child. If these grades are free of lice, screening the rest of the
States have mandated screening for certain other risk groups school serves little purpose. Nurses should consider the cost
and professions. For example, some states require HIV screening effectiveness of health screening and save resources for neces-
as a condition of employment for health care workers or police sary services.
officers. Because the rate of HIV infection is nearly five times All sexual partners should be identified when perform-
higher in prisoners than in the general population, 21 states and ing contact tracing for STDs and HIV. People will occasionally
the federal prison system require HIV testing for all prisoners have multiple sex partners whom they consider casual acquain-
(CDC, 2009d). The CDC recommends mandatory testing of all tances rather than close partners. For contact tracing, all sexual
new inmates and periodic voluntary testing of inmates during partners are level I contacts. Case finding requires patience and
incarceration (CDC, 2006k). As noted earlier, mandatory test- sensitivity on the part of the investigator. Some communicable
ing is controversial. The American Public Health Association diseases, particularly STDs and HIV infection, may be a source
and the WHO oppose mandatory testing. Proponents argue of embarrassment for the infected individuals. If the nurse is
that mandatory testing identifies more HIV-positive persons not accepting and caring during the interviews, clients may not
than does voluntary testing. cooperate, which reduces the chance of locating potential cases.
Anonymous, Blind, or Confidential Testing. In addition to BoxÂ€8-5 provides a number of golden rules that interviewers
undergoing routine testing, people can be screened for com- may find useful when conducting contact tracing interviews.
municable diseases in anonymous, blind, or confidential pro-
grams. These three methods are normally used when screening Specimen Collection
for communicable diseases that carry a degree of public censure Community health nurses are often expected to obtain speci-
or stigma. Blind screening involves testing samples drawn for mens from clients, prepare the specimens for transport to the
other purposes and stripped of identification (e.g., screening of laboratory, and receive the results. Accurate laboratory results
hospitalized patients who have blood drawn for routine admis- depend on correct collection, storage, and transport of speci-
sion blood work). The purpose is to get an accurate estimate of mens. The nurse should take care to follow laboratory direc-
the incidence of communicable disease in the population. Blind tions exactly (e.g., refrigerate the sample, if so directed).
studies can provide valuable information about patterns but do Laboratories require that accurate information accompany the
not allow for treatment, because samples are not traceable to the specimen to assist in the identification of the infectious agent.
person who provided the sample. In addition, nurses need to be safety conscious, because speci-
Anonymous testing allows people to register for screening men collection can be dangerous if the nurse is careless. All
under an identifier code or number, and confidential testing
registers people by name. In both cases, test results are available
only to the client. Anonymous testing is offered as a strategy to
increase people's willingness to come for testing. Provision of Level III
anonymous testing may increase the number of persons willing
to be tested for HIV infection. The CDC recommends the use of
name-based patient testing, and that recommendation has been Level II
adopted by 45 state and local health departments. Hawaii is cur-
rently the only state health department that offers only anony-
mous testing (Kaiser Family Foundation, 2009). Level I
Screening procedures for HIV and AIDS have been altered INTIMATE
to better achieve a decrease in risky behavior. At first, anony-
C
mous and confidential testing results were supplied over the LO
SE FRIENDS
telephone. Currently, however, most programs require individ-
uals who are tested to pick up the results (even when negative) CA
S UA ES
in person to provide an additional opportunity to counsel cli- L ACQ INTANC
UA
ents on risk factors, risky behaviors, and safer sex precautions.
Community health nurses and others involved in HIV screening
programs should be aware that some people become depressed FIGUREÂ€8-10â•‡ Priority of case-finding contacts.
BOXÂ€8-5â•‡GOLDEN RULES OF Wearing of loose clothing and cotton underwear can help to
INTERVIEWING speed healing.
Compliance with the prescribed medication regimen is essen-
â•‡1. Initial contact should be with a named source, not other house- tial. Failure to follow through with the complete medication reg-
hold members. imen is thought to be one important reason for the increasing
â•‡2. If you must leave a telephone message, provide no information number of drug-resistant organisms. Compliance can be partic-
other than your name and telephone number. ularly problematic when therapy is long term, as in TB, for which
â•‡3. Emphasize client confidentiality related to test results and other clients are required to remain on medication long after symp-
services. toms have resolved. Nurses can play a vital role by helping clients
â•‡4. Allow the contact a choice of interview location and time.
understand the importance of maintaining drug treatment and
â•‡5. In cases involving drugs, do not ask for drug sources or specific
by providing oversight to confirm and support compliance.
drugs.
Documenting resolution of a disease is the important last
â•‡6. When tracing is performed, interviewees are not to be given the
name of the initial contact, no matter how insistent they might step in treating the illness. Test of cure is the term used to indi-
become. cate that a treated individual has undergone repeated laboratory
â•‡7. Incomplete information should be recorded because it may help tests and is no longer contagious or is free of the disease. This
with later contact tracing. assessment is particularly important for diseases that can linger
â•‡8. It is possible to be flexible, informal, and supportive and still get or relapse if not completely eliminated in an individual (e.g.,
all the information required in the survey. diphtheria, gonorrhea, chlamydia).
â•‡9. Cooperation may be encouraged by explaining the risks; adopting
a “you help us, we will help you” attitude; and leaving a business Legal Enforcement
card with people reluctant to name contacts at the first interview. Nurses must become knowledgeable not only about agency
10. Respect all contacts. regulations for the control of communicable diseases, but also
about state statutes and regulations as well as enforcement.
Modified from Poulin, C., Gyorkos, T. W., MacPhee, J., etÂ€al. (1992).
Contact-tracing among injection drug users in a rural area. Canadian
States have different regulations concerning enforcement provi-
Journal of Public Health, 83(2), 106-108. sions; thus, nurses must explore the rules of the states in which
they practice. Some regulations give the nurse an enforcement
nurses must consistently follow appropriate infection control responsibility. For example, nurses must report the incidence of
measures, including universal precautions (see ChapterÂ€31). communicable disease or a violation of sanitary codes.
Community health nurses should be familiar with the usual The law allows public health officials to compel individuals
time frame for receiving the results of each test. Bacterial culture to comply with treatment if noncompliance endangers the gen-
results are usually available in a short time because most bac- eral public. Public health officials have the authority to require
teria grow in hours. Mycobacterium organisms (i.e., TB agent) compliance with treatment and the legal means to ensure com-
may take longer (sometimes weeks). Nurses should counsel pliance through forced institutionalization if all other methods
clients about the expected arrival time for the results to help fail. Incarceration is a viable but last-choice option.
reduce some of the wait-time anxiety.
Two highly publicized cases of confinement occurred in 2007,
Comfort Measures both because of failure to comply with treatment require-
Most communicable diseases are treated at home, not in the ments for TB disease. In Phoenix, an Eastern European man
hospital. In addition to care and treatment regimens applica- refused to wear a mask to reduce the risk of infection to oth-
ble to specific diseases, the nurse can teach general symptomatic ers. He was confined to the prison ward of a Phoenix hospi-
comfort and care measures to caregivers. tal. The first federal case of confinement in 40â•›years involved
In general, rest, adequate nutrition and hydration, and fever a U.S. citizen with XDR-TB who traveled by plane outside
control are important. Adequate hydration is essential and may the United States against state health department and CDC
be problematic in children and older adults. The nurse should advice. Upon his return to this county he was confined in
instruct caregivers to be alert for signs of poor hydration (e.g., a hospital under federal statute while undergoing treatment
poor skin turgor, depressed fontanels in infants). Intravenous (Gibbs, 2007).
fluid replacement may be necessary, especially if gastrointestinal
upsets are severe, as may be the case in salmonellosis or shigello- Community health nurses may be involved in monitoring
sis. Aspirin or acetaminophen can be used to reduce fever. High compliance through directly observed medication administra-
fevers are common in children and may require water sponge tion. When clients are not compliant, nurses may be called on
baths for cooling. Aspirin should be avoided in children because to initiate legal action for confinement or to serve as a witness
of the link to Reye syndrome. during court proceedings. Public health laws require that clients
Skin disruptions such as blisters and body rashes require be afforded due rights, including counsel and a hearing, when
scrupulous hygiene to reduce the risk of infection. Scratching constraint measures are indicated (see ChapterÂ€6).
can exacerbate the problem and, in certain conditions, may
spread the disease. Some relief from itching may be gained by Exclusion from School
bathing in tepid water with cornstarch or oatmeal. Children can Children who have a communicable disease should be kept
sleep with cotton gloves on to reduce the risk of scratching in home from school. Parents should be encouraged to keep such
their sleep. Genital eruptions from STDs should be kept clean children at home and should notify the school nurse or daycare
and as dry as possible. A hair dryer on a low heat setting can be personnel when their child has a communicable disease. For
used to ensure that wet skin and skinfolds are completely dry. example, chickenpox is extremely contagious, especially before
the eruption of skin lesions, and no proven effective vaccine has tation can be detected, the easier it will be to prevent further
been produced. Children with chickenpox should not return to spread and provide effective treatment.
school until the vesicles have dried as scabs.
Children are also at risk for rapid acquisition of infections Tertiary Prevention
caused by pests and organisms transmitted through the integ- Tertiary prevention, the rehabilitation of lingering dysfunc-
umentary route. Lice and mites can rapidly infect children in tions after illness, is not as frequently addressed in community
daycare centers, classrooms, and summer camps. Nurses should nursing. Most communicable diseases resolve swiftly, result-
examine all other children and adults when infection is sus- ing in few long-term rehabilitative needs. Several important
pected. Parents and guardians will have to be notified about exceptions are hepatitis, HIV infection, and some STDs, which
the infections so they can initiate treatment efforts. Children produce long-term needs that can be classified as tertiary pre-
are not usually allowed to return to school until they have been vention needs. A significant number of STDs (e.g., herpes infec-
cleared to do so by a health professional. To reduce transmis- tion) have no cure and require lifelong vigilance. Other STDs
sion, nurses can teach children not to share brushes and combs (e.g., gonorrhea and HPV infection) can lead to complications,
and can teach teachers and daycare workers to observe children especially reproductive problems such as impaired fertility, ste-
for frequent scratching and scratch marks. The earlier the infes- rility, or uterine cancer.
KEY IDEAS
1. Knowledge of the characteristics of specific infectious agents, appropriate prevention and treatment protocols. State and
their modes of transmission, and the susceptibility of human local health departments have responsibilities for carry-
hosts helps in identifying ways to prevent the transmission of ing out environmental control, identifying and reporting
communicable diseases. communicable diseases, ensuring the availability of immu-
2. The incidence of many communicable diseases has been nizations, and ensuring that communicable diseases are
reduced in the United States since the 1940s as a result of envi- treated when medically possible. Each state has its own laws
ronmental sanitation, immunization, antibiotic treatment, and governing communicable disease control.
lifestyle changes. Renewed emphasis is being placed on immu- 7. Many of the Healthy People 2020 objectives address reduc-
nizations to prevent communicable diseases of childhood. tion in the incidence of communicable diseases. Populations
3. STDs and infections from HCV and HIV are rising. are targeted for interventions based on the epidemiology of
Multidrug-resistant forms of TB, gonorrhea, and chlamydia specific communicable diseases.
are emerging as a new concern. 8. Community and public health nurses are key health care pro-
4. Health care workers, including community and public viders in preventing and controlling communicable diseases.
health nurses, are at greater risk than the general public is 9. Primary prevention includes minimizing the risk of com-
for contracting blood-borne disease. Following universal municable diseases, emphasizing the importance of immu-
precautions is essential. nizations, and screening to ensure that immunizations are
5. All levels of government have some responsibility for pre- up to date.
venting and controlling communicable diseases to protect 10. Secondary prevention requires community and public
the health of the public. The right of the public to be pro- health nurses to screen for infected persons and to assist
tected may take precedence over an individual's right to refuse persons with communicable diseases in accessing appropri-
treatment. ate medical treatment. Nurses may also be involved in the
6. At the federal level, the CDC collects information on case management of persons who require treatment super-
reportable diseases, conducts research, and recommends vision. Contact tracing is one way of case finding.
THE NURSING PROCESS IN PRACTICE

A Client at Risk for AIDS and STDs Jennifer Maurer Kliphouse
Ms. Roberts enters the health department STD clinic, where the com- health nurse that she has not had sexual contact with anyone except
munity health nurse proceeds with the intake interview. The care at the Mr. Thomas for 6â•›months.
clinic is based on the concept of case management. Personnel consist Ms. Roberts also states that she thinks she might be pregnant. She is
of a nurse, physician, social worker, and family planning counselor who feeling tired all the time and has lost some weight. She has been vomit-
work as a team and have weekly meetings to review cases. ing in the morning and has noticed a yellow cervical discharge and com-
During the interview, Ms. Roberts tells the nurse that she is a 33-year- plains of some vaginal itching. The nurse questions Ms. Roberts and finds
old unmarried woman who suspects that she might have been exposed out that her last menstrual period was 4â•›weeks earlier. Her vital signs are
to the AIDS virus. Ms. Roberts reveals that she is currently sharing her assessed and are found to be within normal limits. Ms. Roberts states
apartment with her partner, Mr. Thomas. Ms. Roberts fears that she that she really would like to be pregnant. She really loves Mr. Thomas,
was exposed to HIV when she was 26â•›years old by sharing needles and they have talked about having a baby in the near future. The com-
with a group of friends who were intravenous drug abusers. She has munity health nurse offers Ms. Roberts voluntary HIV and hepatitis test-
had six sex partners during the last 2â•›years. She does not use condoms. ing according to the clinic protocol. Ms. Roberts agrees to testing, and
No pertinent medical or familial history is revealed. Ms. Roberts denies the nurse takes the blood sample, marks it, and sends it to be tested.
using intravenous drugs for more than 5â•›years. She tells the community Ms.Â€Roberts is given an appointment to return for the test results.
(Continued)
THE NURSING PROCESS IN PRACTICE—CONT'D

The nurse goes with Ms. Roberts to see the clinic physician, who exam- Ms. Roberts's sexual history and explains that Mr. Thomas will need to
ines Ms. Roberts. During the vaginal examination, the physician notes a be tested for chlamydia and HIV status. The nurse makes an appoint-
thick yellow cervical discharge. A sample of the secretion is obtained ment at the clinic for Ms. Roberts's first prenatal visit.
and sent to the laboratory. The sample will be examined and tested for
chlamydia and gonorrhea organisms as a routine measure, in addition to Assessment
screening for other organisms. The nurse tells Ms. Roberts that she will • Conduct family assessment
be notified when the test results are ready. Appointments will be made • Assess family and social supports
as necessary at that time. A pregnancy test is also performed. The nurse • Assess knowledge of both partners regarding STDs, HIV infection,
begins counseling Ms. Roberts about the routes of transmission of HIV and AIDS, including prevention of transmission
and STDs and about safer sex practices. She counsels Ms. Roberts to • Assess attitude toward pregnancy
encourage Mr. Thomas to use a condom with spermicide.
Ms. Roberts's pregnancy test result is positive, as is her test result Nursing Diagnoses
for chlamydia. All the other test results (for gonorrhea, hepatitis B, and • Deficient knowledge related to physiological changes secondary to preg-
hepatitis C) are negative. Her HIV results are still pending. The nurse nancy, chlamydia, and HIV/AIDS as evidenced by new-onset diagnosis
decides to call and tell Ms. Roberts about her test results. When the • Ineffective therapeutic regimen management related to insufficient
nurse calls Ms. Roberts, Ms. Roberts is very excited about the preg- knowledge of condition, modes of transmission, consequences of
nancy and states that she cannot wait to tell Mr. Thomas. She does not repeated infections, treatment, and prevention of recurrences sec-
appear to understand what the chlamydia results mean; thus the nurse ondary to chlamydia infection as evidenced by lack of condom use
decides to arrange a clinic appointment for counseling and treatment. • Risk for infection related to lack of knowledge concerning disease
Three days later, the results from the HIV tests come back positive. transmission as evidenced by multiple sexual partners and lack of
Ms. Roberts sees the nurse for the second time. During the visit, the STD prevention measures
nurse goes over all the test results, including Ms. Roberts's HIV status. • Risk of infection transmission from mother to infant related to exposure
She educates Ms. Roberts about chlamydia and emphasizes the impor- during prenatal and perinatal periods to communicable disease via mother
tance of treatment to reduce risk to her baby. She also reviews again as evidenced by positive HIV status and positive chlamydia test result
Nursing Diagnosis Nursing Goals Nursing Interventions Outcomes and Evaluation

Ineffective therapeutic Client will verbalize The nurse provides chlamydia infection Ms. Roberts successfully attributes cervical discharge
regimen management understanding of the education to the client, including information and vaginal itching to the chlamydia infection and
related to insufficient pathophysiological about common symptoms (urethral or vaginal indicates understanding that it is an STD. She
knowledge of condition, process of chlamydia discharge) or lack of overt symptoms, and indicates shock and disbelief that an infection that
modes of transmission, infection, as well as of long-term effects (e.g., pelvic inflammatory initially appears minor can lead to multiple health
consequences of repeated the treatment plan and disease) following neglect in treating the problems, including sterility. She also appropriately
infections, treatment, and modes of transmission. infection. The nurse also discusses the recounts verbal medication instructions and refers
prevention of recurrences transmission modes of chlamydia, including to the reference pamphlet when she is not exactly
secondary to chlamydia infant exposure during birth, which can lead sure of the regimen. This indicates a successful
infection as evidenced by to neonatal conjunctivitis and blindness. The intervention because she shows competency in
lack of condom use. client receives prescription medication and using the provided reference tools.
treatment protocol counseling, with simple
written instructions for personal reminders.
The client will verbalize The nurse provides free informative brochures When shown pictures of chlamydia infections,
understanding of that include photos of the effects of especially advanced cases, Ms. Roberts yells
complications related chlamydia infection. out, "I could look like THAT!?" While pictures
to multiple chlamydia often shock clients, they can be valuable
infections. learning and prevention tools. The colorful
reaction of Ms. Roberts shows personalization
and the impact of understanding possible future
ramifications.
The client will verbalize The nurse discusses with the client previous Inquiring about previous choices provides insight
and implement proper birth control and sexual disease prevention into Ms. Roberts's sexual disease knowledge
infection control methods, inquiring about Ms. Roberts's and attitude. It also guides the nurse's discussion
techniques. reasons for her past choices. Casual about future choices related to STD prevention.
sexual disease prevention education Unfortunately, the client's HIV status leaves only
follows, including the use of condoms and two choices for sexual encounters: abstinence
abstinence to reduce exposure to STDs. or condom use. Given Ms. Roberts's history of
The nurse reviews the proper technique for multiple sexual partners, the nurse must ensure
condom application. Because Ms. Roberts that she not only understands condom use but
tested positive not only for chlamydia but is willing to use condoms. As the client states,
also for HIV, it is imperative that the nurse "Awww man, I know how to use those," the nurse
impress upon her the importance of condom requests that Ms. Roberts demonstrate proper
use with current and future sexual partners. application to ensure her knowledge.
Free condoms are supplied by the clinic.

The client will successfully The treatment program provides free Ms. Roberts consents to an STD retest following
complete the treatment prescription medications. A confidential completion of the medication regimen. Her
process. STD support group meets biweekly in the chlamydia test result is negative, which suggests
neighborhood; contact information is provided that the client is adhering to the treatment plan.
to Ms. Roberts. The nurse schedules follow-up However, Ms. Roberts will need to continue using
visits with Ms. Roberts to provide consistency condoms because she is HIV positive. Further
of care and to build rapport. Finally, a retest counseling, support groups, and free condoms
is scheduled following completion of the willÂ€be made available through clinic programs.
medication regimen.
Find additional Care Plans for this client on the book's website.
1. Develop a position paper on the following debatable issue: 4. Explore the legal statutes in your state pertaining to control
should individual rights be compromised to control the of communicable diseases.
spread of communicable diseases for the good of society? 5. Investigate the immunization criteria used in your state.
2. Survey the role of boards of health in your community and 6. If possible, make arrangements through a clinical instructor
state to determine how communicable diseases are prevented to visit an STD clinic in your area and spend the day observ-
and controlled. What services do the boards provide? ing and assisting in nursing responsibilities.
3. Develop an educational program for pregnant adolescents to â•›â•›7. Note three diseases with distinctive trends in incidence (see
inform them about communicable diseases. TableÂ€8-3). Determine the reasons for the changes in incidence.

American Academy of Pediatrics: http://www.aap.org/ Recommended Adult Immunization Schedule—can be down-
American Congress of Obstetricians and Gynecologists: http:// loaded from the CDC website.
www.acog.org/ Travelers' Health—CDC website: http://wwwnc.cdc.gov/travel/
Emerging Infectious Diseases (journal): http://wwwnc.cdc.gov/eid/ National Vaccine Injury Compensation Program: http://www.
Sexually Transmitted Diseases (journal)—American Sexually hrsa.gov/vaccinecompensation/index.html
Transmitted Diseases Association: http://journals.lww.com/ Morbidity and Mortality Weekly Report (journal): http://www.
stdjournal/pages/default.aspx cdc.gov/mmwr/
Control of Communicable Diseases Manual, published by the WHO Publications Centre, USA: http://www.who.int/publications/en/
American Public Health Association: http://www.unbound- Health and Human Services (HHS) National AIDS Hotline:
medicine.com/ccdm/ub/index/Communicable-Diseases/Topics/A telephone (800) 342-AIDS http://www.hhs.gov/
The National Center for Immunization and Respiratory Diseases, City, county, and state boards of health and health departments:
CDC: http://www.cdc.gov/ncird/ refer to the local telephone directory
Division of Global Migration and Quarantine, CDC: http://
www.cdc.gov/ncezid/dgmq/
WEBSITE

Visit the Evolve website for this book to find the following study The following items supplement the chapter's topics and are
and assessment materials: also found on the Evolve site.
• NCLEX Review Questions 8A: Conditions for Case Definition in AIDS Surveillance
• Critical Thinking Questions and Answers for Case Studies 8B: Pertussis Report
• Care Plans 8C: Recommended Immunization Schedule for Children age 7
• Glossary Through 18â•›years
8D: Guide to Vaccines Indicated for Adults based on Medical
and Other Conditions
8E: Guide to Contraindications and Precautions to Commonly
Used Vaccines
8F: Vaccine Administration: Visit Record
8G: Prophylactic Treatment Available for Communicable Disease
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CHAPTER
9
Environmental Health Risks: At Home,
at Work, and in the Community
Barbara Sattler*
FOCUS QUESTIONS
What is meant by the term environmental health? What can community/public health nurses do to minimize the
In what ways does the environment affect human health in the adverse effects of the environment on their clients' health?
home, in the occupational setting, and in the community? What are some of the critical resources that are available to
What are some of the key areas that are important to assess the community/public health nurse when working with
in the identification of household, occupational, or clients in the home, in the occupational setting, and in the
community environmental hazards? community?
CHAPTER OUTLINE
Overview of Environmental Health Water and Soil Pollution
Definition of Environmental Health Nanotechnology
Historical Perspective Chemical Policies
Nursing Involvement in Environmental Issues Sustainable Agriculture
Multidisciplinary Approaches Climate Change
Conceptual Model of Ecological Systems Community/Public Health Nursing Responsibilities
Assessment of Environmental Health Hazards Assessment
Environmental Hazards at Home Surveillance
Understanding “Who's in Charge” Risk Communication
Accessing Information and the Right to Know Advocacy
Environmental Hazards in the Occupational Setting Research
History of Occupational Health in the United States The Nurse's Responsibilities in Primary, Secondary, and
Occupational Health and Safety in the Health Care Setting Tertiary Prevention
Occupational Health Nursing Primary Prevention
Environmental Hazards in the Community Secondary Prevention
Environmental Issues for the 21st Century Tertiary Prevention
Air Pollution The Future of Environmental Health Nursing
KEY TERMS
Body burden Fate and transport Occupational Safety and Health
Brownfield Hazardous waste Administration (OSHA)
Dose response Household hazards Precautionary Principle
Ecology Material safety data sheets (MSDS) Right to know
Environmental health Multiple chemical sensitivity (MCS) Risk communication
Environmental justice National Institute for Occupational Superfund
Environmental Protection Agency (EPA) Safety and Health (NIOSH) Toxicology
Exposure assessment Volatile organic compounds (VOCs)
*The chapter incorporates material written for the first three editions by Janet Primomo and Mary K. Salazar.
235
236 CHAPTER 9â•… Environmental Health Risks: At Home, at Work, and in the Community
OVERVIEW OF ENVIRONMENTAL HEALTH • Assess very specific exposures, such as the health risks that
may be associated with pesticide exposures, cleaning prod-
Environmental health comprises those aspects of human health, ucts, personal care products, or even the products that we use
including quality of life, that are determined by physical, chemical, for patient care.
biological, social, and psychological problems in the environment. It is important to note how we begin to understand the
It also refers to the theory and practice of assessing, correcting, relationship between environmental chemical exposures
controlling, and preventing those factors in the environment that and their potential for harm. There are several ways in
can potentially affect adversely the health of present and future which we have historically made such discoveries, including
generations. the following:
In this chapter, the influence of the environment on human • Humans present signs and symptoms that can be connected
health is examined, and the responsibilities of the community to a specific chemical exposure. For instance when workers
health nurse in relation to occupational and environmental have been occupationally exposed, the relationship between
health are defined. Understanding the effects of environmen- time/place and symptom development can help to identify
tal factors on health and disease requires an appreciation of the the causative health hazards.
complex interplay of many factors. Social, cultural, political, • Large, accidental releases of chemicals have befallen a com-
economic, and physical forces (chemical, radiological, and bio- munity and contaminated its air or water and this has
logical) interact with the psychological and physiological ele- resulted in health effects. When this has occurred, we have
ments that form the foundation of human existence. In keeping learned about the chemicals' toxicity to humans, as well as to
with this assertion, this chapter examines a conceptual model of other species in the environment.
environmental health and uses this model to present an analysis • In rare instances, human environmental (and occupational)
and overview of factors affecting the connection between the epidemiological studies have been performed and shown
environment and health. It is hoped that the discussion in this associations. Through such studies, we have learned about
chapter will assist the reader in recognizing the environment as the toxic effects of chemicals.
an important contributor to the health and well-being of indi- However, the most common way in which the relationships
viduals and populations. between chemical exposures and health risks are determined
is when toxicologists study the harmful effects of chemicals
Definition of Environmental Health on animals and we then estimate what the effects might be on
The Institute of Medicine (IOM) defines environmental health humans. This estimation process is called “extrapolation.” There
as “freedom from illness or injury related to exposure to toxic have been over 100,000 man-made chemical compounds devel-
agents and other environmental conditions that are potentially oped and introduced into our environment since World War II;
detrimental to human health” (IOM, 1995, p. 15). Because of we are most often reliant on the data that are created in animal
the multifactorial nature of environmental exposures and the studies to warn us about their potential toxicity to humans. For
myriad potential health effects, it is almost impossible to attri- many chemicals, no toxicity data are available because toxico-
bute a disease or health effects to a single exposure. Despite logical research is not required.
these difficulties, it is essential that health professionals consider
the environment in relation to the health of their clients and to Historical Perspective
understand the nature of risk as it pertains to the environment. Florence Nightingale was a great proponent of clean water
Nursing assessments that ignore occupational and environmen- and fresh air as key elements in promoting the public's health.
tal risk factors may miss an important clue to a patient's or a Her practice improved the health of British soldiers in the
population's health risks. Crimean War and reduced the high infant death rate in London.
All nursing models ask us to consider the environment as Nightingale identified the need for a clean environment with
a predictor of health. There are many ways in which to frame five points: pure air, pure water, efficient drainage (sewage),
environmental health, including the following: cleanliness, and light (Nightingale, 1860).
• Assess risks based on the medium in which they are con- Some of the most significant public health success stories
tained (e.g., air, water, soil, food, products). have resulted from eliminating environmental exposures. The
• Determine whether the health risk is from chemical (e.g., greatest strides in the control of widespread disease occurred
lead or pesticide), biological (e.g., Escherichia coli), or radio- after the acceptance of the germ theory in the late 19th cen-
logical (e.g., radon, UV from sun) exposure. tury (Last, 1998). Such advances in scientific knowledge
• Attribute the exposure to a setting or multiple settings (e.g., about the causes of disease led to the development of sewage
home, work, schools, community). and water treatment systems, which greatly contributed to the
• Incorporate “host” factors, meaning the vulnerability of an control of some of the worst threats to long life and good
individual or populations. For example, those people who health, including typhoid, typhus, and other water-borne dis-
are immunocompromised (e.g., human immunodeficiency eases (Newsome, 2005). Globally, many of these health con-
virus/acquired immunodeficiency syndrome [HIV/AIDS], cerns persist.
medically immunosuppressed) will be more sensitive to While some of the former health concerns persist, the
microbes in drinking or recreational water. During differ- 20th century brought a whole new set of environmental
ent developmental stages, we have different susceptibility concerns resulting from climate change, energy produc-
based on our physiological development and also based tion, the unfettered development of chemicals and products,
on the activities that we are likely to perform (e.g., hand- increasing demands by population growth, antibiotic-Â�
to-mouth activities of infants; work-related Â� exposures resistant strains of infectious diseases, and the introduction
ofÂ€adults). of new technologies. In our poorest communities, there are
CHAPTER 9â•… Environmental Health Risks: At Home, at Work, and in the Community 237
Â�
additional risks from substandard housing, lack of healthy BOXÂ€9-1â•…â•‡ENVIRONMENTAL HEALTH
foods, inadequate access to health care, and higher probabil- PRINCIPLES FOR PUBLIC
ity of working in unhealthy jobs. HEALTH NURSING
Nursing Involvement in Environmental Issues 1. Safe and sustainable environments are essential conditions for
In the 21st century the relationship between the environment the public's health.
and human health will play a significant role in how we assess 2. Environmental health is integral to the roles and responsibilities
and address public health and the delivery of health care ser- of all public health nurses.
vices. Global climate change creates both ecological changes 3. All public health nurses should possess environmental health
and threats to human health. The legacy and continued use of knowledge and skills.
hundreds of thousands of potentially toxic chemicals is already 4. Environmental health decisions should be grounded in sound
affecting our health status. The need for preparedness from nat- science.
5. The Precautionary Principle is a fundamental tenet for all environ-
ural and man-made disasters is essential. And engagement in
mental health endeavors.
the policy arena will be critical to insure that we create laws and
6. Environmental justice is a right of all populations.
regulations that afford the most protection to ecological and
7. Public awareness and community involvement are essential in
human health. environmental health decision making.
Nursing practice is not currently aligned with the depth and 8. Communities have a right to relevant and timely information for
breadth of the current state of environmental health science. decisions on environmental health.
It is critical that nurses integrate knowledge from the mount- 9. Environmental health approaches should respect diverse values,
ing science regarding the relationship between environmen- beliefs, cultures, and circumstances.
tal exposures and human health effects into our education, 10. Collaboration is essential to effectively protect the health of all
practice, research, and policy/advocacy work (IOM, 1995). As people from environmental harm.
nurses, we learn to assess, plan, implement, and evaluate. If we 11. Environmental health advocacy must be rooted in scientific integ-
do not include environmental health in our assessments (indi- rity, honesty, respect for all persons, and social justice.
vidual, family, and/or community) we will have missed an 12. Environmental health research addressing the effectiveness and
important opportunity to prevent or address environmentally public health impact of nursing interventions should be conducted
related health risks and disease. and disseminated.
In 2010, the American Nurses Association (ANA) recog- From American Public Health Association, Public Health Nurses' Section.
nized this critical need and included an Environmental Health (2006). Environmental health principles for public health nursing.
Standard in Nursing: Scope and Standards of Practice (ANA, Washington, DC: Author. Available at http://www.apha.org/membergroups/
2010). This ANA document clearly pronounces that environ- newsletters/sectionnewsletters/public_nur/winter06/2550.htm.
mental health is an essential component for all professional
nursing practice. Public health nurses have been proactive in
their integration of environmental health, and through the we are vulnerable to environmental risks during different devel-
Public Health Nursing Section of the American Public Health opmental stages of life—embryonic/fetal, childhood, adult, and
Association they adopted a set of environmental principles to older adult. Looking at these different approaches we quickly
guide public health nursing practice (BoxÂ€9-1). see that environmental health is complex and wide in scope. In
There are many ways in which environmental health can be this chapter we will look at environmental health from a variety
approached from a nursing perspective. We can look at it from of approaches.
a traditional environmental perspective that categorizes expo- Today, all nurses are challenged to address environmental
sures by media—air, water, soil, food, products. We can sort by problems. The Healthy People 2020 objectives (U.S. Department
chemical, biological, or radiological exposures. We can examine of Health and Human Services [USDHHS], 2010a) address a
exposures from the perspective of where we live (home), work, great many occupational and environmental health issues (see
learn (school), and play (community). We can categorize types the Healthy People 2020 box). For example, one objective is to
of chemicals—heavy metals (lead, mercury), pesticides, sol- reduce asthma rates, another is to reduce lead poisoning in chil-
vents, etc. Or we can look at human development and see how dren, and another is to reduce water-borne illnesses.
HEALTHY PEOPLE 2020

Selected Environmental Health Objectives
1. Reduce emergency department visits for asthma to 95.5 visits per 4. Reduce to 2.94â•›μg/dL the concentration level of lead in blood sam-
10,000 children under age 5â•›years (baseline: 132.7 per 10,000 in ples at which 95% of the population aged 1 and older is below
2005-07). (baseline: 4.2â•›μg/dL 2003-2004).
2. Increase to 36.8% the proportion of persons with current asthma 5. Reduce exposure to selected environmental chemicals in the popu-
who receive written asthma management plans from their health lation, as measured by blood and urine concentrations of the sub-
care provider (baseline: 33.4% in 2008). stances or their metabolites.
3. Reduce to 555.8 hospitalizations per 100,000 population for nonfa- 6. Reduce waterborne disease outbreaks to 2 per year from water
tal injuries (baseline: 617.6 in 2007, age adjusted to the year 2000 intended for drinking among persons served by community water
standard population). systems (baseline: 7 in 1998-2008).
(Continued)
HEALTHY PEOPLE 2020—CONT'D

7. Increase to 91% the proportion of persons served by community 12. Increase to 63.7% of the nation's elementary, middle, and high
water systems who receive a supply of drinking water that meets the schools that use spot treatments and baiting rather than wide-
regulations of the Safe Drinking Water Act (baseline: 89% in 2005). spread application of pesticide (baseline: 57.9% in 2006).
8. Reduce to 10 the number of days per year that the Air Quality Index 13. Reduce to 26.39â•›ng/g of lipid, the pesticide oxychlordane (lipid
(AQI) exceeds 100 (baseline: 11â•›days per year in 2008). adjusted) in serum samples at which 95% of the population aged
9. Reduce toxic air emissions to decrease the risk of adverse health 12 and older is below (baseline: 37.7â•›ng/g of lipid).
effects caused by airborne toxics. 14. Reduce to 1151 the number of hazardous sites that present risks to
10. Reduce to 47.0% the proportion of children aged 3 to 11â•›years human health and the environment (baseline: 1279 in 2010).
exposed to secondhand smoke (baseline: 52.2% in 2005-2008). 15. Reduce to 2.0 million global deaths due to poor water qual-
11. Reduce to 41.0% the proportion of adolescents 12 to 17â•›years ity, sanitation, and insufficient hygiene (baseline: 2.2 million in
exposed to secondhand smoke (baseline: 45.5% in 2005-2008). 2004).
Poverty and race play an important role in health status. Institute of Medicine Report
The same is true for environmental health status. The concept In the early 1990s, a group of nurses and others were convened
of environmental justice refers to the disproportionately high by the National Academy of Science Institute of Medicine to
exposures of low-income and minority populations to environ- assess the integration of environmental health into nursing
mental health hazards, such as air pollution, hazardous waste sites, education, practice, research, and policy/Â�advocacy. The group
pesticides, lead exposure, and unsafe drinking water (Bullard, authored a report in 1995 entitled Nursing, Health, and the
2005; Bullard, 2007; Sattler & Lipscomb, 2003). Such additional Environment (Pope etÂ€al., 1995). It continues to serve as a blue-
exposures further contribute to the health disparities that might print for efforts to enhance nurses' capacity to address cur-
otherwise be experienced in poor and stressed communities. rent and emerging environmental health issues. The following
Dr. Devon Payne-Sturges of the U.S. Environmental Protection competencies were recognized as essential for all nurses:
Agency (EPA) has created a useful model to consider the many 1. Basic Knowledge and Concepts
factors affecting environmental justice and health disparities All nurses should understand the scientific principles and under-
(FigureÂ€9-1). pinnings of the relationship between individuals or Â�populations
Stress-Exposure Disease Framework for Environmental Health Disparities
Race/Ethnicity
Residential Segregation
Residential Location
Community
Level
Neighborhood Community Structural Environmental Vulnerability
Resources Stressors Factors Hazards and
Pollutants
Community
Exposure
Stress
Individual Stressors
Individual Coping Internal Dose
Appraisal process Individual Level
Vulnerability
Individual Stress Biologically
Effective Dose
Health Effect
(Disparities)
FIGUREÂ€9-1â•‡ Environmental health disparities: A framework integrating psychosocial and environ-

mental concepts. (From Gee, G., & Payne-Sturges, D. [2004]. Environmental health disparities: A framework
integrating psychosocial and environmental concepts. Environmental Health Perspectives, 112[17], 1645-1653.
Published online August 16, 2004, doi:10.1289/ehp.7074. © This is an Open Access article: verbatim copying and
redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along
with the article's original DOI.)
and the environment (including the work environment). This similar to pharmacology. Both require an understanding of
understanding includes the basic mechanism and pathways of dose/response and both require us to consider host factors.
exposure to environmental health hazards, basic prevention and Where toxicology and pharmacology differ substantially is
control strategies, the interdisciplinary nature of effective inter- in the regulatory arena. Pharmaceuticals are highly regulated
ventions, and the role of research. from the moment a scientist even considers the development
2. Assessment and Referral of a drug through its final stages of clinical trials and into the
All nurses should be able to successfully complete an environ- market. For chemicals that are not pharmaceuticals and their
mental health history, recognize potential environmental haz- associated products (such as personal care products, lawn and
ards and sentinel illnesses, and make appropriate referrals for pet products, and cleaning solutions) there is virtually no regu-
conditions with probable environmental causes. An essential latory oversight. We will see later in this chapter how this lack of
component is the ability to access and provide information to oversight is impacting human health.
clients and communities and to locate referral sources. Another area of environmental science that is relevant to envi-
3. Advocacy, Ethics, and Risk Communication ronmental health is the study of the fate and transport of chemi-
All nurses should be able to demonstrate knowledge of the role cals. This refers to the way in which pollutants migrate from one
of advocacy (case and class), ethics, and risk communication place to another. For example, the mercury released into the air
in client care and community intervention with respect to the from a coal-fired power plant can wind up in the water, where
potential adverse effects of the environment on health. the microorganisms convert the mercury to organic mercury
4. Legislation and Regulation (which is toxic). These microorganisms are then eaten by larger
All nurses should understand the policy framework and major and larger marine animals, which in turn are eaten by humans.
pieces of legislation and regulations related to environmental Another example is when potentially toxic agricultural chemicals
health. leach into the ground water, which contaminates wells from which
In the years since the IOM report, there has been much prog- the community draws its drinking water. Understanding fate and
ress in the nursing profession regarding environmental health. transport can help public health nurses to consider the best ways
to help communities and individuals avert harmful exposures.
Multidisciplinary Approaches In workplaces, occupationally related exposures are often
Two important scientific disciplines for understanding environ- assessed by industrial hygienists, a group of professionals who
mental health are toxicology and epidemiology. Epidemiology measure air quality, noise levels, and temperature in order to
is discussed in ChapterÂ€7. Toxicology is the study of chemicals determine the level of risk to workers. They address Â�exposures
and their potential to make humans (and other life forms) sick. using a tool called the “Industrial Hygiene Hierarchy of
When studying toxic chemicals, scientists work with inÂ€vitro Controls” (FigureÂ€9-2). This rubric for decision making is a
(working with cultures or cells) and inÂ€vivo models (working useful tool for other environmental exposures, in addition to
with live organisms, such as mice or primates). occupational exposures.
While there is no expectation that nurses become toxicol- In the Industrial Hygiene Hierarchy of Controls, the first line
ogists, it is important for us to know the basic principles of of defense starts with the question: Do we need this toxic chemical
toxicology, as it is a keystone science of environmental health. (or product) in the first place? Can it be eliminated? The Â�second
TableÂ€9-1 contains a side-by-side comparison of a science that is question is: Is there a safe(r) substitute that could be used? Next,
well known to nurses—pharmacology—and the lesser known we look at opportunities to modify the workplace with engineer-
science of toxicology. We can easily see that toxicology is very ing controls such as exhaust hoods that pull potentially toxic
TABLEÂ€9-1â•…â•‡COMPARISON OF PHARMACOLOGY AND TOXICOLOGY

PHARMACOLOGY TOXICOLOGY
Pharmacology is the scientific study of the origin, nature, chemistry, Toxicology is the science that investigates the adverse effects of
effects, and use of drugs. chemicals on health.
Dose refers to the amount of a drug absorbed from an Dose refers to the amount of a chemical absorbed into the body from a
administration. chemical exposure.
A drug can be administered one time, short term, or long term. Exposure is the actual contact that a person has with a chemical.
Exposure can be one time, short term, or long term.
A dose-response curve graphically represents the relationship A dose-response curve describes the relationship of the body's response
between the dose of a drug and the response elicited. to different amounts of an agent such as a drug or toxin.
Routes of administration include oral, intramuscular, intravenous, Routes of entry are ingestion, inhalation, or dermal absorption.
dermal, or topical.
With drugs there are therapeutic responses (desirable) and side effects In toxicology, only the toxic effects are of concern. Toxicity is the ability
(undesirable). Beyond the therapeutic dose, a drug may become toxic. of a chemical to damage an organ system, disrupt a biochemical
process, or disturb an enzyme system.
Potency refers to the relative amount of drug required to produce the The potency of a toxic chemical refers to the relative amount it takes to
desired response. elicit a toxic effect compared with other chemicals.
Biologic monitoring is done for some drugs: clotting time is monitored Biologic monitoring is done for some toxic exposures, such as blood lead
in patients taking anticoagulants such as warfarin. Actual drug levels levels or metabolites of chemicals such as cotinines for environmental
are measured for some drugs such as digoxin. tobacco smoke.
From Sattler, B. (1998). Environmental Health Education Center, University of Maryland School of Nursing. Used with permission.
Traditional Hierarchy other human health-specific work. Both occupational health

of Exposure Control Practices nurses and industrial hygienists are responsible for knowing the
laws and regulations regarding workplace health and safety.
Elimination Another occupational health specialty is ergonomics, the
Substitution study of the interface between people and their physical envi-
ronment. Ergonomists address issues related to work stations
Modification and how well they “fit” the worker, in order to reduce or elimi-
Containment
nate muscular strain, vision problems, and other stressors.
Nursing's role has been evolving in terms of our responsibilities
Ventilation in environmental health. In the state of Vermont, every politi-
Work Practices
cal jurisdiction has an “environmental health nurse” who has
been cross-trained beyond general community/public health to
Personal Protection a wider range of environmental health issues. In the Los Angeles
Health Department, a new role has been created for environ-
FIGUREÂ€9-2â•‡Industrial Hygiene Hierarchy of Controls (most
desired at top). (From CDC: http://www.cdc.gov/niosh/topics/ctrlbanding/).
mental health nurses. At the University of Maryland Medical
Center a role has been created for a nurse (Denise Choiniere,
MS, RN) to lead environmental health and sustainability work
fumes up and away from the workers. We also look at ways to at the hospital. While these positions are still rare, it indicates a
completely contain hazards in contained areas. A home-based growing understanding of how important nurses' skills can be
example of containment is the use of “roach hotels” that have harnessed to address environmental health challenges.
small amounts of pesticides within an enclosed box versus spray- More often what we are seeing is the integration of envi-
ing pesticides throughout a whole room. The next defense against ronmental health principles and practices into existing nursing
toxic chemicals in workplaces is ventilation. Circulating increased work, particularly public health nursing. For example, it is quite
volumes of outside air into a workplace dilutes the chemicals common to have a nurse directing the lead poisoning activi-
inside. Increasing air exchange is often an important activity when ties within a health department or to have nurses involved in
addressing indoor air pollution, even in homes and schools. By risk communication, such as when a swimming area is com-
changing work practices, we can reduce the amount of exposure promised with pathogens. It is equally common to see school
to any given worker. For example, we can limit the amount of time nurses involved in indoor air quality issues or concerned about
any given worker has to spend in an area with known toxic expo- the pesticides that are used on the children's playing fields.
sures. This is done with radiation and is why people who work
around x-rays monitor their exposures. When they have reached Conceptual Model of Ecological Systems
a certain level of exposure, they can no longer work in the areas Ecology refers to the study of living things in relationship to
where they might continue to be exposed. The final and least effec- their environment. The major impetus in the development
tive of the choices is retrofitting the worker with personal proof ecology was from the biological sciences. As early as 1859,
tective equipment (PPE) such as gloves, masks, respirators, and Charles Darwin identified the “web of life” and recognized
protective clothing. When selecting an intervention, the most the highly complex set of interrelationships that were present
effective choices are at the top of the hierarchy and they become between organisms and their environments. The word ecology
less effective as you move down the list. was first used in 1868 by Ernst Haeckel, a German biologist.
Assessment, prevention, and protection in environmental health The term human ecology was coined in the 1920s in a sociologi-
are the job of a great many disciplines. Toxicologists, along with a cal text in an attempt to systematically apply a basic Â�theoretical
wide array of basic and applied scientists (e.g., geologists, biologists,
geographers, neurobiologists) help to provide some of the scien-
tific underpinnings for our understanding of how human health, Input (information, energy, matter)
ecological health, and the environment are all interconnected and
impact each other. In the applied arena, there are sanitarians (who
MACROSYSTEM
are currently renaming themselves “environmental profession-
als”) who often work in the public sector, especially in local health
departments. They are often involved in food safety, vector Â�control,
Political Physical
housing-related environmental risks, and other of the environmen-
tal programs typically found in local health departments.
In the applied arena there are professionals and technicians MICROSYSTEM
who specialize in water quality, air quality, and other media-
Human
specific areas. Such specialists may work in the public sector populations
(e.g., state health and environmental departments, the fed-
eral Environmental Protection Agency). They may also work Economic Cultural
in industry and in the nonprofit world, where they help to
determine necessary environmental controls or advocate for
enhanced environmental protection.
In workplace health settings, occupational health nurses work Social
very closely with industrial hygienists and have some overlap-
ping roles; however, nurses have the distinct role in physical Output
assessments of the workers, maintaining health records, and FIGUREÂ€9-3â•‡ Simplified ecological systems model.
scheme of plant and animal ecology to the study of human and other potentially toxic substances. The list of health risks
communities (Hawley, 1950). Cultural and sociological dimen- that are Â�associated with these chemicals is long and includes
sions, as well as spatial distribution, were later included in the neurotoxicity (e.g., learning disabilities, behavioral problems,
field of human ecology. Parkinsonism), reproductive health problems (e.g., infertility,
Ecological systems generally have several different levels endometriosis), endocrine disruption, and carcinogenicity.
(Bronfenbrenner, 1979). The simplified version illustrated in In the CDC study, three common, toxic chemicals were
FigureÂ€9-3 consists of two levels. The level of system closest to found in almost everyone they tested. These chemicals include
the human population is the microsystem. The microsystem polybrominated diphenyl ethers (PBDE), a fire retardant that
includes the environment immediately surrounding the person is used in textiles, computers/electronics and other products;
(e.g., the family and the home). The macrosystem is the larger bisphenol A (BPA), a reproductive toxicant that is found in plas-
context in which the microsystem is embedded. Culture, tradi- tics, cosmetics and other products; and perfluorooctanoic acid
tions, customs, societal norms, governmental agencies, schools, (PFOA), a chemical used on nonstick surfaces like frying pans.
organizations, economic policies, and the physical environment For women, body burdens of potentially toxic chemicals can be
constitute the macrosystem. unwittingly shared with the developing fetus, as most of these
The basic principles of ecological systems are similar to chemicals cross the placental barrier.
Commoner's laws of ecology—everything is connected to every- In a 2005 study, scientists assayed the cord blood of new-
thing else and everything must go somewhere (Commoner, borns to see what potentially hazardous chemicals could be
1972). Because of the interrelationships and interactions among found in the blood that had been circulating in the baby imme-
the different aspects of a system, change in any portion of a diately before birth. Many of the same industrial chemicals were
system might affect change in other parts of the system. (See found in cord blood (Houlihan etÂ€al., 2005). The evidence of
ChapterÂ€1 for a discussion of general systems theory.) In other our body burden of chemicals is a sign of failed chemical poli-
words, systems are dynamic, and change is constant. For exam- cies and a call to action for all nurses to integrate environmen-
ple, the microsystem or the family of a daycare worker might tal health and precautionary principles into our professional
become infected with Giardia through an infected child at the practice. This will require us to consider how we can integrate
daycare center who drank contaminated water when on a hike primary and secondary prevention into our work. To do this,
with the parents. The child was infected with the Giardia organ- we will need to integrate environmental health into our indi-
ism from the macrosystem (a mountain stream). The organism vidual, family, and community assessments and learn about the
then crossed the boundaries from the macrosystem to the micro- resources that are available to all of us. The presence of the Web
system (the child in daycare) and infected the worker. can catalyze our efforts, as the evidence that we need to under-
An ecological system includes all the physical, social, cul- pin our decisions and practice is now often readily available.
tural, political, and economic conditions that influence the lives
of individuals, groups, and communities. As with other areas of ASSESSMENT OF ENVIRONMENTAL HEALTH
nursing, the focus of nurses in environmental health is to pro- HAZARDS
mote, maintain, and support health, and specifically to explain
how the environment affects well-being (Butterfield, 2002). By its very nature, environmental health requires a public health
Kleffel (1996) has proposed that nurses move toward an eco- approach to disease because environments affect many people
centric perspective that emphasizes the linkages and interrela- simultaneously. An exposure assessment of the potential envi-
tionships among global conditions, environmental hazards, and ronmental hazards should be included in every individual's
human health. In environmental health, particular attention is health history (Sattler & Lipscomb, 2003). BoxÂ€9-2 presents
given to the identification of both positive and negative factors questions that should be part of this assessment. The primary
in the environment that might affect human beings. environments for most individuals can be divided into three
Since 1999, the Centers for Disease Control and Prevention broad areas: the home (Davis, 2007), the work site (Guenther &
(CDC) has been studying the presence of toxic chemicals in the Hall, 2007; Sattler, 2003; Sattler & Hall, 2007; Shaner-McRae
blood and urine of a representative sample of American residents. etÂ€al., 2007), and the community (Gilden, 2003). In the sections
This is a relatively new addition to the long-standing National that follow, these environments are described. Other chapters
Health and Nutrition Exam Study (NHANES) (CDC, 2011a). cover related topics, such as violence (see ChapterÂ€23).
Approximately 5000 people are selected who have their health
history taken, are given a physical exam, and provide urine and Nationally, the Planned Parenthood Association of America
blood samples. The concept that everything must go somewhere sees over 3 million women, primarily for contraceptive care.
is alarmingly demonstrated by the amount of toxic chemicals In 2009, they began a program called Green Choices, in which
that are being found in our urine and blood. The Fourth National they trained their clinical staff in environmental health and
Report on Human Exposure to Environmental Chemicals 2009 added an environmental health assessment to their initial
summarizes the findings from this and past studies during which assessment. They also developed a set of factsheets that they
time 219 potentially toxic chemicals were examined (CDC, 2011a). provide to patients when they discover a potentially harmful
The chemicals that the CDC is measuring do not belong in environmental exposure. This program was started by Sandy
the human body. They are the result of pollutants and poten- Worthington, a nurse–midwife, who recognized the oppor-
tially toxic chemicals that are found in our air, water, food, tunity to engage in primary prevention by helping women to
soil, and products. Many of them persist in the environment decrease their environmental exposures.
because they do not break down. For some persistent chemicals
the human body does not have an effective physiological excre- There are a number of environmental assessment tools that
tion mechanism and therefore they accumulate in our bodies. can be used to supplement the basic community health assess-
These chemicals include fire retardants, solvents, pesticides, ment in order to identify environmental health threats within
BOXÂ€9-2â•…â•‡TAKING AN EXPOSURE HISTORY: I PREPARE

I—Investigate All Exposures • How close to major roadways is the client's home?
• Who is the population I serve, and what are my clients' exposure risks? • Does my client live in an urban or rural area?
• What are their environmental exposure risks at home, at school, or in • Are there polluted waterways near my client's home?
the community or workplace?
• Are my clients responding to usual treatments? P—Past Work
• Do symptoms seem unusual for my client's age or the time of year? • What were my client's duties in previous jobs?
• Has my client done seasonal or volunteer work? What type?
P—Present Work
• What is my client's daily routine at work (home or school)? A—Activities
• Does my client work with chemicals? How does my client come in • What hobbies do my client and my client's family enjoy? Has anyone
contact with chemicals? in the family taken up a new hobby or activity recently?
• Do other members of my client's household have similar symptoms? • Does my client hunt, garden, fish, or swim?
Does my client notice any change in his or her symptoms when away • Does my client engage in alternative or cultural health practices?
from work or home?
R—Resources and Referrals
R—Residence • What are my sources of information and referral for my clients?
• Has my client's home recently been remodeled? • A few examples are ATSDR, AOEC, AAOHN, OSHA, NIOSH, EPA,
• What is the source of my client's drinking water—a private well or health departments, and poison control centers.
public water systems?
• What type of heating system is in my client's home? E—Educate
• How does my client read or receive information?
E—Environment • Are there available cultural, language, or media information sources
• What types of farms, landfills, industries, and factories are (or used applicable to my client's needs and interests?
to be) located near my client's home?
From Agency for Toxic Substances and Disease Registry. (2000). Available at http://www.atsdr.cdc.gov.
a community. On the website http://www.enviRN.org, you can Environmental Hazards at Home

find a number of assessment tools. The National Library of While we would like to think of our homes as safe and healthy
Medicine created ToxTown to help identify and address Â�public havens, they may have hidden risks that we can often easily
and environmental health risks and link the information to reduce or eliminate. These risks may be associated with the
their wealth of databases and peer-reviewed articles (http:// building itself, such as formaldehyde, which is commonly used
toxtown.nlm.nih.gov/). Note that ToxTown allows the viewer to to bind wood chips in pressboard, or with lead-based paint,
choose between a town, city, farm, U.S./Mexico border com- commonly found in housing stock build before the 1950s and
munity, or port, providing a great range of environmental sometimes found in houses built before 1978, when lead-based
health information. Skin Deep is an excellent database created paint was banned from use in house paint.
by the Environmental Working Group that specifies the health There are many assessment tools that have been developed
risks associated with personal care products (http://www.ewg. to determine environmental health risks. Dr. Allison Davis
org/skindeep/). The Household Products Database created by developed a home assessment when she was a graduate nurs-
the National Library of Medicine provides information on the ing student that she used to determine the types of environ-
ingredients and potential health effects from products ranging mental health risks that might be experienced by staff and
from cleaning, automotive, lawn care, and personal care prod- residents in group homes for people with developmental dis-
ucts to pet supplies (http://hpd.nlm.nih.gov/). abilities (FigureÂ€9-4). This quick and easy assessment tool can
When doing a community-wide assessment, environmental help to guide any type of home assessment. Using this tool in
questions to ask are as follows: What is the air quality in the com- combination with the National Library of Medicine's ToxTown
munity? What is the water quality (both drinking water and rec- and the Household Products Database will help to deter-
reational)? Are agricultural and/or lawn chemicals a part of the mine some of the most common health risks that are associ-
landscape (e.g., pesticides, herbicides)? Has the land/soil been ated with most homes. They can help to determine areas for
contaminated by previous or current use? Are pests a problem remediation, product substitution, and general environmen-
(e.g., mosquitoes, rodents, deer)? Is the housing stock sound and tal health education. TableÂ€9-2 discusses common sources of
healthy? Are there major roadways in the community that may home pollution.
contribute to air pollution and particulate Â�matter? Also note that
a neighborhood assessment should include the positive environ- Hygiene and Sanitation
mental attributes that contribute to health and quality of life. Hygiene and household cleanliness contribute to the mainte-
Examples of questions about environmental attributes include nance of family health. Maintaining a clean home and using
the following: Is the community “walkable”; is it served by good closed containers for food sources can significantly reduce the
public transportation; and does it have parks, green spaces, risk of insects such as roaches and ants, as well as rodents (mice/
community gardens, and/or trees? Is there access to affordable, rats), thus avoiding the need for pest control measures.
healthy foods and fresh produce? Does the community have With population increasing, especially in urban areas, the
access to a farmers' market during the growing season? need to manage waste is an important part of Â�environmental
health (Morgan, 2003). Daily, each American produces Radon

Â�approximately 4.5 pounds of solid waste, such as food scraps Radon (whose chemical initial is Rn) is an odorless, colorless,
and paper (USDHHS, 1998). One objective of Healthy People and tasteless naturally occurring radioactive gas that is the by-
2020 is to decrease overall waste and increase recycling. We can product of decaying uranium in the soil. Exposure to radon,
decrease our waste by requesting less packaging on our prod- which is commonly from home exposures, is second only to
ucts, buying in bulk when possible, using reusable shopping smoking as the leading cause of lung cancer in the U.S. (EPA,
bags and recycling. In some cities, like San Francisco, there is 2011). Reducing exposure to radon is a Healthy People 2020
now curbside pickup of “compostables”—kitchen waste and objective. Because it comes from the soil, it is most likely to
green waste from the garden. This significantly decreases the come into the basements of homes, particularly if there are
overall waste that must be sent to a landfill or waste incinera- cracks or crevices. If the basement provides living space for
tor. Many cities and counties have regular or periodic collection family members it is particularly important to test for radon.
centers for household hazardous wastes such as batteries and Inexpensive tests for radon can be found at hardware stores and
paints, which should never be thrown in the regular garbage. building supply stores. The EPA provides excellent guidance to
A detailed case study about disposable diaper use is provided in homeowners who discover that they have unhealthy levels of
Website Resource 9A. â•… Hazardous wastes are discussed later radon. Radon can also get into ground water and, in turn, into
in this chapter. well water. It is important to include radon in the battery of tests
Home Environmental Health and Safety Assessment Tool
Assessment Yes No N/A Standard of Practice

Home built before 1978 Test homes built
before 1978 for lead
Home tested for lead
Maintain home to
Living space in basement prevent chipping or
Attached garage peeling paint
Remove shoes indoors
Home radon test
Test first three floors of
Home radon ventilation system all homes for radon
Do not idle car in
Living space in basement garage
Ensure proper venting
Combustion heating source
of all combustion
Gas, kerosene or propane heating sources.
space heater Annual assessment to
ensure proper
Wood stove function.
Do not use grills or
Fireplace
generators indoors
Gas dryer Gas dryers, hot water
heaters, and stove
Vented
need to vent outdoors
Gas hot water heater
Vented
Gas stove
Well water Routine well testing
and maintenance of
Lead pipes private wells
Water tested for contaminants Review consumer
confidence reports for
Known contaminants: public water supply
Smoke detector Smoke detector on all
floors and in
Carbon monoxide detector bedrooms
Fire extinguisher
Carbon monoxide
Fire evacuation route detector on all levels
in homes with
Emergency phone numbers
combustion source or
Disaster plan garage
Shelter–in-place supplies
FIGUREÂ€9-4â•‡ Home environmental health and safety assessment tool. (Copyright Del Bene Davis
Home Environmental Assessment Tool, University of Maryland, Environmental Health Education Center.
[March 2007]. Used with permission.)
Continued
Assessment Yes No N/A Standard of Practice

Insects in home Use of integrated pest
management
Rodents in home techniques for
If yes what
what: controlling pests
Pesticide spraying in home Use least hazardous
methods of pest
If yes what / how often: control
Pesticide contract
Frequency:
Air freshener used in home Minimize use of air
fresheners. Use less
Candles hazardous and
Plug-ins irritating alternatives
to control odors.
Incense
Use of low VOC
How many times per day: household cleaners
and green cleaning
Use of strong smelling cleaners
techniques
See federal and state
Tuna fish served in home
recommended fish
consumption
advisories
If yes, how often per week:
Wash all fruits and
vegetables before
Fresh fruit/vegetables used eating
Consider organic or
Local/organic products used locally grown
products
Mercury thermometer in house Use non–mercury-
containing medical devices
Other mercury devices
Needle boxes for needles Dispose of all mercury
devices and batteries
Use of traditional or cultural per local hazard waste
remedies containing mercury collection procedures
Smoking allowed in home Institute no smoking
indoors policy
House smells like smoke
Cigarette products present
FIGUREÂ€9-4, Cont'd
done on well water. Certain parts of the country are more likely more concerned about the health effects of lower blood lead lev-
to have radon. Maps from the EPA (see Community Resources els than they were in the past. Scientific evidence shows us that
for Practice) show areas of high concentration. smaller and smaller amounts of lead can contribute to a range
of health threats, particularly neurological effects in children.
Lead In early 2012, the Advisory Committee on Childhood Lead
The reduction of childhood lead poisoning is one of the most Poisoning Prevention (ACCLPP) of the Centers for Disease
significant public health achievements in recent years. Leaded Control and Prevention (CDC) recommended that the CDC
gasoline and lead-based paint were both banned in the 1970s. encourage more focus on primary prevention of lead poisoning
In the years following the ban on leaded gasoline there was a in children. This is because research in large, diverse populations
dramatic reduction in the average blood lead level of children in of children indicates that all levels of lead have unhealthy effects.
the U.S. Lead-based paint continues to be found in most homes There is no “safe” level of lead and the effects appear irreversible.
built before 1950. While paint surfaces that are well maintained Effects at blood lead levels (BLLs) < 10 μg/dL include IQ deficits
do not create a risk, chipping and peeling paint and paint dust and “other behavioral domains, particularly attention-related
that is created by friction points, such as double hung windows behaviors and academic achievement. New findings suggest that
and sills, continue to contribute to the persistent problem of the adverse health effects of BLLs less than 10 μg/dL in children
lead poisoning in children. Despite the removal of lead from extend beyond cognitive function to include cardiovascular,
paint, gasoline, and food cans, lead persists in the paint and immunological, and endocrine effects” (ACCLPP, 2012, p. ix).
plumbing of many older structures, and in contaminated soil Therefore, we should not wait until children are exposed to
(Sanborn etÂ€al., 2002). The Centers for Disease Control is now lead. Primary prevention should focus on improving the Â�housing
TABLEÂ€9-2â•…â•‡COMMON SOURCES OF HOME POLLUTION

AGENT DESCRIPTION SOURCES IN HOME
Radon Colorless, odorless, radioactive gas from the natural breakdown Soil or rock under the home, well water, building
(radioactive decay) of uranium; it is estimated that radon causes materials
up to 36,000 lung cancer deaths per year
Asbestos Mineral fiber used extensively in building materials for insulation and Sprayed-on acoustical ceilings or textured paint,
as a fire retardant; asbestos should be removed by a professional pipe and furnace insulation materials, floor tiles,
if it has deteriorated; exposure to asbestos fibers can cause automobile brakes and clutches
irreversible and often fatal lung diseases, including cancer
Biological Include bacteria, mold and mildew, viruses, animal dander and Mold and mildew, standing water or water-damaged
contaminants saliva, dust mites, and pollen; these contaminants can cause materials, humidifiers, house plants, household pets,
infectious diseases or allergic reactions; moisture and dust ventilation systems, household dust
levels in the home should be kept as low as possible
Indoor combustion Produces harmful gases (carbon monoxide, nitrogen dioxide), Tobacco smoke, unvented kerosene or gas space heaters,
particles, and organic compounds (benzene); health effects range unvented kitchen gas stoves, wood stoves or fireplaces,
from irritation to the eyes, nose, and throat, to lung cancer; leaking exhaust flues from gas furnaces and clothes
ventilation of gas appliances to the outdoors will minimize risks dryers, car exhaust from an attached garage
Household products Can contain potentially harmful organic compounds; health effects Cleaning products; paint supplies; stored fuels; hobby
vary greatly; the elimination of household chemicals through the products; personal care products; mothballs; air
use of nontoxic alternatives or by using only in well-ventilated fresheners; dry-cleaned clothes
rooms or outside will minimize risks
Formaldehyde Widely used chemical that is released to the air as a colorless Particleboard, plywood, and fiberboard in cabinets,
gas; it can cause eye, nose, throat, and respiratory system furniture, subflooring, and paneling; carpeting,
irritation, headaches, nausea, and fatigue; might be a central durable-press drapes, other textiles; urea-
nervous system depressant and has been shown to cause formaldehyde insulation; glues and adhesives
cancer in laboratory animals; remove sources of formaldehyde
from the home if health effects occur
Pesticides Including insecticides, termiticides, rodenticides, and fungicides, Contaminated soil or dust that is tracked in from outside;
all of which contain organic compounds; exposure to high levels stored pesticide containers; residue if used inside
of pesticides might cause damage to the liver and the central
nervous system and increase cancer risks; when possible,
nonchemical methods of pest control should be used; if the
use of pesticides is unavoidable they should be used strictly
according to the manufacturer's directions
Lead A long-recognized harmful environmental pollutant; fetuses, Lead-based paint that is peeling, sanded, or burned;
infants, and children are more vulnerable to toxic effects; if the automobile exhaust; lead in drinking water;
community health nurse suspects that a home has lead paint, it contaminated soil; food contaminated by lead from
should be tested lead-based ceramic cookware or pottery; lead-related
hobbies or occupations; folk remedies
in which children live. One-third of the dwellings in the United the domain of public health nurses, either alone or in col-
States have lead-based paint hazards. “Housing policies to pro- laboration with environmental health specialists. Developing
tect children against lead exposure must target the highest risk targeted lead surveillance and intervention programs in areas
properties for priority action; ensure that lead-safe practices are with poor children who live in older housing stock has proven
followed during renovation, repair and painting of pre-1978 to be a successful form of secondary prevention. Because sur-
homes; and prohibit lead-based paint hazards, including dete- veillance finds active cases of lead poisoning, instead of pre-
riorated paint, in pre-1978 homes” (ACCLPP, 2012, p. x). venting the exposures, it is a secondary prevention approach.
Secondary prevention should be initiated at the “97.5th Nurses working with families must identify those at risk for
Â�percentile of NHANES-generated distribution of children 1-5 lead toxicity while educating children, teachers, parents, and
years old (currently 5 μg/dL)” (ACCLPP, 2012, p. x). Treatment other health care providers about how to prevent lead toxicity
should include lead education, environmental investigations, (Arvidson & Colledge, 1996; Davis, 2007).
and medical monitoring. Previously, the recommended treat- Other sources of lead exposure include contaminated soil,
ment level was > 9 μg/dL. Website Resource 9B â•‡ provides airborne particles from industrial and municipal incinerator
additional information about symptoms and recommended sources, water from lead pipes, food cooked in ceramic ware with
interventions for the secondary prevention of lead poisoning lead glaze, and hobbies such as target shooting, stained glass, and
starting at blood levels greater than 9 μg/dL. pottery making.
Some local health departments, particularly in urban set- In recent years, lead has been recognized as a hazard when
tings, have lead poisoning prevention programs. Some states, renovating older homes. Unfortunately, families renovat-
such as Maryland, have created statewide blood lead registries ing older homes are often unaware that lead poisoning might
in order to track childhood and adult lead poisonings and be a risk (Agency for Toxic Substances and Disease Registry
intervene appropriately. Lead poisoning programs are often [ATSDR], 1995; Sanborn etÂ€al., 2002). Early signs of lead
Â� oisoning include disturbances in cognition, behavior, learning,

p Carbon Monoxide
attention span, and growth and development. Colic, constipa- Carbon monoxide (CO) is a colorless and odorless gas that is
tion, and upper extremity weakness are signs of chronic expo- a by-product of combustion and can be an insidious, fatal poi-
sure. Continued high-level exposure can lead to central nervous son. Possible sources are improperly vented furnaces, blocked
system symptoms (e.g., encephalopathy) and renal and hemato- flues or chimneys, generators, and automobile exhausts, partic-
logical effects. Such exposures and symptoms can occur in chil- ularly when a garage is attached to a house. Low-level exposure
dren and also in adults, particularly those who have significant to carbon monoxide can cause dizziness, headache, Â�drowsiness,
occupational exposures to lead. In such worker exposure situ- nausea, or flu-like symptoms. Higher levels can result in uncon-
ations it is important to make sure that “take home lead” (as sciousness and death. Persons who have cardiovascular or
would be true with other workplace toxins) is not brought into respiratory diseases are particularly vulnerable to the effects of
the home on workers’ clothing and shoes. carbon monoxide. The activities of smoking tobacco and cook-
ing also produce carbon monoxide. When possible, range hoods
At a school health fair, the Marino family learned about with exhaust fans should be used during cooking. As with form-
their health department's program to reduce lead Â�exposure aldehyde, there is an increased risk in well-insulated houses.
in young children. They talked with the school nurse, Alice Nurses can recommend that combustion appliances (fueled by
Johnson, about their children's risks and jointly used a check- gas or oil) be checked annually (dryers, ovens/stoves, as well as
list to determine if they should test their 5-year-old twin boys furnaces) and that carbon monoxide detectors be installed if
for lead. The Marinos discovered their children were at risk combustion appliances are used (Davis, 2007).
for lead poisoning because they lived in an older home and
were planning to remodel. The twins' blood lead levels were Environmental Tobacco Smoke
10 mcg/dl, a level at which behavioral problems, impaired The health risks associated with tobacco smoke for both the smoker
learning, and diminished growth can occur. Ms. Johnson and those in the presence of environmental tobacco smoke (ETS)
referred the Marinos to the health department for information are well documented. Secondhand tobacco smoke has carcinogenic
about reducing lead exposure. They took protective measures and toxic agents that are similar to those in mainstream smoke;
during their remodeling, hired a licensed contractor to remove the EPA classifies tobacco smoke as a carcinogen. Increasingly,
the lead paint, and stayed with family members while the work state laws are being passed to create smoke-free spaces in health
was being done. To reduce exposures, they put walk-off mats facilities, restaurants, government buildings, and even in bars.
at each entry door, removed shoes at the door, and used damp Reducing children's exposure to ETS continues to be an objec-
mops to clean the floors to reduce tracked-in dust and dirt that tive in Healthy People 2020. It is a major contributor to earaches and
might contain lead. They emphasized thorough hand-washing respiratory tract infections, such as pneumonia, bronchitis, and
and increased intake of calcium-rich and iron-rich foods. After asthma. ETS is both a cause of asthma and a trigger for asthmatic
6â•›months, the boys' blood levels began to decrease. events among those with a diagnosis of asthma (Goldman, 2000).
Formaldehyde
Amanda is a 7-year-old girl with mild, persistent asthma, and
Formaldehyde is a colorless, flammable gas that has a distinct, her family recently moved to a new apartment. Amanda's
pungent odor. Formaldehyde is a common building block for the coughing, wheezing, and shortness of breath were increas-
synthesis of more complex compounds and materials. Worldwide, ingly troublesome and she was using her rescue drugs more
over 50 million tons of formaldehyde are used annually in a wide frequently. Her mother, Senzie Mott, referred to Amanda's
range of products, including household products such as car- asthma management plan and decided to make an appoint-
pets, draperies, paper, shampoos, and cosmetics. It is also used in ment with her health care provider. During the visit, the
glues for plywood and fiberboard; thus many homes have form- nurse, Sandra Grember, inquired about changes at home.
aldehyde in their cabinetry and furniture. In 2011 the National Amanda's mother reported the family moved recently and
Toxicology Program pronounced that formaldehyde is “known wondered if that might account for Amanda's symptoms.
to be a human carcinogen” (National Toxicology Program, 2011). Ms. Grember asked specific questions about the home environ-
The most common acute symptoms associated with exposure to ment, including the presence of allergen-impermeable Â�pillow
formaldehyde are eye and nose irritation, respiratory symptoms, and mattress covers, carpets, moisture, mold, smoking, pets,
nausea, headache, and fatigue. Young children can have abdomi- and pests, such as cockroaches and rodents. She discussed how
nal complaints. Less toxic products are available and should be to reduce home environmental asthma triggers and provided
recommended when new purchases are being made. If formalde- a brochure from the EPA. Amanda's mother welcomed the
hyde is present, it can be helpful to increase ventilation in a room information about how to reduce asthma triggers,
Â� such as dust
by increasing air exchange or by opening windows. mites, pests, secondhand smoke, mildew, and mold. She agreed
Formaldehyde falls into a large category of chemicals called to increase her own cleaning regimen to reduce household dust
volatile organic compounds (VOCs). These are chemicals that and mildew, wash Amanda's bedding and stuffed animals in
are gases at room temperature. If they are in solution with other hot water weekly, and ask the landlord about removing the car-
chemicals they may escape into the air as a gas. This process is pet that smelled of smoke and pets. A telephone follow-up was
known as outgassing. For people who are highly sensitive to chem- planned for 2â•›weeks to check on Amanda's symptoms.
icals, VOCs present a particular problem because they can readily
outgas from everyday products and become part of the indoor air.
There is a subset of the population that is particularly susceptible Implications for Nurses
to chemical exposures even at very low levels. Formaldehyde is but Community/public health nurses can address environmen-
one of the chemicals that some people react to at low doses. tal heaÂ�lth from an educational, practice, research, and/or
policy/advocacy approach. For example, from an educational Â�

determine what common practice was. Her research demonstrated
perspective, nurses can provide guidance to their pregnant that potentially dangerous chemicals were being used. Armed with
patients about preparing an environmentally healthy and safe her research, she then engaged in educating the field managers and
nursery by addressing potential lead-based paint risks, pes- others about alternatives to using harmful chemicals.
ticide use, and carbon Â�monoxide exposures, as well as safety The environmental health policy arena is huge—ranging
issues such as Â�covering electrical outlets. They can also coach from clean air policies to natural gas “fracking,” to mandates
patients on product selection such as choosing infant toys that for integrated pest management in schools, all of which have
do not contain phthalates or bisphenol A. Such approaches direct and indirect impacts on human health. Nurses have made
constitute primary prevention measures. a difference when they have entered policy discussions with
Environmental exposures can be subtle and may require inves- lawmakers. It was nurses who helped to pass safe chemical laws
tigative work by the nurse. For example, water contaminants in Washington state and a clean air law in Maryland. We are
might not produce a visible change in the water, and some chemi- seen as highly credible sources of information and we are seen
cals (e.g., carbon monoxide in air) are not easily detectable. as having an unbiased concern for the public's health.
Jan Brant, a school nurse in Baltimore, was following one of her Understanding “Who's in Charge”
elementary school children who was having headaches. Jan had Understanding “who's in charge” of environmental health
recently attended a presentation about environmental health is a very big task and can be a very complicated one. Federal,
and was particularly alert to environmental health risks. When state, and local agencies all have both distinct and overlapping
the student had a seizure, she began to look at environmen- roles (see Chapters 3 andÂ€6). All branches of government can
tal possibilities. Brant discovered that the mom was also hav- be involved: the federal legislative branch as it passes sweeping
ing headaches. It was late fall, when people were starting to use laws such as the Clean Air Act, or a specific state law that bans
their heat. Brant wondered if it was possible that carbon mon- toxic fire-retardant materials from use in products (as recently
oxide (CO) was the problem and she called the family and sug- occurred in Washington state). The executive branch includes
gested that they have their home tested. The family called in an the executive/regulatory agencies at a federal, state, and local
expert and discovered that they had extremely high levels of level where they develop regulations and standards and con-
CO from a faulty furnace in their basement. Their son spent duct compliance inspections to make sure that the regulations
more time than anyone else in the basement family room, are being followed. Even the judiciary branch can be involved
which was where the television was located. The family tem- when it orders an emergency standard for a chemical exposure
porarily relocated while the furnace was fixed. The son's symp- or makes a decision regarding the legality of a new regulation.
toms subsided but the mother's symptoms became chronic. For local environmental health issues, the two most Â�important
agencies are the state department of environmental Â� quality
It is highly likely that the cause of this family's ailments and the local health departments. The health departments of
would have been missed for quite some time had Brant not large cities and populated counties often have a significant
recently learned about environmental health risks in homes. We environmental health division with a range of services. Some
will continue to miss opportunities unless we prepare ourselves large cities (such as San Francisco) and large counties (such as
in this new arena of knowledge and skills. Baltimore County, Maryland) have dedicated environmental
From a practice perspective, there are a number of ways in protection agencies. But most cities and counties have limited
which interventions can be considered. First and foremost, a Â�environmental health services.
good assessment must be completed, including the elements It is the responsibility of state-level environmental protec-
identified previously in this chapter. Once a risk factor is iden- tion agencies to determine how much pollution a factory or
tified, the nurse must determine whether the problem can be other institution can emit into the air or water. Agencies do this
addressed at the individual level or whether a more population- by issuing a permit, which essentially is permission to pollute.
based approach is needed. If a population-based approach is These permits are public documents. Unfortunately, there is no
warranted, then the nurse will need to know whether a pub- cap on the number of permits that an agency can allow and con-
lic agency holds some responsibility in addressing the issue. sequently some communities have a large number of facilities
For instance, if a community is concerned about the safety of with permits. This can have a serious impact on air and/or water
a body of recreational water, this question can be addressed quality. Though public hearings are required as part of the per-
most readily by the state-level department of environmen- mitting process, they are often pro forma and the mechanism
tal quality (or environmental protection), which is respon- by which most community members would hear about them is
sible for administering the elements of the Clean Water Act. often inadequate.
If a community is concerned about the number of municipal It is the responsibility of the city or county to determine how
buses that idle across from a city elementary school, then this land is to be used, and the mechanism that they use is their zon-
issue might be best addressed by the transportation authority. ing laws. Land can be zoned for use as residential, commercial,
Research is another tool in nurses’ armament for addressing light or heavy industry, rural/farming or some combination
environmental health. Robyn Gilden, a doctoral student with of these. It is through these important land-use decisions that
young children, saw a set of warning flags on the local playing field it will be determined how densely an area will be populated,
that warned of the pesticides that had been applied. She knew whether a factory can be built next to a daycare center, or if
some of the health risks associated with pesticides and wanted land should be set aside for green space, for example. Zoning
to know what was being used where children played soccer and decisions can have a direct impact on a community's quality of
other sports. Gilden devised a survey for those people who were life, environmental health, and property values. No one wants
responsible for public and private playing fields in the region to a hazardous waste site to be placed in their neighborhood and
yet more hazardous waste sites are located in African American each state has its own state laws regarding how citizens can gain
and Latino neighborhoods than in white neighborhoods in the access to state agency information. This can be used for any sort
United States (Bullard & Wright, 1993). More African American of information, not just environmental issues.
residential neighborhoods are zoned for mixed use than white There is still quite a bit of room for improvement regarding
neighborhoods, which leaves African American neighborhoods the public's right to know. While there are a good many things
open to varied use by commercial entities and even light industry. that can be found on a food label, there are some important
The expression “Smart Growth” was coined in the 1990s to things we do not currently have the right to know about at the
describe an approach to land-use decisions that maximize the point of purchase. For example, none of the following infor-
best use of space for locating public transportation, bike routes, mation is required to be on a food label: the use of pesticides/
parks, and recreational facilities, while retaining green spaces herbicides when growing produce; the use of genetically modi-
and farmlands. It also calls for development in areas that already fied organisms; the use of nontherapeutic antibiotics in animal
have water, electric, sewer, and transportation infrastructures feed for beef, hogs, poultry, or farmed fish; or the adminis-
rather than creating new developments in undeveloped areas. tration of recombinant bovine growth hormone (rBGH) to
The people who are responsible for such decisions are called dairy cows. We can learn about certain nutritional values of
planners and they reside in the planning offices of cities, coun- our foods (e.g., calories, fats, proteins, carbohydrates) but not
ties (parishes, boroughs), and states. Zoning and planning deci- about the potentially hazardous chemicals or pharmaceuticals
sions can have a great impact on local and area environmental (Huffling, 2006).
quality. Public health professionals should be aware of and In the workplace, employees have the right to know about
engaged in this decision making. potentially hazardous chemicals that they may be exposed to
during the course of doing their jobs. Employers must label
Accessing Information and the Right to Know potentially hazardous chemicals/materials, maintain chemi-
One of the best sources for information about environmen- cal information sheets (known as material safety data sheets
tal conditions is the U.S. EPA website (http://www.epa.gov/ [MSDS]), and train all employees about the potential health
enviro). On this site, state, local, and zip code-level informa- and safety risks. Most products are labeled in health care set-
tion can be found. (Note that some of the information, such as tings and, if you ask the person in charge of health and safety,
emissions and effluent from factories, is reported by the regu- you can usually track down a copy of an MSDS. Where most
lated industry, and not actually collected or corroborated by employers fall short is in the training of employees. Consider
the EPA.) whether, as a nurse, you received formal training about the
Statutes and regulations can establish the public's “right potential health risks from exposure to glutaraldehyde, ethyl-
to know” about specific contaminants released into our ene oxide, or other common sterilizing agents found in health
environment. For example, all public drinking water suppli- care. Did you receive information on the potential health effects
ers must test the water regularly and they must alert their associated with floor cleaning products, pesticides used in and
customers immediately if a chemical, radiological, or bio- around the hospital, or air fresheners in the rest rooms? It is the
logical contaminant that might create a health risk exceeds right of all workers to be trained about potential health risks
standards. Additionally, once a year the supplier has to com- and how to protect themselves through proper work practices
pile a report that describes the testing that has been done, and, if necessary, protective equipment (e.g., gloves, masks, ven-
the results, and information on the source(s) of the water. tilation hoods, respirators).
These reports are called Consumer Confidence Reports and The Health Care Without Harm campaign, an interna-
are required by law. tional effort to address environmental health risks in the
Another right-to-know law requires that companies that health care sector, published a report on the presence of
store or emit (into the air or water) any of 600 potentially toxic chemicals commonly used in hospitals that are either pri-
chemicals must report this to the EPA and, in turn, this informa- mary asthmagens (meaning they are known or suspected of
tion is to be accessible to the public. This is commonly known as causing asthma) or asthma triggers (those chemicals that can
the “community right to know” law. Another part of the same cause an asthma event in someone who already has the diag-
law requires that every local area (usually city/county designa- nosis of asthma). A summary of the report has been created
tions) and state have an emergency planning committee. These (TableÂ€9-3).
committees are mandated to assess the chemicals that are trans-
ported, stored, or used in their area and note whether there is a Environmental Hazards in the Occupational Setting
potential for a leak, spill, explosion, or transportation accident Most Americans spend a substantial portion of their adult lives
and to make a plan to address such an event. in work environments. These work environments are char-
Under the Clean Air Act, there is a requirement that all acterized by a wide range of health and safety hazards that
companies that transport, store, or use potentially hazardous might result in the occurrence of occupational injuries and
chemicals develop a set of “worst case scenarios” for things that illnesses. On average, 15 workers die each day from traumatic
might go wrong. These chemical risk management plans were injuries. Overall, 5400 workers died in 2007 from an occupa-
originally intended for community review but since the events tional injury and more than 4 million workers had a nonfatal
of September 11, 2001, this information has been deemed con- injury or illness (CDC, 2011b). The true extent of the problem
fidential. It is possible, though difficult, to gain access to this is unknown, because many incidents of injury and illness are
information (Afzal, 2003). not reported, and, in some cases, are not recognized as being
Another mechanism to access information from the govern- occupationally related.
ment (state and federal) is through the Freedom of Information The immense losses resulting from occupational injury and
Act (FOIA). There is a single federal act that provides a mecha- illness affect individuals and organizations at multiple levels.
nism for accessing information from federal agencies and then The employee suffers physically, as well as from the loss of a
TABLEÂ€9-3â•…â•‡ASTHMA RISKS POSED BY CHEMICALS USED IN HEALTH CARE ENVIRONMENTS

ASTHMAGEN OR
CHEMICAL USE IN HOSPITALS ASTHMA TRIGGER? HOW TO REDUCE EXPOSURE SAFER ALTERNATIVES
Cleaners, Cleaning products, Asthmagen and Use microfiber mops, refine Products free of: Ethylene
disinfectants/ equipment sterilizers asthma trigger cleaning practices, isolate oxide, formaldehyde,
sterilizers chemicals glutaraldehyde; Green
Seal–approved products
Natural rubber latex Gloves, catheters, and other Asthmagen, possibly Use nonlatex or powder-free Nonlatex or powder-free
hospital products asthma trigger latex gloves latex gloves
Pesticides Indoor and outdoor areas Asthmagen Integrated Pest Management IPM: using nontoxic pest
(IPM) programs* control methods and
products
Volatile organic Formaldehyde: building Asthmagen, possibly Increase general ventilation Low- or no-VOC products
compounds (VOCs) materials, paper products, asthma trigger to diffuse VOC offgassing Formaldehyde-free
tissue fixatives products
Baking flour Kitchens and bakeries Asthmagen and Mechanical flour sprinklers, Precombined dry ingredients,
asthma trigger good ventilation systems, low-dust flour, ready-to-
quick cleanup of spills with bake dough
wet mop
Acrylics: methyl Acrylic resins used in Asthmagen and Isolate, enclose, and Products free of: Methyl
methacrylate and medical and dental asthma trigger automate processes that methacrylate
cyanoacrylate polymers and cement use acrylic compounds; Cyanoacrylate
improve ventilation systems Acrylic compounds
Perfumes/fragrances Scented cleaners, fragrance- Asthma trigger Institute fragrance-free Fragrance-free products
emitting devices, people policies
wearing perfume
Phthalates Widespread: plastics, Undetermined Improve ventilation for moisture Phthalate-free products (both
(plasticizers) medical devices control to decrease emissions medical and office products)
Environmental Individuals who smoke Asthmagen and Maintain a smoke-free facility
tobacco smoke asthma trigger and grounds
Biological allergens Mold/fungus, indoor pollen, Asthmagen and Good housekeeping and
dust/dust mites, pet hair, asthma trigger building maintenance practices,
cockroaches moisture control
Pharmaceuticals Antibiotics, laxatives, Asthmagen Hoppers, ventilation hoods, Clinical substitutions if
antihypertensives, personal protective possible
antituberculars, H2 blockers equipment, respirators
*Integrated Pest Management (IPM) is a systematic approach to managing pests that provides a comprehensive framework for assessing pest
problems; assessing the sources of food, water, and nesting that support growth and reproduction of pests; determining the nontoxic and least-
toxic techniques and products to be employed; and evaluating success and/or need for additional considerations. For more information on IPM,
see: http://www.beyondpesticides.org.
This table was derived from the Health Care Without Harm report entitled Risks to asthma posed by the indoor health care environments: A guide
to identifying and reducing problematic exposures, created 2008 by Laura Evans, MPH, and Barbara Sattler, RN, DrPH, FAAN, of the Environmental
Health Education Center, University of Maryland School of Nursing. Used with permission.
portion of his or her wages. Technically, medical care associated Â�

suffer from the loss in productivity, high absenteeism and turn-
with workplace injuries and illnesses should be paid by work- over, and low employee morale. The Healthy People 2020 objec-
ers’ compensation, but in reality the worker is often hard-pressed tives also address occupational safety and health (see the Healthy
to prove that an exposure has caused an illness. Employers can People 2020 box).
HEALTHY PEOPLE 2020

Selected Occupational Safety and Health Objectives
1. Reduce work-related injury deaths to 3.6 per 100,000 full-time 5. Reduce occupational skin diseases and disorders to 4 per 10,000
equivalent workers (baseline: 4.0 in 2007). full-time workers (baseline: 4.4 in 2008).
2. Reduce nonfatal work-related injuries to 3.8 injuries per 100 full- 6. Reduce new cases of work-related, noise-induced hearing loss to
time equivalent workers (baseline: 4.2 in 2008). 2.0 cases per 10,000 workers (baseline: 2.2 in 2008).
3. Reduce work-related homicides to 565 deaths (baseline: 628 deaths 7. Increase the proportion of employees who have access to workplace
in 2007). programs that prevent or reduce employee stress (developmental).
4. Reduce to 26.64 injury and illness cases per 10,000 workers that 8. Increase to 47 the numbers of states, territories, and the District
involve days away from work due to overexertion or repetitive of Columbia with a comprehensive asthma surveillance system for
motion (baseline: 29.6 in 2008). tracking asthma cases, illness, and disability (baseline: 43 in 2009).
There are two federal governmental bodies involved in occupa- organizations are downsizing and restructuring; others are
tional health and safety. The first is the Occupational Safety and expanding their Â�businesses across national borders. All of these
Health Administration (OSHA), a part of the U.S. Department changes and a trend toward outsourcing of services have resulted
of Labor. OSHA is the regulatory agency responsible for devel- in an increased level of job insecurity and stress in many work-
oping regulations and standards. About half the states have state- places. Job stress poses a major threat to the health of workers.
level occupational safety and health agencies and the other half
rely on federal OSHA to make sure that employers are in com- Occupational Health and Safety in the Health Care Setting
pliance with regulations and that workers are safe and in healthy Health care settings were long considered relatively safe places to
conditions. The National Institute for Occupational Safety work, as compared to a factory or mine, but new data about expo-
and Health (NIOSH) is a research institution under the Centers sures in health care are helping us to understand that we have our
for Disease Control. NIOSH's responsibility is to develop and own challenges in health and safety. Nurses are now the second larg-
implement research strategies to determine the extent of work- est group of workers to be diagnosed with adult-onset asthma—
place injuries and illnesses and the efficacy of workplace inter- second only to janitors. The nonprofit organization Health Care
vention to decrease injuries and illnesses. Without Harm commissioned a report on asthmagens (things that
NIOSH has created a national, public process for developing actually cause the disease of asthma) and asthma triggers (things
its research agenda, called the National Occupational Research that create an asthma event in someone who already has the diag-
Agenda. Research priority areas are organized into three major nosis) in the health care setting. See TableÂ€ 9-3 for asthma risks
categories: disease and injury, work environment and workforce, posed by chemicals used in healthcare environments.
and research tools and approaches. These data are available on The organization Physicians for Social Responsibility (PSR)
this book's website as Website Resource 9C. assembled 12 physicians and 8 nurses and tested their blood and
NIOSH supports a set of multidisciplinary, academic research urine for the presence of some of the hazardous chemicals com-
and educational centers around the country. Through these cen- monly found in the health care setting (PSR, 2009). Of the 62
ters, graduate-level education is provided for nurses, physicians, chemicals (including congeners) that were tested, each of the
industrial hygienists, and safety managers. A complete list of people tested had at least 24 chemicals in their blood or urine.
NIOSH-funded occupational health nursing programs is available These chemicals were bisphenol A (BPA, found in plastics and
on NIOSH's website. (For environmental health nursing, the only other products), perfluorinated compounds (used in nonstick
graduate programs are at the University of Maryland in Baltimore surfaces), phthalates (found in plastics and personal care prod-
and the University of Washington.) ucts), PBDE (a flame retardant found in mattresses, computers,
and fabrics), and triclosan (found in antimicrobial soaps and
History of Occupational Health in the United States personal care products). The following health effects are associ-
Attention to health and safety in the workplace is a recent phe- ated with these chemicals:
nomenon. The Industrial Revolution played a major role in the • BPA – endocrine disruption, reproductive toxicant, breast and
development of the field of occupational health. During the prostate cancer, brain and thyroid dysfunction, and obesity
19th century, masses of Americans, including children, worked • Perfluorinated compounds – endocrine disruption, immu-
in factories and sweatshops, on the railroads, or in the mines. notoxicity, liver/pancreatic tumors (in animals)
They were exposed to machinery, chemicals, dusts, extremes in • Phthalates – reproductive development
temperatures, backbreaking chores, and other deplorable con- • PBDE – neurotoxicity (brain function, memory, behavioral
ditions. As concerns for health and safety grew, job safety laws problems)
slowly began to be passed. Website Resource 9D provides a • Triclosan – endocrine disrupting, thyroid dysfunction
list of legislative efforts to protect workers. In a survey organized and implemented by a collabora-
Workers' compensation was a significant contribution to worker tive effort between the ANA, Health Care Without Harm, the
protection. It provides a partial reimbursement of lost wages and University of Maryland School of Nursing and Environmental
full payment for medical expenses to workers who are injured Working Group, over 1500 nurses responded to a web-based
or become ill as a result of their job. There continue to be major survey in which they described their chemical exposures and
deficiencies in the system. For example, compensation for certain also noted their health problems, Â�including reproductive health
occupational diseases, such as chemical sensitivity or stress-related problems and birth outcomes. The results of simple frequency
conditions, is very limited. This is largely the result of the difficul- tabulations noted that nurses who are exposed to certain com-
ties in establishing links between the disease and the work setting. mon chemicals in the hospital had higher incidence of cancer,
Even when employees are compensated for an injury or illness, reproductive health problems, and health problems among their
they seldom recover the full value of lost wages and expenses. children. This was the first survey of its kind and compels us as
Although there has been substantial improvement in occu- nurses to do further research and to be mindful of the potential
pational health and safety with the passage of the Occupational for harmful chemical exposures at work. A more comprehensive
Safety and Health Act, the Americans with Disabilities Act, and report (Environmental Working Group, 2008) can be found on
other mandates, rapidly changing workplaces continue to pose the following website: http://www.ewg.org/sites/nurse_survey/
major challenges to occupational health and safety professionals.
Â� analysis/summary.php.
These changes are reflected in the organization of work, work The major safety issues associated with health care are
processes, and the workers themselves. Advances in technol- caused by back injuries from lifting and moving patients, inju-
ogy have increased the speed of production and the subse- ries associated with sharps, and violence in the workplace. In
quent demands on workers. New chemicals, materials (such as each of these instances, the ANA has been actively engaged with
nanoparticles), and processes, with unknown health and safety OSHA and NIOSH to develop educational programs, Â�guidance,
effects, are constantly being developed and marketed. Many and regulations.
Occupational Health Nursing

BOXÂ€9-3â•…â•‡DESCRIPTION OF ROLES OF
Occupational health is a specialty within nursing that focuses OCCUPATIONAL HEALTH AND
primarily on disease and injury prevention. The principal tar- SAFETY SPECIALISTS
get of occupational health nursing practice is the aggregate of
workers in the many occupational settings across the country. Toxicologist—Studies and describes the toxic properties of agents
In the late 19th century, the first occupational health nurses used in work application to which workers might be exposed.
were called industrial nurses, and their primary responsibil- Industrial hygienist—Recognizes, evaluates, and controls toxic
ity was to care for injured workers and their families. Much of exposures and hazards in the work environment.
their care was provided in the home, and they often took care Occupational physician—Focuses on prevention, detection, and
of other family members and taught them about general sanita- treatment of work-related diseases and injuries.
tion and hygiene. Safety specialist—Includes safety engineers and other safety pro-
With the rapid expansion of industries in the early 1900s, and fessionals who focus on the prevention of occupational injuries and
the passage of workers' compensation laws, the demand for indus- the maintenance or creation of safer workplaces and safe work
practices.
trial nurses increased dramatically. Occupational health services
Ergonomist—Studies, designs, and promotes the healthy interface
began to focus more on injuries to the workers in the work set-
of humans, their tools, and their work.
ting than on family-member services in the home. With the onset Epidemiologist—Studies and describes the natural history of occu-
of World War II, the demand for industrial nurses increased. By pational diseases and injuries in population groups.
1942 there were more than 11,000 industrial nurses (Parker-
Conrad, 2002). In 2004 there were more than 30,000 occupa- Data from Levy, B. S., & Wegman, D. H. (2000). Occupational health:
tional health nurses in the United States. By 2008 that number Recognizing and preventing work-related disease (4th ed.). Boston:
Little, Brown.
had dropped to almost 19,000 (possibly due to the reduction in
U.S. manufacturing and the economic recession). Furthermore, Â�
established by the profession and by company management,
there are more who do not identify themselves as occupational nurses often determine the priorities appropriate to a situa-
health nurses but nevertheless provide occupational health ser- tion, establish goals and objectives, and determine the most
vices (USDHHS, 2010b). This latter category includes employee suitable course of action. The roles of occupational health
health nurses, infection control nurses, and case managers. nurses vary greatly from one setting to another. Their activi-
ties might be categorized as follows: primary care provider,
Roles and Functions of Occupational Health Nurses counselor, advocate and liaison, administrator, educator,
The role of the occupational health nurse has evolved and monitor, professional member of the health team, and
expanded in the past decade; principal functions continue to researcher (BoxÂ€9-4). The occupational health nurse might
be promotion, protection, and maintenance of the health and function in as few as one or as many as all of these roles,
safety of the workers. There is an expanded emphasis on well- depending on the particular work site.
ness and lifestyle changes in addition to the reduction of risks
associated with environmental exposures. The practice of this
Maria is a public health nurse in an agricultural Â�community in
specialty involves primary, secondary, and tertiary prevention.
eastern Washington state. Some community members approÂ�
Special skills include training in safety hazards, disaster plan-
ached her with concerns about health problems related to
ning, familiarity with safety equipment, and the ability to plan
pesticide exposure. Some of them had skin rashes; other people
and implement health education programs. Special knowl-
who worked with them complained of nausea, dizziness, and
edge includes an understanding of the principles of safety, tox-
headaches; and some had difficulty breathing. Maria agreed to
icology, epidemiology, environmental health, and industrial
meet with all the workers and the families who were concerned
hygiene. As an interdisciplinary specialty, occupational health
for a health education program. At the meeting, she provided
nurses work with multiple health and safety specialists, includ-
information about pesticides, including common health prob-
ing toxicologists, industrial hygienists, occupational physicians,
lems, routes of exposure (absorption, inhalation, and inges-
safety specialists, ergonomists, and epidemiologists (BoxÂ€ 9-3).
tion), and strategies to minimize their risks. She cautioned
Occupational health nurses are also required to have up-to-date
the workers who may be exposed to pesticides in the fields to
knowledge of current legal standards that affect the working
remove their clothes before touching/hugging their children in
population (Welker-Hood etÂ€al., 2007).
order to reduce their exposures. She stressed the importance
The American Association of Occupational Health Nurses
of eliminating any exposure for their children, because chil-
(AAOHN) has developed standards of practice that enable occu-
dren are prone to more severe reactions to pesticides. Maria
pational health nurses to measure the quality of the service that
and several other public health personnel scheduled a meet-
they deliver. In addition to assessment, planning, implementa-
ing with the Growers Association to educate these employers
tion, and evaluation, the standards cover such areas of practice as
about safety precautions, including the OSHA requirement to
resource management, professional development, research, and
train workers about potentially hazardous exposures and the
ethics. The Core Curriculum for Occupational and Environmental
law that requires pesticide applicators to be registered with
Health Nurses (Salazar, 2006) provides further guidance.
the state and appropriately trained. When farm workers are
The occupational health nurse is often an independent
exposed, so are the growers. It all gets tracked into their homes.
practitioner and is frequently the only health care provider in
It is in everyone's best interest to eliminate the use of dangerous
an organization. Because management might not understand
pesticides or select the least toxic. Because of her efforts, Maria
the roles and functions of occupational health nurses, these
became known as a community resource for growers, farmers,
nurses might need to write their own job description. Whereas
and their families about issues related to pesticides.
occupational health nurses perform according to the Â�guidelines
BOXÂ€9-4â•…â•‡FUNCTIONAL ROLES OF to imagine the potential for abuse of this privilege. The occu-
OCCUPATIONAL AND pational health nurse has an ethical responsibility to protect
the confidentiality of the employee. For this reason, it is cru-
ENVIRONMENTAL HEALTH
cial to establish and enforce written guidelines that prevent
NURSES
the indiscriminate use of records. The AAOHN has issued two
Clinician—Primary responsibilities are aimed at preventing work- useful advisories related to confidentiality (AAOHN, 2004)
related and non–work-related health problems and restoring and and record-keeping (1996; revised 2002), which can serve as
maintaining health. guides for the protection of health information in the occupa-
Case manager—Coordinates health and rehabilitation services for tional setting. (AAOHN's code of ethics and interpretive state-
an individual worker from the onset of an injury or illness to an opti- ments and advisories are available on the AAOHN website; see
mal return to work status or a satisfactory alternative. Community Resources for Practice at the end of this chapter
Occupational health service coordinator—Functions as the sin- for access.)
gle occupational health nurse for a business or organization. Because occupational hazards are often preventable causes
Health-promotion specialist—Develops and manages a compre- of disease, disability, and death, the field of occupational health
hensive, multilevel, broad-range health-promotion program that has the potential to make a major contribution to public health
supports organizational business objectives.
and the general welfare of societies. A concern of occupational
Manager—Directs, administers, and evaluates an occupational and
health professionals is that despite the fact that most persons
environmental health and safety service and its policies, maintain-
spend at least a third of their waking hours at work, an occu-
ing consistency with organizational goals and objectives.
Nurse practitioner—Uses additional specialized preparation, meet- pational health assessment is often an overlooked element of
ing state requirements for advanced practice nursing to critically the health history. Even if a person does not work, she or he is
evaluate the health status of workers through health histories, likely to live with someone who does, and that, too, can have
physical assessment, and diagnostic tests. an impact on the current state of health. Retired persons might
Corporate director—Responsible for the total occupational and have experienced hazardous working conditions that can result
environmental health and safety program at the policy-making in adverse effects many years after the exposure occurred.
level.
Consultant—Serves as an advisor for developing, selecting, imple- Environmental Hazards in the Community
menting, and evaluating occupational and environmental health There are many examples of events that resulted in environ-
and safety services. mental hazards. The devastation of Hurricane Katrina and
Educator—Assumes programmatic and administrative responsibili- the continued health effects suffered by those who lived or
ties for curricula and/or clinical experiences in occupational and
worked close to the September 11, 2001 ground zero site are
environmental health nursing.
two significant environmental health disasters. In Katrina's
Researcher—Identifies occupational and environmental health
wake, whole communities continue to be uninhabitable and/
problems, develops researchable questions with consideration for
research priorities, assesses study feasibility, and initiates and con- or uninhabited. The World Trade Center events resulted in
ducts research studies using all the elements of the research process. exposure to smoke, products of combustion, dust, hazardous
substances, and air pollution as well as psychological distress
From Dirksen, M. (2006). Occupational and environmental health (CDC, 2002).
nursing: An overview. In M. K. Salazar (Ed.), Core curriculum for Since the events of September 11 and Hurricane Katrina, the
occupational and environmental health nursing (3rd ed.). St. Louis:
U.S. has embarked on a comprehensive reworking of the emer-
Saunders.
gency preparedness and emergency response systems, includ-
ing communications, public health strategies, and emergency
As with many professionals in recent years, occupational health services. (See ChapterÂ€22.) Such preparedness will hold
health nurses often struggle with ethical and legal dilemmas in us in good stead for future events that might include natural
their practice. The struggle may be precipitated by the nurse's disasters like hurricanes and earthquakes, but also events asso-
dual responsibilities to the employer and the employee. It is ciated with nuclear power plants, transportation spills involv-
complicated even further by the nurse's responsibility to the ing hazardous substances, or industrial accidents in which there
larger community. Legal and ethical problems seldom result in are large-scale injuries or air and water contamination. Disaster
simple resolutions (see the Ethics in Practice box). It is incum- plans can also be invoked in the event of terrorist activities.
bent upon occupational health nurses to keep abreast of laws Most of the environmental health risks in our communities
and to develop lines of communication with other profes- do not occur in the form of a disaster but rather from long-term
sionals with whom they can confer when difficult issues arise. exposure to hazardous chemicals in our air, water, food sup-
Occupational health nurses must regularly read professional plies, and contaminated soil. As nurses, we should know what
publications so that they are able to make decisions based on the the background exposures are in our communities. Where does
latest available evidence and information about best practices. a community's drinking water come from and what are the com-
Although there are often no easy answers, an underlying mon contaminants that have been found? Does the air in our
principle in these conflicts is the responsibility to know and to community attain the standards developed under the Clean Air
uphold the standards of the profession. Decision making must Act, or do we live in a “nonattainment” area? Are there hazard-
be guided by commonly held and documented standards and ous waste sites in our area that pose health threats to the com-
practices, as well as by the code of ethics advanced by AAOHN. munity members? All of these questions can be answered in a
Sometimes, there is a conflict between what is legal and what one-stop shop created by the EPA called Envirofacts (http://www.
is ethical. It is legal, for example, for managers or supervisors epa.gov/enviro/). Here you can query the EPA about pollution in
to access employee health records in certain instances. It is easy your community by placing your address and/or zip code into
ETHICS IN PRACTICE
The Nurse as Advocate Gail A. DeLuca Havens, PhD, RN
Audrey is an occupational health nurse at a wallpaper Â�manufacturing has a responsibility to act in the employer's best interests as well. She
plant who is responsible for the on-the-job health and safety of all also is concerned about continuing her employment. The potential for ter-
employees who are exposed to or use hazardous materials in their work. mination seemed a very real possibility judging from the general manager's
Audrey has practiced in this plant since 2005, and is an employee of a reference to her position in the company. Her family depends on her sal-
corporation that owns and operates six similar plants. She is responsible ary and to be without it would jeopardize their well-being. In this particular
for ongoing review and revision and implementation of the hazard com- case, to act in the employer's best interest it is likely that Audrey will not
munication program (commonly known as the worker “right to know” be able to act in the best interests of her fellow employees. In fact, it is pos-
program) for the plant. She is to ensure that the plant will remain in com- sible that she could be harming them. Should Audrey act as a “responsible”
pliance with the Occupational Safety and Health Administration (OSHA) employee herself, by complying with her employer's direction regarding the
hazard communication standard, effective in 1983. care of her fellow employees, or should she continue with this issue to
The hazard communication program includes provisions for a mate- advocate for her fellow employees?
rial safety data sheet (MSDS) for each hazardous chemical used at the If Audrey follows Tom's suggestion, she will avoid immediate finan-
facility, labeling of hazardous chemicals, training and information for cial expenditures for the company. This would remove a lot of the pres-
employees exposed to hazardous chemicals, and access to manufac- sure, reduce her stress, and maintain the security of her position in the
turers' MSDSs to gain information about specific hazardous risks that company and her ability to continue to support her family. As any other
might be required in the investigation and evaluation of any specific parent does, she has a moral obligation to attend to the safety and well-
exposures. Because of Audrey's efforts, plant employees have become being of dependents.
aware of potential environmental hazards in the workplace and do not However, Audrey is an occupational health nurse who must balance the
exceed recommended exposure times to maximum concentrations of rights of the employees with the responsibilities of the company, as set
hazardous materials. They report any unusual signs and symptoms so forth in its policies and standards (Greenberg, 2007). She has a profes-
that Audrey can investigate potential hazardous sources in the work- sional obligation, according to the Code for Nurses of the American Nurses
place. Finally, they are alert for any changes in the work environment, Association (ANA) and the American Association of Occupational Health
such as poor ventilation, that might contribute to increased hazards. Nurses Code of Ethics, to maintain the health, welfare, and safety of the
This morning Audrey is meeting with Tom, the plant's general manager, client. The nurse is an advocate for the client. As such, she or he “must
to discuss the recent increase in the incidence of headaches and painful examine the conflicts arising between their own personal and professional
eye irritations among employees who work in one of the plant's printing values, the values and interests of others who are also responsible for cli-
areas. Audrey summarizes her findings: “Forty percent of the employees in ent care and health care decisions . . . to resolve such conflicts in ways
print section E had an onset of headaches and painful eye irritations in one that ensure client safety, guard the client's best interests, and preserve
24-hour period last week. In investigating, I discovered that the day before the professional integrity of the nurse” (ANA, 2001, p. 10). Advocacy is
the onset of these symptoms the section had begun using a different paint regarded as a core moral concept of nursing. Accountability is regarded as
pigment in one of its print runs. I reviewed the MSDS related to the pig- another of the profession's central moral concepts. To be accountable is to
ment's ingredients and, in general, found nothing unusual. There was, how- be “answerable to oneself and others for one's own actions. . . . Nurses are
ever, a recommendation for use of a specific filter to be used on the workers’ accountable for judgments made and actions taken in the course of nursing
respirators when this pigment is being used, and we are not using this filter. practice” (ANA, 2001, p. 16). The existing policies of the employing agency
Employees in this section continue to experience headaches and painful eye do not relieve the nurse of the accountability to act in clients' best interests.
irritation. According to the manufacturer's MSDS, no definitive long-term In this situation, an appropriate course of action for Audrey would be
effects from exposure to this pigment have been confirmed. Consequently, to report her findings through the official channels established within
the manufacturer's MSDS does not include any warning, but only an alert her company for such actions. Reporting mechanisms should exist within
that 'continued exposure to this pigment without benefit of the recom- an employment setting so that employees feel comfortable voicing con-
mended respiratory protection might lead to respiratory and liver problems.’” cerns about particular problems within the work setting without fear of
(Audrey had double checked the health effects of the chemical by looking reprisal. Having voiced her concerns to the plant manager without a sat-
at the ToxNet programs provided by the National Library of Medicine to find isfactory response, Audrey should inform the next person in the chain of
the most current, peer-reviewed toxicological information. MSDS informa- command and should inform the plant manager of her action. Although
tion is often outdated and commonly written in an unclear manner.) it is not always easy to bring such concerns to an employer, the nurse's
Tom replies, “Audrey, I, too, am concerned about the physical symptoms accountability to the workers in this plant obligates her to take action
that employees are experiencing. I have discussed the problem with the that will serve to avoid harm to them from improper ventilation.
engineering personnel and with the company's corporate and legal staffs. An alternate course for Audrey would be to not pursue the reporting of
To accommodate the recommended filtration in the plant's ventilating sys- employee symptoms. Because OSHA has not classified the chemical as
tem we would have to make substantial modifications in the system, at an one requiring a warning, but only an alert, Audrey could rationalize this
expense the company is not in a position to incur. Because no health warn- course of action as an acceptable one. It is a strategy that would also
ings are associated with exposure to this pigment, the company will not serve to preserve Audrey's standing in the company, which is extremely
be making any changes to the ventilating system at this time. I trust that important to her position as family breadwinner. Which course of action
you will continue to be responsive to employees' symptoms, so that they would you pursue?
are alleviated as much as possible, without compromising the integrity of
the company and your position in it.” References
Because of the company's decision in this matter, Audrey finds herself in American Nurses Association. (2001). Code of ethics for nurses with inter-
the midst of a dilemma precipitated by competing obligations. On the one pretive statements. Washington, DC: American Nurses Publishing.
hand, she is responsible for the on-the-job health and safety of company Greenberg, M. R. (2007). Contemporary environmental and occupational
employees, which includes fostering the well-being of employees while health issues: More breadth and depth. American Journal of Public
minimizing their exposure to harm. On the other hand, as an employee she Health, 97(3), 395-397.
the search. See the Web Resources on the Evolve site for other Chemical Hazards
place-based information about environmental health risks. Chemicals come in a wide variety of forms (solids, liquids,
There are literally thousands of potential hazards in our envi- dusts, fumes, mists, vapors, and gases) and can affect almost
ronment. For the sake of clarity, these hazards are classified accord- every system in the body (Dirksen, 2006). Our surroundings
ing to their predominant characteristics. TableÂ€9-4 lists potential are inundated with chemicals. Not only is the environment full
sources of hazards and the toxic effects of each class. These clas- of potentially toxic chemicals, but also our bodies accumulate
sifications are by no means exclusive of one another; neither are these substances (as noted earlier in this chapter) and pose a
they all-inclusive. Humans are exposed to multiple risks at any “body burden” of chemicals in our blood, fat, breast milk, and
given time, and yet most of us remain healthy. The human body other tissues and body fluids (Thornton etÂ€al., 2002).
has a tremendous capacity for self-repair. Still, there are a large The toxic effects of chemicals are frequently subtle, and
number of diseases and disorders that are on the rise, and for people suffering from exposures are often misdiagnosed. The
many of them there is evidence of risk factors that are associated extent of biological damage produced by a chemical depends
with the environment (e.g., asthma, autism, Parkinsonism, learn- on two things: the amount of the exposure, or its dose, and the
ing disabilities, obesity, cardiovascular diseases). response (dose response) of the person exposed. When plot-
The Precautionary Principle states that if there is some evi- ted out on an X and Y axis, this is called a dose-response curve.
dence about the relationship between toxic substances or envi- As a general rule, the higher the dose, the greater the response.
ronmental hazards and human health, even if scientific evidence However, some people have hypersensitivities or hypersuscep-
about cause and effect is uncertain, precautionary measures tibilities to certain chemicals, and therefore have a response
should be taken to protect the environment and human health at a much lower than expected dosage. Some individuals have
(Goldman, 2000). In 2003 the ANA adopted the Precautionary “multi-organ hypersensitivity caused even by small amounts
Principle as a position of the ANA (Brody & Melamed, 2004). In of chemical exposure that is generally considered nontoxic”
keeping with that position, the ANA will use the precautionary for other individuals (Shinohara etÂ€al., 2004, p. 84). Multiple
approach in occupational and environmental health practice chemical sensitivity (MCS) is defined as “[1] a chronic condi-
and will advocate for public policy that focuses on prevention tion [2] with symptoms that recur reproducibly [3] in response
of hazards to people and the environment. to low levels of exposure [4] to multiple unrelated chemicals and
[5] improve or resolve when sources of exposures are removed,
along with a 6th criterion . . . requiring that symptoms occur in
multiple organ systems” (Bartha etÂ€al., 1999, abstract).
TABLEÂ€9-4â•…â•‡EXAMPLES OF
It is impossible, within the limitations of this section, to
ENVIRONMENTAL HAZARDS describe the incalculable health effects that can result from
AGENTS AND SOURCES OF EXAMPLES OF HARMFUL exposure to the expansive array of common chemicals to
HAZARDS EFFECTS which we are exposed on a regular basis. Think of the personal
Chemical care and cleaning supplies, petroleum products, solvents, pes-
Insulation (formaldehyde) Increased respiratory allergies, ticides, gardening materials, medical products, building sup-
chemical sensitivity plies, and plastic items that are a part of our day-to-day lives.
Automobile exhaust (lead) Behavior disorders, It is of crucial importance to recognize chemical exposures
neurological symptoms might have profound effects on the health of individuals and
Pesticides (polychlorinated Chloracne, liver disease, our communities. As health professionals, it is our responsibil-
biphenyls [PCB]) headache, birth defects ity to participate in the education of community leaders and
residents regarding these issues (Welker-Hood etÂ€al., 2007).
Biological and Infectious An excellent resource about chemicals in the environment is
Water supply (Giardia lamblia, Diarrhea, bloating, ToxNet (http://www.toxnet.nlm.nih.gov), which is comprised
Cryptosporidium) malabsorption
of a number of information, literature, and data sources on
Food (Salmonella, Fever, nausea, watery diarrhea
chemicals in our homes, workplaces, schools, and commu-
Escherichia coliâ•›)
Mosquito (malaria, West Chills, fever
nities. The Agency for Toxic Substances and Disease Registry
Nile virus) (ATSDR) also provides helpful information about toxic chem-
icals (http://www.atsdr.cdc.gov).
Physical
Physical hazards (faulty building Unintentional injury or death Biological Hazards
or playground construction) Infectious disease is considered environmentally transmitted
Noise (motor vehicles, airplanes, Hearing problems, stress, when it is spread from a common source, such as water, food,
lawn mowers) fatigue or animal vectors. In the past, many of the environmental health
Radiation (radon gas) Infertility, birth defects, leukemia problems were related to infectious agents, such as typhoid or
cholera, largely because of an inadequate understanding of sani-
Psychological tation and hygiene. Today, in the United States, we are concerned
Natural disasters (e.g., flooding, Hypertension about community-acquired Methicillin-resistant Staphylococcus
forest fires)
aureus (MRSA), a bacteria that causes infections that are highly
Low economic status Heart disease, ulcers
resistant to some antibiotics. This has become an even greater
(unemployment, poverty)
problem in hospitals where MRSA infections can be devastating
Multiple role demands (working Depression, anxiety
parent) to postoperative patients, patients with compromised immunity,
or patients with other severe vulnerabilities.
Despite the great advances in understanding microbes and the length of exposure. The OSHA standard requires that sound
hygiene, infectious disease continues to be a major public health levels in the workplace not exceed an average of 90â•›dB in an
problem in developing countries (see ChapterÂ€5). Although 8-hour period. However, sound levels of much lower intensity
the problems are not as great in this country, they do exist. might cause gastrointestinal, cardiovascular, or neuroendocrine
Outbreaks of food-borne diseases, such as salmonellosis, E. coli, disturbances. There is no decibel limit for sound levels in the
and hepatitis A, often occur. An excellent resource about infec- community or in our homes. Noise from a jet engine 25 miles
tious and communicable disease is the Control of Communicable away has been measured at 140â•›dB, a jackhammer at 100â•›dB, and
Diseases Manual published by the American Public Health a live performance of a rock band at 110â•›dB.
Association (Heymann, 2009). When a nurse becomes aware that someone is exposed to
Vector-borne diseases are spread by flies, mosquitoes, cock- persistent sound, the first approach should be to isolate the
roaches, ticks, and rodents (Heymann, 2009). Two vector- noise if at all possible, either by using sound-absorbent mate-
borne diseases that have captured attention recently among rial or by moving the client away from the source of noise. If
outdoor workers are Lyme disease (tick-borne) and West Nile these measures are not feasible, a less desirable approach is to
virus (mosquito-borne) (see ChapterÂ€8). Workers can pro- recommend some type of hearing protection. In some cases,
tect themselves against these and other vector-borne diseases both approaches are used. Clients should be advised that the
by wearing long sleeves and long pants; self-checking for ticks noise levels at concerts and discotheques might cause damage
after exposure; and minimizing potential breeding grounds for to the ear. Radio and music headsets might also contribute to
mosquitoes. increases in hearing loss if the volume is turned up too high.
Daycare settings are known to be sites where respiratory and
enteric diseases, such as giardiasis, are easily transmitted among Radiation
children, staff members, and families. The presence of children There are two types of radiation: ionizing and nonioniz-
in diapers, combined with children's natural tendency to put ing. Ionizing radiation is produced when atoms disintegrate.
objects in their mouths, contributes to the spread of infection. Sources of ionizing radiation include x-ray machines, cosmic
To prevent the spread of disease in daycare settings, a number of rays, uranium and other minerals, radon, nuclear power plants,
interventions are recommended (Schneider & Freeman, 2000): and atomic fallout. Nonionizing radiation, a lower energy form
• Proper hand-washing by staff members and children of radiation, transforms energy into heat. Examples include
• Exclusion or segregation of sick children microwaves, television and radio waves, infrared sources (e.g.,
• Routine cleaning of play objects welding arcs), ultraviolet rays in sun lamps or sunlight, and
• Separation of food-handling and diaper-changing areas and lasers. Although radiation is a natural part of our environment,
staff exposure to excessive amounts causes serious health effects.
• Use of sanitary diaper-changing procedures The largest source of man-made exposure to ionizing radia-
tion is the use of x-rays. Many household products emit ion-
Physical Hazards izing radiation.
Physical hazards in the environment include poorly designed The health effects from radiation are directly related to the
or unsafe construction of equipment, buildings, roads, or play- amount of exposure. Of greatest concern is the damage that
grounds; improperly placed items; and general lack of atten- occurs to chromosomes exposed to ionizing radiation. Excessive
tion to safety, noise, and radiation. Motor vehicle fatalities have and prolonged exposure can cause mutagenic, carcinogenic, and
been decreasing over the past decade, in part because of safer teratogenic effects (Levy etÂ€al., 2011). Epidemiological studies of
vehicle design. There were still 10.2 million motor vehicle acci- populations exposed to high doses of radiation, such as atomic
dents in 2008 and 37,000 associated deaths, so there is still much bomb survivors and clients undergoing radiation therapy, have
room for improvement (U.S. Census Bureau, 2011). Many more found a much higher than expected incidence of cancer follow-
people suffered disabling injuries. In addition, there were ing exposure (Davis, 2007).
approximately 4400 pedestrian deaths. Vehicle safety is The effects of nonionizing radiation vary according to the
addressed in Healthy People 2020 including a call for increased source. Ultraviolet radiation causes skin cancer and is proba-
use of child car restraints and safety belts. Nurses can partic- bly responsible for the increasing incidence of malignant mela-
ipate in school, work site, and community educational cam- noma. Infrared and ultraviolet light can cause thermal burns.
paigns to improve pedestrian safety and increase the use of seat Microwave radiation can cause deep thermal burns and has
belts, child seats, and helmets. been associated with impaired fertility. Lasers can cause reti-
nal damage and severe burns. Although there has been some
Noise question about the health effects of radiation from video dis-
Noise, although often perceived as innocuous on a day-to-day play terminals, conclusive evidence is lacking that they are in
basis, has been described by some as one of the most noxious fact harmful. Nurses can educate communities about radiation
and pervasive pollutants in our modern environment. The hazards. For example, school nurses can participate in primary
noise levels in our society have increased dramatically, and the prevention of skin cancer by teaching children to use sunscreen
most obvious health effect of noise is an impairment of the abil- and to wear protective clothing.
ity to hear. Other problems that have been associated with noise
include stress-related conditions, mental illness, social malad- Home Safety
justment, and pathological conditions, such as atherosclerosis For many Americans, the home is a refuge from the strains and
and heart disease. stresses of everyday life. In addition to environmental health
The amount of damage incurred by exposure to noise is risks, there can also be safety risks that need to be addressed.
directly related to the frequency and intensity of the noise and In 2007, approximately 124,000 Americans died as a result of
14
13.8
12
11.1
Rate per 100,000 population

10
10.2
7.0
6
3.1
2
0.95
0
2
MVA1 Poisoning Firearms Falls Suffocation Fires
& Drowning
Cause of Death
1 MVA = Motor vehicle accidents
2 Includes intentional
FIGUREÂ€9-5â•‡Causes of death from unintentional injuries in the United States, 2007. (Data from
Centers for Disease Control and Prevention, National Center for Health Statistics. [2011]. Mortality: Unintentional
injury deaths 2007. Retrieved September 3, 2011 from http://www.cdc.gov/hchs/fastats/acc-inj.htm; and U.S.
Department of Health and Human Services. [2010]. Healthy People 2020. Washington, DC: U.S. Government
Printing Office. Retrieved September 21, 2011 from http://www.healthypeople.gov/2020/default.aspx.)
unintentional injuries and others suffered disabling injuries than 60â•›years are at greater risk of dying as a result of accidental
(CDC, NCHS, 2011b). The leading causes of accidental death in poisoning from medications than are younger persons.
the home are poisonings and falls (FigureÂ€9-5). Other causes of Families can be encouraged to minimize the use of house-
death include fires and burns, choking and suffocation, drown- hold chemicals and pesticides and to ensure safe storage when
ing, and firearm accidents resulting from playing with or clean- they are used. Proper ventilation should be ensured when
ing guns. The greatest number of documented accidental deaths chemicals are being used. Educating families about what to
in the home occurs in the very young (younger than 4â•›years of do in case of accidental poisoning is essential. Poison control
age) and the very old (older than 75â•›years of age). According centers are located in most major cities in the United States.
to the National Safety Council, one home death occurs every 16 Their telephone number can usually be found in the front of
minutes, and one home injury occurs every 4 seconds (National the yellow pages. If not, contact the local telephone operator.
Safety Council, 2003). Safety campaigns to modify products and A well-trained poison control center staff, which includes phar-
teach people how to prevent accidents are effective. macists, nurses, and physicians, is available around the clock
Poisoning. Poisonings are the primary cause of unintentional to provide information about the prevention and treatment of
deaths and accounted for more than 29,500 deaths in 2007 poisonings.
(CDC, NCHS, 2011b). Deaths from poisonings in the newborn Falls. Falls are the second major cause of unintentional
to 4-year-old age group have fallen dramatically since 1958, in injuries and accounted for approximately 22,500 deaths in 2007;
part because of the introduction of child-proof containers and the vast majority of these occur in adults older than 65â•›years
educational campaigns such as “Mr. Yuk” (National Safety (CDC, NCHS, 2011b). Falls are the leading cause of uninten-
Council, 1991). Poisoning deaths include those from illicit drugs tional injury deaths for adults older than 75â•›years of age (see
(such as cocaine, pain medications, cleaning substances, mush- ChapterÂ€28). Common environmental fall hazards in the home
rooms, and shellfish) in addition to commonly used household include lack of stair rails and grab bars, tripping hazards,
poisons (e.g., pesticides, herbicides) (Davis, 2007); this helps unsteady furniture, poor lighting, loose electrical cords and
explain the higher number of deaths in the 25- to 44-year-old rugs, slippery surfaces, and clutter, all contributing to falls in
age group than other age groups. A study that examined poison- older adults. Baby equipment has been under scrutiny for con-
ing among older adults in Massachusetts suggested that older tributing to serious falls in young children. Windows that do
adults might be at higher risk than adults in younger age groups not have guards are hazards for small children. Nurses can pro-
for poisoning from prescription medications (Woolf etÂ€al., vide useful information to all family members concerning the
1990). A compromising health condition, medication interac- prevention of falls in the home. For example, parents should be
tions, possible dementia, and failing eyesight—problems not advised never to leave a child unattended on a diaper-changing
uncommon in older adults—might lead to an unintentional table and to always strap children into strollers and high chairs.
overdose, with tragic consequences. The findings from this Suffocation and Drowning. Suffocation, drowning, and near
study indicated that men older than 70â•›years and women older drowning are a major cause of morbidity and mortality in this
country. Suffocations are highest among infants 0-12â•›months of groups suffer even more frustration, as they seem to fall further
age at 22.5 per 100,000 infants. For those older than 65â•›years, behind the mainstream of society. As the gap between rich and
the suffocation rate is 8 per 100,000 (CDC, NCHS, 2011b). poor widens, the anxiety and alienation experienced by certain
Drownings are the leading cause of injury death in toddlers. groups deepen. Societal stresses such as crime, poor economic
For each drowning death, it is estimated that there are one to conditions, changing mores, and unemployment affect the well-
four near drownings that result in hospitalization. The loca- being of populations.
tion of drowning differs among age groups, with infants most Many natural occurrences hasten stress. Recently, this coun-
likely to drown in bathtubs, children ages 1 to 4â•›years in swim- try has experienced major and devastating earthquakes, floods,
ming pools, and children 5â•›years and older in rivers, lakes, and hurricanes, tornadoes, droughts, extreme heat and cold, and
other natural water sites (Brenner, 2003). Unfortunately, there is volcanic explosions; each has taken its toll on life and property.
a disparity between African American and white children ages 5 Concerns about the environment are becoming more prevalent.
to 19â•›years: the rate of drowning for African American children Stress is a manifestation of an effort to maintain a sense
is 2.4 times the rate for white children. Community programs of order. Humans have the ability to adapt within certain
to teach parents about drowning prevention are recommended Â�parameters. When the psychological or physical input becomes
(National Safe Kids Campaign, 2009). excessive, a stress response is likely to occur. If coping mecha-
Fires and Burns. Fires and burns are the fifth highest cause nisms are in place, the stress can actually have positive outcomes.
of home death (USDHHS, 2010a). These deaths include However, if the stresses are constant, the health of the individual or
fire-related injuries, such as smoke inhalation and asphyxiation, the community might be severely affected. Nurses can encour-
falls, and trauma from falling objects. Common causes of home age clients and community residents to discover the underlying
fires include faulty electrical wiring of appliances, chimneys, causes of their stress and to manage their stress. Clients might be
and space heaters. Deaths are highest among those considered given referrals to local mental health centers to assist in manag-
to be the most dependent: the very young and very old. One of ing their stress. Families can be encouraged to prepare for natu-
the Healthy People 2020 objectives (USDHHS, 2010a) is to have ral environmental disasters, such as floods and earthquakes, to
functional smoke detectors on each floor of all residences. By minimize stress. In the event of a natural disaster, the American
encouraging families to install smoke detectors, nurses can help Red Cross and other community agencies can be called on to
prevent burn injuries and deaths. assist families (see ChapterÂ€22). Advocating for the reduction of
Firearms. Firearms accounted for over 31,000 deaths in 2007 environmental health hazards can ultimately decrease commu-
(CDC, NCHS, 2011b). Unintentional deaths result from firearms nity stress and promote environmental justice.
while people are playing with or cleaning firearms (National
Safety Council, 2003). Most firearm deaths are the result of sui- ENVIRONMENTAL ISSUES FOR THE 21ST CENTURY
cides and homicides. Approximately 85% of these deaths are in
males. In 2007, the overall suicide rate (10.2 per 100,000) was Environmental contaminants threaten the very things that we
higher than the homicide rate (6.1 per 100,000) (USDHHS, depend on to sustain our lives: the air we breathe, the water we
2010a). The greatest absolute number of homicide deaths drink, the food we eat, and soil that is so integral to our lives.
occurs in persons older than 44â•›years of age (almost 11,000), Air, water, and soil pollution not only threaten our health, but
but the fatal firearm-related deaths per 100,000 are highest also threaten our very quality of life. FigureÂ€9-6 represents some
for the 15- to 24-year-old age group. Nurses and other health environmental influences on health. Numerous Healthy People
professionals are challenged to provide education about proper 2020 objectives focus on environmental health issues and give
gun storage to minimize firearm injuries and deaths and to direction to health professionals and communities as they pro-
address violence in school and work settings (McClelland etÂ€al., mote community health and prevent disease.
1996). Issues related to societal violence and the availability of
firearms are complex and require communities to work together Air Pollution
to reduce both homicides and suicides (see ChapterÂ€23). The air can become polluted from a variety of sources:
Unintentional injuries tend to be more prevalent for families manufacturing industry emissions, coal-fired power plants,
Â�
living in substandard housing because of poor construction or automobiles and other combustion engines, wood-burning
poor repair. However, no family is immune to home hazards. (or other fossil fuel) stoves and heating systems, forest fires,
Psychosocial Hazards. The last category of hazards is prob- and many other sources. In the United States, the Clean Air Act
ably the most difficult to describe because it is more difficult to was signed into law in 1970, the same year that the EPA was
measure. There is little doubt, however, that psychological fac- established. In lieu of creating a standard for every conceivable
tors have a profound effect on the health and well-being of our air pollutant, a set of “criteria pollutants” were established that
communities. Stress is just as pervasive in today's environment reflect critical toxicants or categories of chemicals that together
as the other hazards mentioned. The principal difference is that create a metric for air quality. These are called the National
it is often much easier to determine the link between physical Ambient Air Quality Standards (http://www.epa.gov/ttn/naaqs/).
agents and disease than it is to identify the relationship of an 1. Sulfur dioxide is produced during combustion and industrial
illness to psychological factors. processes.
Environmentally induced stress is a natural by-product of • Sulfur dioxide is a major contributor to acid rain.
our fast-paced society as well as a result of natural or man-made • It is associated with respiratory illness, alterations in pul-
disasters. Many people find it difficult to keep up with rapidly monary function, aggravation of existing cardiovascular
changing technological developments and feel frustrated in disease, and asthma.
their efforts to do so. The latest and greatest computer today 2. Nitrous dioxide is produced during combustion; it affects the
might be obsolete by tomorrow. Persons in lower Â�socioeconomic lungs, immune function, and asthma.
• The burning of fossil fuel (e.g., in diesels, industrial

Â�boilers, power plants) and waste incineration are two
major contributors.
• Bad, ground-level (man-made) ozone can irritate the resÂ�
piratory system, aggravate asthma, reduce lung Â�function,
Toxics/Waste and inflame and damage the lung epithelium.
Water quality There are a wide array of health effects associated with air
pollution, including asthma and other respiratory diseases,
cardiovascular diseases (including hypertension), cancer, immunoÂ�
logical effects, reproductive health problems (including birth
defects), and neurological problems. Air pollution standards
Global
Outdoor air environmental are based on protecting the health of healthy, middle-aged
quality health white males. The standards may not be as protective of more
vulnerable populations, and it should be noted that adverse
health effects have been found at levels below the EPA air qual-
ity standards. Children and older adults and those with chronic
pulmonary and/or vascular diseases may be at increased risk
Healthy homes and Infrastructure/
healthy communities Surveillance
for mortality from short-term increases in both indoor and
outdoor air pollution.
As discussed earlier, fate and transport refers to the process
by which a pollutant moves through (and sometimes back and
FIGUREÂ€9-6â•‡ Environmental influences on community and pop- forth from) the air, soil, surface water, and ground water. Fate
ulation health. (From U.S. Department of Health and Human Services. and transport also includes the residence time that the pollutant
[2000]. Healthy People 2010 [2nd ed.]. Retrieved August 14, 2003 from
http://www.healthypeople.gov/2010/redirect.aspx?url=/2010/document/
is in plants, the human body, and animals. Some pollutants are
html/volume1/08environmental.htm.) considered persistent bioaccumulative toxins (PBTs) because
they remain in the environment and our bodies for a very long
3. Carbon monoxide is produced during the burning of fossil fuel. time. They do not biodegrade into something less toxic, and
• Carbon monoxide is produced in large amounts by motor maintain their original chemical structure.
vehicles and burning fossil fuels. In May 2007, the U.S. Supreme Court ruled that the EPA
• Carbon monoxide binds very effectively with Â�hemoglobin, must take action on greenhouse gases from motor vehicles. This
precluding the binding of oxygen and resulting in anoxia; resulted in executive orders from Presidents Bush and Obama
the most sensitive population are those with cardiovascular to regulate greenhouse gas emissions from motor vehicles.
diseases.
4. Particulate matter (PM) consists of liquid and solid aerosols Water and Soil Pollution
from fuel combustion, motor vehicle exhaust, high-temperature Despite advances that have been made in the quality of Â�drinking
industrial processes, and incineration. water, water contamination remains a threat, particularly in some
• Particulate matter includes dust, dirt, soot, smoke, and rural and suburban communities (Afzal, 2006) (FigureÂ€9-7). The
liquid droplets. three main sources of water contamination are industrial wastes,
• The lungs are a prime site for damage and exacerbation sewage, and agricultural chemicals. Antibiotic-resistant microbes,
of underlying disease; the size of the particle determines endocrine disrupters, and also human medication and medica-
how deep into the lungs the particles travel and deposit. tion by-products have been found in stream water. Providers of
5. Lead in particulate matter found in the air is from indus-
trial processes and incineration. Lead is toxic to the nervous,
immune, cardiovascular, and reproductive systems, as well as
damaging to heme synthesis and to the kidneys.
6. Ozone is an odorless, colorless gas composed of three atoms
of oxygen. Ozone occurs both in the earth's upper atmo-
sphere and at ground level. Depending on where it is found,
ozone is categorized as “good” ozone or “bad” ozone.
• “Good” ozone occurs at a layer in the stratosphere about
10 to 25 miles above Earth and it serves to protect people
from the most damaging ultraviolet (UV) rays. It has been
significantly damaged by chlorofluorocarbons (CFCs).
• “Bad” ozone is ground-level ozone that is created by reaction
of hydrocarbons, which include VOCs and nitrogen oxides
in the presence of sunlight.
• VOCs are emitted from a wide range of sources: dry cleaners,
FIGUREÂ€9-7â•‡Oil containment boom placed in Swanson Creek,
cars, chemical manufacturers, paint shops, and many others. tributary to the Patuxent River, after oil spill at power-Â�generating
• The prime target organ for ozone is the lung, to which it plant. (From National Oceanic and Atmospheric Administration, DepartÂ�
causes damage, diminishes lung function, and sensitizes ment of Commerce. NOAA Photo Library. Available online at http://www.
the lung to other irritants. photolib.noaa.gov/htmls/line1633.htm.)
public drinking water are required to test water quality and report overhaul of their chemical policies has resulted in a new approach
any dangerous exceedances of EPA drinking water standards to to product manufacturing that places the burden on the manu-
the public. People who depend on well water may be more vul- facturer to prove a product is safe. This is quite different from U.S.
nerable because there is no requirement for periodic testing; policy, which allows products to come to market and then has
however, contamination can occur in any water supply. little/no mechanism to withdraw them if they are discovered to
Hazardous waste includes infectious wastes, agricultural be toxic. Nursing organizations in the United States are engaged
and industrial by-products, radioactive substances, flammable in a coalition that advocates for safer chemical policy. In the com-
products, and chemical agents. Hospitals, medical offices, and ing years, we can expect robust debate about our chemical poli-
laboratories must dispose of hazardous waste separately from cies and more products developed using “green chemistry,” a new
regular solid waste. approach to chemical formulations that are inherently less toxic
Soil serves as a receptacle for many of the pollutants, such as (Welker-Hood etÂ€al., 2007).
heavy metals, radioactive materials, pesticides, and other pollut-
ants that are deposited from the air or water. Radioactive matter Sustainable Agriculture
that disperses into the environment eventually falls to the ground In the United States, wide-scale industrial agriculture is
and settles in the soil. Human and animal excreta are often increasingly under scrutiny for its effects on the environment
disposed of improperly. Contamination of soil by hazard- and on human health. More and more, the public is demand-
ous waste dumps and the legacy of chemicals that were used ing food products that have been grown/produced in a more
during past land uses are an ongoing and increasing problem sustainable way: fair trade products, organically grown (with-
(Gilden, 2003). It is estimated that at least 10,000 hazardous out the use of pesticides—including herbicides—and chemical
waste dumps in the United States pose a threat to public health Â�fertilizers), locally grown, without the use of Â�nontherapeutic
(Last, 1998). antibiotics, without the use of hormones or genetically modi-
Soil that has been contaminated and now poses a threat fied Â�organisms, and otherwise grown in a way that promotes
to human health can fall into two regulated categories, once long-term sustainability. School districts and hospitals are
Â�governmental agencies are involved. The first category is called using their institutional purchasing power to demand food
a Superfund site (EPA, 2007). This is a site that has been evalu- products that have been grown sustainably from the perspec-
ated and is determined to pose a hazard. The most dangerous tive of human and ecological health. Nurses can play a big
sites are on a National Priority List. You can find out if there role in promoting healthy and sustainable foods. See the Food
are Superfund sites in your community through the EPA's Work Group resources for Health Care Without Harm (http://
Envirofacts – http://www.epa.gov/enviro/. The other category is noharm.org/all_regions/issues/food/).
called Brownfield sites. A Brownfield site receives its Â�Â�designation
based on the fact that a property is designated for redevelop- Climate Change
ment and there is a concern that some past use has created a An Inconvenient Truth, Al Gore's movie, brought climate
health risk. There are a set of directions that property owners change science into local theatres and helped to launch local,
must follow in order to develop the property. Both Brownfield state, and national awareness and policies regarding this very
and Superfund regulations require community involvement in critical issue. The predictions for increased storm activity,
the assessment, planning, and implementation stages. extremes in temperatures, and changes that will impact food
Â�production all have the potential to create significant health
Nanotechnology needs. In addition to being strong advocates to address climate
Nanotechnology refers broadly to a field of applied science and change, we also need to be prepared for the near-future, pub-
technology whose unifying theme is the control of matter on lic health consequences (Afzal, 2007). “There is mounting evi-
the molecular level in scales smaller than 1 micrometer, nor- dence that global climate change is already affecting human
mally 1 to 100 nanometers, and the fabrication of devices within health through extreme weather events, changes in air and
that size range. This new technology has been applied to every- water quality, and changes in the ecology of infectious diseases”
thing from car waxes to makeup. Because of the extremely small (Afzal, 2007, p.Â€3). The campaign Health Care Without Harm
size of nanocomponents, there is concern about their ability to has been a major force in educating health care providers about
easily penetrate deep into the human body. Nanomaterials have climate change and our clinical and advocacy roles.
proved toxic to human tissue and cell cultures (Oberdörster
etÂ€al., 2005). Unlike larger particles, nanomaterials may be
taken up by cell mitochondria and the cell nucleus (Porter etÂ€al., COMMUNITY/PUBLIC HEALTH NURSING
2007). Studies demonstrate the potential for nanomaterials to
cause DNA mutation and induce major structural damage to
RESPONSIBILITIES
mitochondria, even resulting in cell death (Geiser etÂ€al., 2005). The responsibilities of the community health nurse in Â�relation
Many more questions than answers exist at this time. to environmental factors include assessing, monitoring,
Â�educating, advocating, and role modeling (Butterfield, 2002;
Chemical Policies Choi etÂ€ al., 2006; Sattler & Lipscomb, 2003). Case studies by
As the public becomes increasingly aware of the connection Clark etÂ€al. (2002), Green and Slade (2001), and Phillips (1995)
between the products that they commonly use in their daily lives provide excellent examples of the role of nursing in environ-
(such as personal care products and cleaning agents) and their mental health. Website Resource 9E provides an extensive
potential relationship to health risks, there is a growing discus- list of web-based resources for environmental health that can
sion about how the chemical policies in the United States have assist nurses in their practice. See also Community Resources
failed to protect the public's health. In Europe, a comprehensive for Practice at the end of the chapter.
Assessment Â�
advocates for institutional, legislative, and regulatory change
Toxicologists, epidemiologists, and other disciplines can help to because they are one of the most trusted professionals in soci-
determine the possible connections with environmental Â�factors, ety and they bring a good scientific background combined with
but within communities nurses can use surveys to determine excellent communication skills. Within our institutions (such as
the biggest concerns and hazards that are identified by the com- hospitals, clinics, or schools), we can advocate for policies that
munity. A new tool in the public health armament is the use of call for integrated pest management, nontoxic cleaning prod-
geographic information systems (GIS) (Choi etÂ€al., 2006). This ucts, asthma-safe products, and products that are made from
is a term that refers to a number of computer programs that can recycled products. School nurses can help to develop policies
link individual data units to a geographical location. It allows about nontoxic art supplies.
for health outcomes and exposure data to be mapped and over- In our state houses, we can advocate for legislation that pro-
laid so that analysis of risk factors for health outcomes can be motes clean air and water, sustainable food production, safe
Â�conducted. A map can also be created that provides a visual rep- products, and other environmentally healthful policies. In
resentation of the data. For example, you could create a map many states, the state nurses' associations are actively engaging
that illustrates the following community data points: location of in environmental policy work.
older Â�housing stock and the location of children less than 5â•›years The ANA has created a Â�pollution prevention toolkit for
old. With these combined data, a public health nurse could then nurses; passed several resolutions, including one that calls for
determine the best sites to deploy a mobile lead testing unit. banning the use of nontherapeutic Â�antibiotics in animal feed;
and adopted a set of environmental principles. These princi-
Surveillance ples are intended to guide the profession of nursing in practice
While there is no federal law regarding the reporting of environ- and policy work. Earlier in this chapter, Box 9-1 presents the
mental diseases, there are health outcomes that are required to be Environmental Health Principles adopted by the Public Health
reported in some states that are associated with environmental Nurses' Section of the American Public Health Association.
exposures. This includes cancer registries, birth defects registries,
and blood lead level registries. Nurses can be involved in or initi- Research
ate environmental surveillance programs for environmental health Environmental health research is conducted by a range of
problems, such as creating lead poisoning or birth defects regis- scientific disciplines, such as clinical practitioners, epidemiolo-
tries. With registry data, clusters of problems may be noted. The gists, and toxicologists. Intervention studies have helped us to
federal government has begun the longitudinal National Children's understand the best ways to eliminate or reduce environmental
Study, which will be following 100,000 children from the time the health risks. In the nursing literature you will find some articles
woman is pregnant through the child's 21st birthday. This study on environmental health, but few of them are actual research
will include the collection of information about exposures and articles. There is a huge need for nurses to engage in this area
health effects and will be an invaluable source of information for as researchers. The best single source of research on environ-
researchers to mine (http://www.nationalchildrensstudy.gov/). mental health is Environmental Health Perspectives, which is
the official peer-reviewed journal of the National Institute of
Risk Communication Environmental Health Sciences (http://www.ehponline.org/).
In nursing, we are often communicating about health risks. We
talk to parents about the risks associated with not using car seats
or helmets. We talk to teenagers about the risks associated with THE NURSE'S RESPONSIBILITIES IN PRIMARY,
unsafe sex. In environmental health, in addition to communi- SECONDARY, AND TERTIARY PREVENTION
cating with individuals, our risk communication often occurs
in a community and usually occurs when there is already some The levels of prevention used in public health can be applied
concern about an exposure. For example, a recent transporta- to environmental problems as a way to understand the various
tion accident in which a tanker car released highly toxic chem- points of intervention (BoxÂ€9-5).
icals near a residential community will be cause for concern
by parents, pregnant women, and others in the community. Primary Prevention
A Â�public health nurse might be called upon to help the commu- Health promotion and illness prevention in the home, at work
nity understand whether there is cause for concern and what, if or school, and in the community are aimed at reducing the risk
anything, community members should do. of exposure and illness. The focus of interventions is on the
When engaging in risk communication around environmen- conditions that influence, produce, or predict health and illness
tal risks, it is important to recognize that community members in human beings. Nursing strategies are geared toward provid-
may be afraid and/or anxious and they may not trust someone ing people with information about environmental health risks
who comes from a governmental agency. It is extremely impor- and assisting them to eliminate, minimize, or avoid exposure
tant to listen to the community members to understand their to hazards.
real concerns; this means that if a risk communication pro- In the home, nurses can assess for physical hazards (e.g., asthma
gram is organized, there must be an opportunity for commu- triggers, lead, formaldehyde, radon, chemical storage, unsafe play
nity members to speak. The ATSDR/CDC (1997) have created areas), provide education for health promotion, and facilitate and
guidance documents on risk communication. coordinate a health-promoting environment. Families should be
encouraged to use community resources and obtain testing for
Advocacy household hazards such as lead, radon, or CO. Nurses can also
Nurses are fierce defenders of the health of individuals, fam- be role models for members of the community and advocate for
ilies, populations, and communities. Nurses can be the best changes in habits.
BOXÂ€9-5â•…â•‡PREVENTION INTERVENTIONS are in strategic positions to make decisions about the types of
FOR ENVIRONMENTAL/ products used and can apply the same waste-reduction principles
as in the home. Furthermore, nurses can pressure Â�manufacturers
OCCUPATIONAL HEALTH
to reduce the packaging in many materials used in health care
AND SAFETY
settings. At the community and global levels, changes in policy
Primary Prevention are supported to reduce air, soil, and water pollution. Nurses can
• Advocate safer environmental design of products such as needles, participate in public education and assist community members
automobiles, playground equipment, and buildings. in interpretation of data about environmental risks.
• Teach home safety related to falls and fire prevention, especially to
families with children, older adults, and those with disabilities. Secondary Prevention
• Communicate the risks of keeping firearms in the home and review A critical role of the nurse is to develop appropriate interven-
safe methods of storage if a firearm is kept at home. tions when environmental exposures are noted. For example,
• Counsel women of childbearing age regarding exposure to environ- a toddler living in an older building who is observed eat-
mental hazards. ing cracking paint or playing on a dusty floor should have a
• Teach avoidance of ultraviolet exposure and use of sunscreen.
blood test to screen for lead poisoning. Farm workers who are
• Use and advocate use of environmentally preferable products, such
exposed to pesticides should be screened for neurological and
as the least toxic cleaning supplies and chemicals.
other symptoms. A thorough health history of occupational
• Advocate use of protective devices, such as earplugs for noise, seat
belts, and bicycle helmets. and Â�environmental exposures is essential for all individuals.
• Immunize occupationally exposed workers for hepatitis B. The early diagnosis and treatment of environmental illness, or
• Develop work site health and safety programs in work settings to secondary prevention, is traditionally part of the community/Â�
prevent back injuries. public health nurse's responsibility.
• Support the development of exposure standards for toxins. In the community, nurses are involved with other health
• Advocate for safe air and water. care professionals in the surveillance of health conditions that
• Support programs for waste reduction, recycling, and effective might be related to environmental and occupational exposures.
waste management in health care settings and schools. For example, environmental health specialists in local and state
health departments play a key role in ensuring safe water, food,
Secondary Prevention and air. The reporting of disease, follow-up, and intervention are
• Assess homes, schools, work sites, and communities for environ- all part of surveillance of environmental and occupational dis-
mental hazards. ease. Sources of data include health care providers, emergency
• Routinely obtain environmental and occupational health histories room admissions, pharmacy purchase trends, death certificates
for individuals, counsel about hazard reduction, and refer for diag- and autopsy reports, birth certificates, disease registries, work-
nosis and treatment. ers' compensation claims, insurance or hospital billing data, and
• Screen children from 6â•›months to 5â•›years of age for blood lead
specific environmental sampling. Nurses can participate in all
levels.
the phases of data collection, analysis, interpretation, and dis-
• Monitor workers for levels of chemical and radiation exposure.
semination. Nurses might be in the best position to interpret
• Screen at-risk workers for lung disease, cancer, and hearing loss.
• Participate in data collection regarding the incidence and preva- scientific findings to the community and to provide individual-
lence of injury and disability in homes, schools, and work sites. ized and group education as needed.
Tertiary Prevention Tertiary Prevention

• When air pollution is high, encourage limitation of outdoor activity Tertiary prevention is aimed at minimizing disability and
to minimize exposure. Â�maximizing functional capacity. At this level of intervention, treat-
• Support cleanup of toxic waste sites and removal of other hazards. ment strategies are used to assist the individual or community to
• Provide appropriate nursing care at work sites or in the home for adapt to changes resulting from the illness. For example, after a
persons with chronic lung diseases and injury-related disabilities. nuclear accident, such as that in Japan in 201â•›l, rapid evacuation
• Refer homeowners to approved lead abatement resources. of residents is imperative to minimize the exposure to radiation.
Because the food and water supplies were contaminated by the
Compiled by Claudia M. Smith, PhD, MPH, RN-BC.
radiation, it was essential to obtain new sources of food and water
to limit exposure. If malignancies occur following a nuclear acci-
For example, to reduce the volume of garbage produced in the dent, treatment and palliative care, which are activities of tertiary
United States, nurses could incorporate trash-reduction practices prevention, are appropriate. Risk communication about environ-
into their personal shopping habits. Buying in larger quantities or mental hazards with the public is also part of the nurse's role.
bulk, purchasing items manufactured in less packaging or Â�recyclable Nurses can stay informed of environmental issues by
packaging, or using reusable products (razors, cloth diapers) rather Â�reading newspapers and becoming active in consumer- and
than disposable ones are ways to reduce household trash. health-related organizations. Being well informed is a first step
Nurses who work in health care settings have an opportunity in influencing the political system on environmental issues.
to protect the environment (see Health Care Without Harm and Communicating effectively with persons in power through
Practice Green Health in the Community Resources for Practice groups, such as the ANA, AAOHN, American Public Health
at the end of the chapter). For example, health care professionals Association, Health Care Without Harm, the Alliance of Nurses
in numerous health care settings are now using many reusableÂ� for Healthy Environments (ANHE), or other groups is vital (see
products instead of disposable ones, including cloth diapers, Community Resources for Practice). Networking with others
metal wash basins, and float-type mattress pads. Nurse Â�managers who share the same interests is highly effective as well. Because
environmental health issues have complex origins and involve Â�

understood, not only as isolated hazards but also in their
many professionals, an interdisciplinary approach is most complex interaction. The health effects of chronic, low-dose
effective. exposures to ubiquitous chemicals and their influence on
genetic and hormonal changes need to be explored further in
the 21st century (Thornton etÂ€al., 2002).
THE FUTURE OF ENVIRONMENTAL HEALTH A greater focus on occupational health is being included in
NURSING nursing practice, education, and research (IOM, 1995). Nurses
interested in occupational health need to engage in teamwork
Community/public health nurses must continue to explore beyond the bounds of the health care system. “Communication
environmental conditions that are potentially detrimental to should extend beyond counseling individual clients and families
human health. All community/public health nurses should to facilitating the exchange of information on environmental haz-
recognize environmental hazards and illnesses, make appro- ards and community responses” (IOM, 1995, p. 10). Minimally,
priate referrals, educate and advocate for reduction of risks, every community/public health nurse should elicit environmen-
and contribute to environmental health policy (ANA, 2010; tal, home, and occupational health histories and observe for links
IOM, 1995). Nurses are providing safer health care environ- between the environment and illness. As research reveals more
ments for health care employees, patients and families, as about the complex interaction of hazards, continuing education
well as reducing occupational hazards for nurses. Chemical, in the multiple dimensions of environmental health will be essen-
physical, Â�biological, and psychosocial hazards must be Â�better tial for up-to-date community/public health nurses.
KEY IDEAS
1. The interaction of human beings with the environment 7. Occupational health nursing is a branch of community/
(physical, political, social, economic, and cultural aspects) public health nursing concerned with promoting, pro-
affects health status. The home, the workplace (or school), tecting, and maintaining the health and safety of workers.
and the community are important sources of environmental Occupational health nurses can face ethical issues because
hazards that affect health. of competing interests of employers and employees.
2. Healthy People 2020 objectives address prevention of home 8. More disabling injuries occur in workplaces than in homes.
injuries, reduction of worker illnesses and injuries, and reduc- The most frequent work-related illnesses and injuries are
tion of human exposure to toxic agents. Hazards include chemi- traumatic injuries, skin disorders, and lung diseases.
cals, infectious agents, mechanical forces, noise, and radiation. 9. The federal Hazard Communication Standard of 1986
3. Poisonings (including drug overdoses), falls, and drowning requires employers to notify employees of exposure to toxic
are the top three causes of unintentional injuries and deaths substances.
in homes. 10. All community/public health nurses need to include occu-
4. Persons who are physically dependent, such as preschool pational and environmental histories when assessing the
children and older adults, are at highest risk of preventable health of individuals and their families.
home injuries. 11. Clean air and water; a safe, sustainable food supply; and
5. Chemicals such as radon, formaldehyde, carbon monoxide, effective waste management and chemical policies remain
pesticides, and environmental tobacco smoke in homes con- critical issues for the 21st century. Community/public
tribute to respiratory illnesses. Lead poisoning causes cogni- health nurses can advocate for collective community action
tive and behavioral disabilities in children, as well asÂ€other to preserve natural resources.
neurological, renal, and hematological damage. 12. Health effects of climate change, nanotechnology, and
6. Community/public health nurses provide education regard- the interactions of numerous chemicals in human bod-
ing safe home environments and assist families in identifying ies are important areas for health research and risk
hazards that can be removed in the home. communication.
1. Use the home assessment tool to assess your own home and hazards and the role of each professional in protecting the
compare results with fellow students; then conduct an expo- public from environmental hazards.
sure history with a fellow student using the questions in Box 4. Outline the teaching that you would consider appropriate for
9-2, “I PREPARE.” the environmental health risks found in a home assessment
2. Describe an environmental issue in your community (such of a client.
as a hazardous waste site, chemical pollutants from a plastics' 5. Contact an occupational or environmental health nurse
manufacturer, contaminated well water, or pollution from in your community. Using Box 9-4 as a guide, describe the
an incinerator) and the role of the community/public health responsibilities of this nurse. See whether you can identify
nurse in monitoring health, raising awareness, and Â�promoting at least one example of primary, secondary, and tertiary pre-
education and advocacy. vention activities that the nurse performs.
3. Spend a day with an environmental health specialist in your 6. Conduct an Internet search, and read information from
local health department, an occupational health nurse, or a the National Library of Medicine ToxNet or ToxTown, the
daycare nurse consultant, or visit community agencies, such Agency for Toxic Substances and Disease Registry, or the
as the local poison control center. Identify the environmental Environmental Protection Agency about lead or mercury.

FEDERAL AGENCIES American Public Health Association—Public Health Nursing
Centers for Disease Control and Prevention—National Center Section and Environmental Health Section http://www.apha.
for EnvironÂ�mental Health and Agency for Toxic Substances org/programs/
and Disease Registry http://www.atsdr.cdc.gov/
Consumer Product Safety Commission http://www.cpsc.gov/ NONGOVERNMENTAL ORGANIZATIONS
Department of Housing and Urban Development http://portal. American Lung Association http://www.lungusa.org/
hud.gov/portal/page/portal/HUD American Red Cross http://www.redcross.org/
Department of Energy http://energy.gov/ Center for Health, Environment & Justice http://chej.org/
Environmental Protection Agency http://www.epa.gov/ Children's Environmental Health Network http://www.cehn.org/
Food and Drug Administration http://www.fda.gov/ Environmental Defense Fund http://www.edf.org/
National Institute of Environmental Health Sciences http://www. Environmental Working Group http://www.ewg.org/
niehs.nih.gov/ EnviRN (sponsored by ANHE) http://envirn.org/
National Institute for Occupational Safety and Health http:// Health Care Without Harm http://www.noharm.org/
www.cdc.gov/NIOSH/ Healthy Schools Network http://www.healthyschools.org/
Occupational Safety and Health Administration http://www. March of Dimes Birth Defects Foundation http://www.mar-
osha.gov/ chofdimes.com/
Office on Smoking and Health http://www.cdc.gov/tobacco/osh/ National Environmental Health Association http://www.neha.
org/index.shtml
PROFESSIONAL ASSOCIATIONS National Safety Council http://www.nsc.org/Pages/Home.aspx
Alliance of Nurses for Healthy Environments http://envirn.org/ Physicians for Social Responsibility http://www.psr.org/
American Nurses Association—Center for Occupational and Poison Control Centers (look in local phone book for listing)
EnvironÂ�mental Health http://nursingworld.org/MainMenu Safer Chemicals, Healthy Families http://www.saferchemicals.org
Categories/OccupationalandÂ�Environmental.aspx Sierra Club http://www.sierraclub.org/
American Association of Occupational Health Nurses https://www. Union of Concerned Scientists http://www.ucsusa.org/
aaohn.org/
WEBSITE

Visit the Evolve website for this book to find the following study These items supplement the chapter's topics and are also found
and assessÂ�ment materials: on the Evolve site:
• NCLEX Review Questions 9A: Case Study: Environmental Issues Related to Disposable
• Critical Thinking Questions and Answers for Case Studies Diapers and Application of the Ecological Systems Model:
• Care Plans Disposable Diapers
• Glossary 9B: Secondary Prevention of Lead Poisoning: Levels, Symptoms, and
Interventions
9â•›
C: National Occupational Health Research Priorities and
Occupational Health Research Priorities in the U.S. Health
Care Sector
9D: Legislative and Other Efforts to Protect Workers
9E: Web-Based Resources for Environmental Health
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An anthropological approach to the evaluation Cengage Learning.
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in Mexico. Environmental Health Perspectives, environmental health in occupational health
American Lung Association, Environmental 106(6), 347-353. Retrieved February 18, 2012 nursing. American Association of Occupational
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(1995). Indoor air pollution: An introduction Keleher, K. (1995). Primary care for women: Vintage.
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Academy of Pediatrics Collaborative Project. precautionary principle and public health: a changing environmental health role. Public
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CHAPTER
10
Relevance of Culture and Values for
Linda Haddad and Claudia M. Smith∗
FOCUS QUESTIONS
What are culture, race, and ethnicity? Why should community/public health nurses be concerned
What is the relation of culture to health and health behaviors? with being culturally competent?
How do values influence attitudes, beliefs, and behaviors What core categories should community/public health nurses
related to health and illness? explore when assessing culture?
What are health disparities and disparities in health care? What nursing interventions are most effective when
How do cultural differences influence cultural assessment, working in culturally appropriate ways with diverse
planning, intervention, and evaluation of care for communities?
individuals, families, and communities?
What is cultural and linguistic competence?
How are the National Standards for Culturally and
Linguistically Appropriate Health Care Standards (CLAS)
in health care used by community/public health nurses to
develop cultural and linguistic competence?
CHAPTER OUTLINE
Cultural Pluralism in the United States Culture-Bound Syndromes
Culture: What It Is Cultural Patterns of Care
Subcultures Culture's Relationship to Health and Health Beliefs
Differences between Health Care Provider's and Client's Seeking Health Care
Culture or Subculture Folk Medicine and Folk Healers
Values Complementary and Alternative Therapies
Race Meaning of Pain and Suffering
Ethnicity Community/Public Health Nurse's Role in a Culturally
Racial and Ethnic Health and Health Care Disparities Diverse Population
Role of Insurance in Health Disparities Culturally Competent Nursing Care
Strategies for Eliminating Health Disparities Cultural Assessment for the Community/Public Health
Understanding Cultural Differences Nurse
Time and Space Culturally Appropriate Strategies for the Community/Public
Communication Health Nurse Working with Diverse Communities
Preferred Greetings and Body Language Contemporary Issues and Trends
Rites and Rituals Refugee and Immigrant Populations
Religion Socioeconomic Status of Minority Populations and
Role of Food Health
Family and Kinship Sexual Orientation
Sexuality Racism and Discrimination
Biological Variations
*This chapter incorporates material written for the second edition by Frances A. Maurer and Kathryn Hopkins Kavanagh, for the third edition by Rachel W. Smith,
and for the fourth edition by Margaret M. Andrews.
266
CHAPTER 10â•… Relevance of Culture and Values for Community/Public Health Nursing 267
KEY TERMS
Asylees Discrimination Racism
Cultural and linguistic competence Ethnicity Refugees
Cultural assessment Ethnocentric Rite
Cultural competence Health care disparities Ritual
Cultural pluralism Health disparities Stereotyping
Cultural self-assessment Health literacy skill Subcultures
Culture Immigrants Values
Culture-bound syndromes Race
CULTURAL PLURALISM IN THE UNITED STATES BOXÂ€10-1â•…â•‡CLASSIFICATION STANDARDS

Cultural pluralism can be defined as mutual appreciation and FOR FEDERAL DATA ON RACE
understanding of the various cultures and subcultures in a soci- AND ETHNICITY
ety. It means that there exist cooperation between and among • White: A person having origins in any of the original peoples of
members of different groups and harmony in the presence of Europe, the Middle East, or North Africa. Included are people who
diverse lifestyles, communication patterns, religious traditions, indicate their race as white or write entries such as Irish, German,
family structures, expressions of care, and health-related beliefs Italian, Lebanese, Near Easterner, Arab, or Polish.
and practices. With a population that exceeds 310 million, the • Black or African American: A person having origins in any of
United States is a nation of rich cultural pluralism. More than the black racial groups of Africa. Included are people who indicate
110 million people, or one in three individuals, self-identify their race as black, African American, or Negro or provide written
with one or more of the federally recognized racial and/or eth- entries such as African American, Afro American, Kenyan, Nigerian,
nic minority groups described in BoxÂ€10-1. The term cultural or Haitian.
pluralism can refer to a wide variety of characteristics, including • American Indian and Alaska Native: A person having origins in
religion, gender, sexual orientation, age, and related factors. The any of the original peoples of North and South America (including
federal census data provide an overview of the types of racial Central America) and who maintain tribal affiliation or community
and ethnic diversity found in contemporary U.S. society. Much attachment.
of the community/public health nurse's practice is intercon- • Asian: A person having origins in any of the original peoples of the Far
nected with population demographics, especially characteris- East, Southeast Asia, or the Indian subcontinent, including, for exam-
tics related to racial and ethnic trends and the socioeconomic ple, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam. Included are Asian Indian,
backgrounds of individuals, families, groups, and communities.
Chinese, Filipino, Korean, Japanese, Vietnamese, and Other Asian.
FigureÂ€10-1 summarizes the current U.S. population by racial
• Native Hawaiian and Other Pacific Islander: A person having
and ethnic categories. The country's 197 million non-Hispanic origins in any of the original peoples of Hawaii, Guam, Samoa, or
whites comprise 63.7% of the total population (Humes, Jones, & other Pacific Islands. Included are people who indicate their race
Ramirez, 2011). In discussing the growth among racial and eth- as Native Hawaiian, Guamanian or Chamorro, Samoan, and Other
nic minority populations, former Census Bureau Director Louis Pacific Islander.
Kincannon reported that there are more people from minority • Some other race: Includes all other responses not included in
groups in this country today than the total U.S. population in the white, black or African American, American Indian and Alaska
1910. To put this into a broader context, the U.S. minority pop- Native, Asian, and Native Hawaiian and Other Pacific Islander race
ulation is larger than the total population of all but 11 countries categories described above. Respondents providing write-in entries
in the world (U.S. Bureau of the Census, 2010a). such as multiracial, mixed, interracial, or a Hispanic or Latino group
Hispanics comprise the largest ethnic minority group, with (e.g., Mexican, Puerto Rican, Cuban, or Spanish) in the Some other
50 million people, or 16.3% of the total population (Humes, race category are included here.
Jones, & Ramirez, 2011). The Hispanic population grew by
From Humes, K., Jones, N., & Ramirez, R. (2011). Overview of race
over 40% during the period between 2000 and 2010. California and Hispanic origin: 2010. 2010 Census briefs, U.S. Census Bureau.
(37.6%) and Texas (37.6%) have the largest Hispanic popula- Retrieved September 26, 2011 from http://www.census.gov/prod/
tion of any states, followed by Florida. Blacks comprise the larg- cen2010/briefs/c2010br-02.pdf.
est racial minority group, with 39 million, or 12.6% of the total
population. The black population increased by 12% between the total population) reside in California, Oklahoma, Arizona,
2000 and 2010. Texas has the largest population of blacks of Texas, Florida, and Alaska. Native Hawaiians and other Pacific
any state (3.1 million) followed by New York (3 million) (U.S. Islanders (540,000, or 0.2% of the total population) are found
Bureau of the Census, 2010a). primarily in Hawaii, California, and Washington. In the 2010
The other federally defined racial minority groups are Asians census, almost 35% of respondents reported that they belonged
(14.6 million, or 4.8% of the total population), with the larg- to two or more races. By the year 2030, Hispanics will represent
est numbers found in New York and Texas (Humes, Jones, & 19% of the population, and Asians are expected to increase to
Ramirez, 2011; U.S. Bureau of the Census, 2010a). The Asian 7% (U.S. Bureau of the Census, 2007).
population also grew by over 40% between 2000 and 2010. Many Greater diversity in the population means that community/
of the American Indians/Alaska Natives (3 million, or 0.9% of public health nurses are likely to come into frequent contact
268 CHAPTER 10â•… Relevance of Culture and Values for Community/Public Health Nursing
Asians (4.8%)
Native Hawaiians & Total Population 308 million
other Pacific Islanders
American Indian (0.2%)
& Alaskan Natives Hispanic or Latino
(0.9%) (16.3%)
Black (12.6%)
Some other race
(6.2%)
Two or more
races
(2.9%)
Non-Hispanic or
Latino (83.7%)
A White (72.4%) B
FIGUREÂ€10-1â•‡ A, U.S. population by race. B, U.S. population by Hispanic and non-Hispanic ethnic
origins. Note: Total is slightly higher than 100% due to rounding. (Data from Humes, K., Jones, N.,
& Ramirez, R. [2011]. Overview of race and Hispanic origin: 2010. 2010 Census briefs, U.S. Census Bureau.
Retrieved September 26, 2011 from http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf.)
with members of different cultures and subcultures. The nurse's • Common patterns of clothing
health-related cultural beliefs and values may vary Â�significantly • Predictable socialization patterns
from those of individuals, groups, and communities different • A shared sense of beliefs
from his or her own. Bridging the racial, ethnic, and cultural According to the nurse–anthropologist Madeleine M. Leininger,
divides in health poses a challenge for all nurses, especially for who established the specialty called transcultural nursing, the term
community/public health nurses, who provide care to diverse culture refers to the learned and shared beliefs, values, and life ways
groups of individuals and families in community settings. of a group that are generally transmitted from one generation to
Cultural and linguistic competence is a requisite skill for all the next and influence people's thoughts and actions. An integral
nurses to provide culturally congruent, appropriate, and mean- part of daily living, culture has many hidden and built-in directives
ingful nursing and health care; avoid unnecessary misunder- and rules of behavior, beliefs, rituals, and moral–ethical decisions
standings and miscommunication; and ensure that the public that give meaning and purpose to life (Leininger & McFarland,
receives the highest quality of community/public nursing care. 2006). Community/public health nurses’ knowledge of culture
and skill in conducting comprehensive cultural assessments guide
A first-grade Vietnamese girl was sent to the school health them in providing culturally competent care to people from diverse
office because the teacher noticed welts on the back of her cultures.
neck. The teacher and the nurse suspected child abuse and It should be noted that there are nonethnic cultures such as
reported the family to a social service agency. An investiga- those based on occupation or profession (e.g., culture of nurs-
tion revealed that the mother had rubbed the back of the ing, medicine, or the military); socioeconomic background
little girl's neck with a coin because the girl was not feeling (e.g., culture of poverty or culture of affluence); sexual ori-
well before school. Coining is a traditional form of healing entation (gay, lesbian, or transgendered cultures); age (e.g.,
practiced in Southeast Asia and other parts of the world that Â�adolescent culture or culture of older adults); and ability/
involves vigorously rubbing the body with a coin to rid the disability (e.g., culture of the deaf/hearing impaired or cul-
person of the “bad wind” that is believed to be responsible ture of the blind/visually impaired). Shared life experiences
for causing illness. Among those who embrace explanatory (e.g.,Â€homelessness or surviving a war) are another basis for
models of health and illness involving balance or harmony nonethnic cultures.
(e.g., yin/yang and hot/cold theories), coining is practiced for For community/public health nurses who provide care for
the purpose of restoring balance in the body. The resulting diverse populations, an understanding of the concept of culture
red welts may be mistaken for child abuse by those unfamil- and its importance in health care is paramount. Symbols, gestures,
iar with coining as a cultural healing practice (Transcultural and behaviors are often misunderstood because they have different
nursing, 2012). meanings for the nurse and the client. Failure to effectively com-
municate cross-culturally may lead to serious misunderstandings,
CULTURE: WHAT IT IS frustration, and/or conflict between clients and nurses. For exam-
ple, an Afghani family anxiously awaits the results of the mother's
There are more than 1.8 million websites containing definitions clinical tests. When the nurse comes out to greet the family with
of culture. However, most anthropologists agree that culture is the results of the tests, she smiles broadly and gives the American
dynamic and refers to a group of people who have the following “thumbs up” gesture. The family, horrified, rushes out of the office
characteristics: in distress. In the U.S. culture, the “thumbs up” gesture indicates
• A shared pattern of communication that everything is fine, but in many Middle Eastern cultures, this
• Similarities in dietary preferences and food preparation same gesture is considered a vulgar sign.
Culture affects the manner in which people determine who is Differences between Health Care Provider's and Client's
healthy or sick; what causes health or illness; what healer(s) and Culture or Subculture
intervention(s) are used to prevent and treat diseases and illnesses; Differences between the client's and the provider's cultures or
how long a person has an illness; what is appropriate role behav- subcultures become apparent when the client has traditional
ior in sickness; and when a person is believed to have recovered perceptions, beliefs, and practices that differ from the nurse's
from an illness. Culture also influences the way people receive practices. The community/public health nurse must be sensi-
health care information, exercise their rights and protections, and tive to differences among individuals that may result in practices
express their symptoms and health-related concerns. In some such as coming to the clinic at unscheduled times, inability to
instances, biomedicine can conflict with cultural beliefs concern- describe symptoms accurately, failure to follow treatment plans,
ing health and illness. For example, although an estimated 30% and lack of confidence in the medical system. A client's mis-
of the world population has tuberculosis (TB), in many parts of trust and lack of confidence in the health care system influence
Mexico and Asia, the persistent cough and night sweats associated the client's acceptance of, and participation in, the health care
with the disease are so prevalent that these symptoms are con- planning process. Although nurses may view these behaviors as
sidered normal. Because people fail to recognize that they have noncompliant, these behaviors may have a cultural basis. In one
a disease, they do not seek treatment. Thus, cultural beliefs can study, 51% of physicians surveyed in Los Angeles indicated that
adversely affect large populations because infected individuals their clients do not adhere to treatment because of cultural and
unknowingly transmit the TB bacillus to others. language barriers (Youdelman & Perkins, 2002). Some African
Americans are likely to mistrust the health care system because of
Subcultures the Tuskegee experiments, in which 400 African American men
Subcultures are groups of individuals who, although mem- were denied treatment for syphilis from 1932 to 1972 as part of a
bers of a larger cultural group, have shared characteristics that government study tracking the path of the disease from onset to
are not common to all the members of the larger culture. The autopsy (Bloche, 2001). Other studies reported that fewer than
subculture is a distinguishable group. Such groups and cul- one half of Hispanics and Asian Americans felt confident of their
tural differences within the groups may be based on geography ability to get the needed health care (Collins etÂ€al., 2002).
(north or south, urban or rural), economic status (poor or afflu-
ent), ethnicity, and other factors. For example, persons living in VALUES
Appalachia are a subcultural group based on geographical loca-
tion. Differences can also be found within an identifiable subcul- Values are preferences (or ideals) that give direction to human
ture. For example, Mexican Americans, Puerto Ricans, Cubans, life by influencing beliefs and behaviors. Culture, family, per-
and Central and South Americans are all Hispanics, yet all these sonality, and life experiences contribute to the formation of val-
groups have distinct subcultural patterns that distinguish them ues. Values make us who we are and are important in nursing
from one another. For this reason, the federal pan-ethnic catego- because they have the potential to create barriers or facilitate
ries used in gathering census data and reporting health dispari- communication and relationships between nurses and clients.
ties are sometimes criticized for failing to recognize significant When people interact, as nurses and clients do, their values
intragroup differences. interact. Values influence human behavior, including behavior
Persons acting in a particular social capacity or group related to health and illness; they are the foundation for accep-
can also be considered a subculture. These groups develop tance and participation or rejection and repudiation of health
their own standards of behavior, goals, and values. The nurs- care planning and health care (Andrews & Boyle, 2008).
ing profession and the health care system are examples of Differences in values and customs can be found among cul-
cultures or subcultures that have their own standards and tures. The culture and the society in which the individual lives
beliefs, including the following (Ludwig-Beymer, 2007; or with which he or she identifies strongly influence that per-
Spector, 2004): son's values. Although members of a particular culture tend to
• Standardized definitions of health and illness and the impor- share many ideas and values, differences in values exist within
tance of technology that culture as well. Any assumption on the part of health care
• Health care practices (immunizations, annual physical providers that a given idea or custom is shared by all members of a
examinations, and Papanicolaou [Pap] tests) culture can be dangerously misleading.
• Habits (charting, consistent use of jargon, and a systematic The most prominent values in the United States are reflec-
approach and problem-solving methodology) tive of the dominant white, Anglo-Saxon, Protestant (WASP)
• Likes (promptness, neatness and organization, and adherence) cultural group. Individualism and mastery over nature are
• Dislikes (tardiness, disobedience, and disorganization) American values that permeate many aspects of health care.
• Customs (professional deference and adherence to the Privacy rights and personal freedom are based on the value of
pecking order found in autocratic and bureaucratic sys- individualism. Individuals are responsible for seeking health
tems, hand-washing, and certain procedures regarding care and cooperating with health care providers and for pro-
birth and death) moting their own health and preventing illness. Medicine
• Rituals (performing physical examinations, taking the com- attempts to control disease and distress, which is represented in
munity health nurse's bag when making home visits, and such aggressive terms as conquering cancer and fighting tuber-
completing lengthy, detailed paperwork associated with new culosis. Scientific knowledge, sophisticated technologies, and a
case openings) belief in intervention and mastery over problems, not a fatal-
• Expectations about pain (self-control, ability to provide istic submission to illness, are evident in health care practice.
detailed descriptions, and denial or downplaying of the pain Other significant and dominant U.S. values include materialism
observed in others) (importance of possessions and money), reliance on Â�technology,
orientation to instant time and action, emphasis on youth, and Had the nurse been aware of the value placed by the gypsy
less respect for authority and older adults. (Roma) group on providing support to members in crisis, the
In some of the cultures and subcultures in the United States, nurse might have anticipated a large gathering and preplanned
however, individualism is not a primary value. Belonging to family accordingly. In such a situation, the nurse might acknowledge the
and community is more important. Personal privacy may not be family's need for closeness and negotiate a reasonable limit on the
that important; rather, sharing of information and family or group number of people in attendance. The nurse might identify suit-
participation in the decision-making process may be of greater able accommodations for the remainder, for example, alternate
value. Health may or may not be a primary value. Acceptance of family members between the hospital room and the cafeteria.
health conditions, rather than seeking interventions aimed at curing TableÂ€10-1 provides a sample list of cultural values for select
or fixing the problems, may be more important. The meaning of ill- cultures and identifies some implications for nurses providing
ness and differences in Â�client–provider cultural and subcultural health care to these populations.
Â�values may become evident during client–provider interactions.
RACE
One member of a gypsy (Roma) family became ill and was
The concept of race is separate from the concept of ethnicity,
seen at a clinic. When the seriousness of the problem was
although the terms are often used interchangeably. Race has
made known, all members of the community came to the
traditionally referred to a group of individuals who share com-
clinic to support the family. The nurse, unprepared to receive
mon biological features. Nonetheless, race as a valid biologi-
a large number of visitors and family members, informed the
cal concept is being challenged, and many people have called
family members that they would not all be permitted to wait
for abandoning the concept of race altogether (Fullilove, 1998;
in the building (space constraints, noise, and privacy of other
Osborne & Feit, 1992). The Human Genome Project, an exten-
clients were concerns). The family members became enraged,
sive worldwide gene-mapping project, has determined that
refused to leave, and demanded that they be accommodated.
although clear differences in appearance are sometimes evident,
TABLEÂ€10-1â•…â•‡CULTURAL VALUES FOR SELECT GROUPS—IMPLICATIONS FOR

COMMUNITY/PUBLIC HEALTH NURSES
CULTURAL VALUES HEALTH CARE IMPLICATIONS
Anglo American Culture
(Mainly U.S. Middle and Upper Classes)
1. Individualism—focus on self-reliance 1. Stress alleviation by physical and emotional means
2. Independence and freedom 2. Personalized acts (e.g., doing special things or giving individual attention)
3. Competition and achievement 3. Self-reliance (individualism) by reliance on self, self-care, independence, or
reliance on technology
4. Materialism (things and money) 4. Health education: desire to be given the medical facts on how
5. Technology dependent to care for self
6. Instant time and actions
7. Youth and beauty
8. Equal gender rights
9. Leisure time highly valued
10. Reliance on scientific facts and numbers
11. Less respect for authority and older adults
12. Generosity in time of crisis
Mexican American Culture

1. Extended family valued; children highly valued 1. Succorance (direct family aid)
2. Traditional family is foundation of society 2. Involvement with extended family
3. High respect for authority and older adults 3. Filial love or loving; touching
4. Religion is major influence on health care practices and beliefs 4. Respect for authority
5. Food is primary form of socialization 5. Mother as care decision maker
6. Traditional folk-care healers for folk illnesses 6. Protective male care
7. Belief in hot and cold theory of disease prevention 7. Acceptance of God's will
8. Use of folk-care practices
9. Healing with foods
Haitian American Culture

1. Extended family as support system 1. Involve family for support
2. Religion—God's will must prevail 2. Respect and trust
3. Reliance on folk foods and treatments 3. Succorance
4. Belief in hot and cold theory 4. Spiritual healing and touching
5. Male decision makers and direct caregivers 5. Use of folk food
6. Reliance on native language 6. Avoid evil eye and witches
TABLEÂ€10-1â•…â•‡CULTURAL VALUES FOR SELECT GROUPS—IMPLICATIONS FOR

COMMUNITY/PUBLIC HEALTH NURSES—CONT'D
CULTURAL VALUES HEALTH CARE IMPLICATIONS
African American Culture
1. Extended family networks and respect for older adults 1. Concern for brothers and sisters
2. Religion and religious behavior valued 2. Being involved
3. Interdependence with other African Americans for daily survival 3. Giving physical presence; touching appropriately
4. Technology valued (e.g., radio, car) 4. Family-support and family-centered activities
5. Folk (soul) foods and folk medicine or healing models 5. Reliance on home remedies
6. Music and physical activities 6. Rely on Jesus to save us with prayers and songs
American Indian Culture

1. Harmony with nature (land, people, environment) 1. Establishing harmony with people, the environment
2. Giving back or reciprocity with Mother Earth 2. Actively listening
3. Spiritual inspiration; religion as a way of life 3. Using silence (“Great Spirit”) as guidance
4. Folk healers (shamans) (the circle and four directions) 4. Rhythmic timing based on the harmony among nature, the land, and people
5. Practice culture rituals and taboos 5. Respect for folk healers, caregivers, and curers
6. Rhythmicity of life and nature 6. Maintaining reciprocity
7. Authority of tribal elders; respect and value for children 7. Preserving cultural rituals and taboos
8. Pride in cultural heritage and nations 8. Respect for older adults and children
Asian and Pacific-Islander Culture

1. Family—large extended family networks, hierarchical 1. Succorance (direct family aid) and involvement with extended
structure,Â€loyalty family
2. Devotion to tradition 2. Preserving cultural traditions
3. Many religions, including Taoism, Buddhism, Islam, and 3. Respect for authority and folk healers
Christianity
4. Use of silence, nonverbal and contextual cueing 4. Hospital equals an alien place
5. Prefer less physical contact 5. Touching is inappropriate
6. Use of herbal remedies, acupuncture, moxibustion 6. Cupping (creating a vacuum in glass and placing over skin surface), bleeding
(with leeches), and massage (pushing and pulling)—often used in remedies
7. Belief in yin and yang—everything in the universe contains 7. Illness is the disharmony of yin and yang
twoÂ€aspects, which are in opposition and also in unison 8. Respect for older adults and children
Data compiled from Andrews, M., & Boyle, J. (2003). Transcultural concepts in nursing care (4th ed.). Philadelphia: Lippincott, Williams & Wilkins;
Lipson, J., Dibble, S., & Minarik, P. (1996). Culture and nursing care: A pocket guide. San Francisco: University of California, San Francisco Press;
Purnell, L., & Paulanka, B. (2003). Transcultural health care—A culturally competent approach. Philadelphia: F. A. Davis; and Spector, R. E. (2004).
Cultural Diversity in health and illness (6th ed.). CT: Appleton-Lange.
no genetic differences exist among races. In other words, the forms, material culture such as clothing and food, and cultural
minute Â�differences among gene types are as much the result products such as music, literature and art” (Smedley etÂ€al., 2003,
of differences among members of the same race (white versus p. 523). Ethnicity provides a sense of social belonging and loy-
white, black versus black) as of differences between races (white alty, and each of us belongs to an ethnic group of one kind or
versus black versus Asian). another. One of the most important characteristics of ethnicity
Despite the scientific evidence, racial and ethnic distinctions is that it provides a sense of belonging or identity.
are reflected in the formal reporting and presenting of federal As noted earlier, ethnicity is commonly used interchange-
health and vital statistics data. Although both terms are impor- ably with race, although differences between the terms do exist.
tant determinants in collecting data and presenting health sta- Federal documents and reports delineate data by four major
tistics, the concept of race as used by the U.S. Census Bureau racial groups: (1) American Indian, including Alaska Natives,
reflects self-identification by people indicating the race or Eskimos, and Aleuts; (2) Asian Americans and Pacific Islanders;
races with which they feel most closely related, and this clas- (3) blacks; and (4) whites; and by one ethnic group, Hispanics,
sification includes both racial and national-origin groups. The under the combined term racial and ethnic groups. Hispanics
racial classifications that the U.S. Census Bureau uses adhere to create a conundrum for census takers because they are consid-
the October 30, 1997, Federal Register notice entitled Revisions ered to belong to either of two racial groups. Some Hispanics are
to the Standards for the Classification of Federal Data on Race considered black and some white. Data are sometimes collected
and Ethnicity, issued by the Office of Management and Budget. by ethnic distinction alone—Hispanic and non-Â� Hispanic—
These classifications are presented in BoxÂ€10-1. in which case, most people of various races fall into the non-Â�
Hispanic category. Data are sometimes collected by race and
ETHNICITY ethnic groups. When this distinction is made, Hispanics are
listed as an ethnic group, and members of black and white racial
Ethnicity refers to a “shared culture and way of life, especially as groups who are not Hispanic are listed as black non-Hispanic
reflected in language, folkways, religious and other institutional or white non-Hispanic. Collecting data by racial and ethnic
categories is considered important in health care because Â�certain BOXÂ€10-2â•…â•‡SELECTED HEALTH CARE
groups tend to be more resistant or vulnerable to specific health DISPARITY STATISTICS FOR
problems. The collection and value of such data for health care
THE UNITED STATES
professionals will diminish as groups intermarry and their progeny
become increasingly multiracial. Selected health measures that were worse for Hispanics
Because the terms race and ethnicity are often used inter- andÂ€blacks compared with non-Hispanic whites, 2010
changeably, community/public health nurses must understand • Cancer: Adults age 50â•›years and over who ever received colorectal
the distinctions between the terms. Nurses should avoid label- cancer screening
ing clients by using skin markers or other features as identifiers • Mental Health: Adults with major depression episode in the last
and classifying individuals on the basis of group association. In 12â•›months who received treatment
some instances, knowing the client's race or ethnic type is help- • Timeliness of care: Adults who need care right away for illness
ful in identifying individuals and groups at increased risk for and can get care as soon as wanted
certain diseases, recognizing normal and abnormal biocultural Selected health measures that were worse for Hispanics
variations in the physical assessment, and evaluating clients’ compared with non-Hispanic whites, 2010
responses to certain medications. The most appropriate way to • Diabetes: Adults 40â•›years and over with diagnosed diabetes who
determine the client's racial or ethnic identity is to ask, “How do received three recommended screenings in the past year: at least
you identify yourself?” one hemoglobin A1c test, a retinal eye examination, and a foot
examination
• Patient Centeredness: Adults and children with ambulatory visits
RACIAL AND ETHNIC HEALTH AND HEALTH CARE
who reported poor communication with health care providers
DISPARITIES
Selected health measures that were worse for blacks
Disparities in health and health care exist across the spec- Â�
compared with non-Hispanic whites, 2010
trum of racial and ethnic groups and involve a range of • Cancer: Breast cancer diagnosed at advance stage per 100,000
health concerns (BoxÂ€10-2). Health disparities are differ- women age 40â•›years and over
ences or inequalities in health status, including differences • Dental: Children age 2 to 17 who had a dental visit in the last
in life expectancy, mortality, and morbidity. Healthy People Â�calendar year
2020 states that health disparities are “a particular type of
Data from USDHHS Agency for Healthcare Research and Quality.
health difference that is closely linked with social, eco-
(2011). 2010 National healthcare disparities report. Retrieved
nomic, and/or environmental disadvantage. Health dispari- September 28, 2011 from http://www.ahrq.gov/qual/qrdr10.htm.
ties adversely affect groups of people who have systematically
experienced greater obstacles to health based on their racial
or ethnic group; religion; socioeconomic status; gender; age;
mental health; cognitive, sensory, or physical disability; sex- not available, the higher incidence of diabetes and liver Â�disease
ual orientation or gender identity; geographic location; or in these populations increases the likelihood that they will live
other characteristics historically linked to discrimination or fewer years (Indian Health Service, 2012; Office of Minority
exclusion” (U.S. Department of Health and Human Services Health, 2007a, 2007b).
[USDHHS], 2010). Most racial and ethnic minority groups have higher infant
Although significant progress has been made in improv- mortality rates; higher rates of death from cancer, heart dis-
ing life expectancy and overall indicators of health, health ease, diabetes, human immunodeficiency virus (HIV) infec-
disparities have persisted. The objectives set forth in Healthy tion, and acquired immunodeficiency syndrome (AIDS);
People 2020 (USDHHS, 2010) were designed to increase more chronic and disabling diseases; and lower immuniza-
quality and years of healthy life and eliminate health dis- tions rates. For example, African American, American Indian,
parities for each of the ethnic minority groups. Although and Puerto Rican infants have markedly higher death rates
significant progress has been made in reducing some health compared with white infants. For the past two decades, there
disparities, there is compelling evidence that race and has been a widening disparity between African American and
ethnicity correlate with persistent and often increasing white infant death rates. African American women are more
health disparities among multiple racial and ethnic minority than twice as likely to die of cervical cancer compared with
groups at all stages ofÂ€life. white women and more likely to die of breast cancer compared
Life expectancy rates are often considered reflections of with women of any other racial or ethnic group. Although
the overall health of a population. Since the beginning of the heart disease and stroke are the leading causes of death among
twentieth century, life expectancy at birth has increased from all racial and ethnic groups, death rates for heart disease are
less than 50â•›years to more than 77.8â•›years. Life expectancy at 20% higher and death rates for strokes are 40% higher among
birth increased gradually for whites and blacks of both genders African American adults than among white adults. American
from 2000 through 2009. During this period, life expectancy Indians and Alaska Natives are 2.6 times more likely to have
increased the most for black males (2.7â•›years) and black females diabetes, with the incidence of non–insulin-dependent dia-
(2.3â•›years) but also for white males (1.5â•›years) and white females betes mellitus being as high as 60% in some Indian nations.
(1â•›year). Life expectancy reached a record high for whites of Compared with their white Â�counterparts, African Americans
both genders in 2009; for blacks of both genders, it remained are 2 times and Hispanics 2.9 times more likely to have been
unchanged from 2008 to 2009 (Centers for Disease Control and diagnosed with diabetes (CDC, 2006; Indian Health Service,
Prevention [CDC], 2010). Although current life expectancy 2012; Office of Minority Health, 2007b; Smedley etÂ€al., 2003;
data for Hispanics and American Indians/Alaska Natives are USDHHS, 2001a).
Some minority populations experience problems with access environment, and specific individual health behaviors and
to and quality of health care services. Research indicates that beliefs play a role in the problem. A complex and fragmented
some minority individuals, groups, and communities receive health care environment makes receiving continuity of care
a lower quality of health care than do nonminority ones, even difficult for people. Managed care and Medicaid managed
when insurance status, income, age, and severity of conditions care plans often disrupt community-based care and displace
are equal (CDC, 2006; Office of Minority Health, 2007a, 2007b; providers who are familiar with the culture and values of an
Smedley etÂ€al., 2003). ethnic community. Language barriers contribute to the prob-
Health care disparities (emphasis added) may be defined as lem, especially when care providers are unfamiliar with the
“racial or ethnic difference in the quality of health care that are language spoken by their clients. Geographically distant clin-
not due to access related factors or clinical needs, preferences, and ics and hospitals pose access problems, especially for eco-
appropriateness of intervention” (Smedley etÂ€al., 2003, pp. 3-4). nomically stressed families without transportation. Some
The occurrence of many illness and other health prob- American Indians are required to travel more than 90 miles
lems is disproportionally higher in some racial and ethnic one way to obtain care at Indian Health Service facilities, and
groups in the United States; access to health care may be more the wait ranges from 2 to 6â•›months for appointments in cer-
restricted. In populations with equal access to health care, dis- tain specialties such as obstetrics/gynecology and outpatient
parities exist because of the operation of the health care sys- mental health (Agency for Healthcare Research and Quality,
tem and discrimination, biases, stereotyping, and uncertainty 2005; Government Accountability Office, 2005; Indian Health
of the clinicians (Smedley etÂ€al., 2003). For example, African Service, 2007).
Americans have the highest incidence of end-stage renal dis-
ease but are less likely to receive renal dialysis, be referred for ROLE OF INSURANCE IN HEALTH DISPARITIES
transplantation, or receive a kidney transplant. Hispanic and
African Americans are less likely to receive evidence-based With 17.6% of the national gross domestic product (GDP) allo-
mental health care in accordance with professional treatment cated to health care in 2009, the United States leads the world
guidelines, and more than one fourth of Asian Americans in health care spending (Centers for Medicare and Medicaid,
report experiencing difficulty in accessing specialists (CDC, 2011). And yet, nations spending substantially less sometimes
2006; Office of Minority Health, 2007b; Smedley etÂ€al., 2003; have healthier populations than the U.S. population. The U.S.
USDHHS, 2001b). performance is adversely affected by deep inequalities linked to
Even when conditions are comparable (e.g., comparable income and health insurance coverage. The United States is the
insurance status, educational level, income level, access to health only Western industrialized nation without a universal health
care professionals), minority members are less likely than whites insurance system. Instead, the United States relies on employer-
to receive appropriate treatment or surgical procedures. African based private insurance and public coverage that fail to reach
Americans are more likely to be diagnosed as psychotic but are all citizens, with minority populations being at higher risk than
less likely to be given antipsychotic medicines and more likely whites for being underinsured or uninsured (see ChapterÂ€21).
to be hospitalized involuntarily, to be regarded as potentially Although more than one half of the U.S. population has health
violent, and to be placed in restraints (Agency for Healthcare insurance coverage through their employers and nearly all
Research and Quality, 2005; CDC, 2006; George, 2000; Office of older adults are covered through Medicare, more than 1 in 6
Minority Health, 2007b; Polyakova & Pacquiao, 2006; Smedley Americans who are not older adults (49.9 million) lack health
etÂ€al., 2003). insurance (U.S. Census Bureau, 2011a) (FigureÂ€10-2). Lack of
A wide array of factors contributes to health Â�disparities. health insurance among vulnerable populations contributes to
Patterns of segregation and discrimination, the health care poorer access to health care and ultimately to health disparities.
40
30
Percent
20
10
0
Hispanic** American Hawaiian Black Asian White
Indian* and other
Pacific Islander
* Includes Alaskan Native.

** Hispanic may be of any race.
FIGUREÂ€10-2â•‡ Rate of uninsured by race and ethnic group, United States, 2010. (Data from U.S.
Census Bureau. [2011]. Income, poverty and health insurance coverage in the United States: 2010. Retrieved
September 24, 2011 from http://www.census.gov/hhes/www/hlthins/hlthins.html.)
Hispanic Americans are almost three times more likely to be People in other parts of the world perceive time differently.
uninsured compared with whites (31% versus 12%), whereas They view time as being circular (continuous and never end-
21% of African Americans are without health insurance. The ing). Time may be seen as a gift to be enjoyed rather than a
cost of treatment is a major barrier to health care access in the limited commodity to be used. People with this view of time
United States. may not have or use a watch, may not be concerned about
More than 40% of the uninsured have no regular health care punctuality, and may not feel stressed to do chores at a set
facility to go to when they are sick, and more than one third time. If time is a gift to be enjoyed, practically anything may
of the uninsured report that they or someone in their family take precedence over a clinic appointment, a nurse's visit, or a
went without needed care or prescription medicines because of day at school or work.
cost (Government Accountability Office, 2005; Kaiser Family Individuals and groups also differ in time orientation with
Foundation, 2010; Rowland & Hoffman, 2005; U.S. Census regard to health planning. Cultural groups with a past-time
Bureau, 2011a). orientation, for example, many Asian Americans, tend to lean
toward traditional approaches to healing. Persons with a pre-
STRATEGIES FOR ELIMINATING HEALTH dominantly present-time orientation, for example, African
Americans, Native Americans, and Hispanics, may be less able
DISPARITIES to look toward the future and practice preventive health mea-
Eliminating health disparities is one of four major goals of the sures. Pain, dysfunction, or limitations cue the search for treat-
Healthy People 2020 objectives (USDHHS, 2010). The objectives ment. If these cues are absent, a present-orientated person might
are especially focused on eliminating health disparities by 2020 not appreciate the need for treatment to avoid a future conse-
in key areas that cut across different racial and ethnic groups: quence. For example, a middle-aged African American woman
• Infant mortality with hypertension may be unable to see the need for controlling
• Cancer blood pressure through medication to prevent a future problem
• Heart disease such as stroke. By contrast, the middle-class white American cul-
• Diabetes ture tends to be future oriented as reflected by its emphasis on
• HIV infection and AIDS punctuality, technology, and prevention. Time is structured and
• Immunizations scheduled, including leisure time, which is often planned ahead.
Federal and state governments, as well as Â�nongovernmental Community/public health nurses and other health care pro-
health organizations, are committed to reducing health dis- fessionals should be aware that clients may have a time perspec-
parities in the U.S. population (USDHHS, Office of Minority tive that is different from their own. Some African Americans
Health, 2010b). Website Resource 10A provides a detailed and Mexican Americans believe that time is flexible and that
list of recommended strategies to reach this goal. Community/Â� activities will start on their arrival. There is no need to rush to an
public health nurses need to be aware of health disparities appointment; a delay is acceptable. If this perception is the usual
among and within racial and ethnic groups. All nurses should one in the community, community/public health nurses should
be aware of barriers to achieving optimal health and methods to incorporate this information in planning program activities.
facilitate attaining culturally competent health care for everyone. How human beings view and structure space differs among
Recognizing cultural differences is the first step. cultures in ways that are as profound and important as are the
differences in how time is viewed and structured. Space is linked
UNDERSTANDING CULTURAL DIFFERENCES with issues of territoriality, living, work and health care arrange-
ments, touch, sound, and smell. Space as a physical boundary or
Different cultures have different views and perspectives regard- territory is an important concept; just as animals protect their
ing everyday concepts and normal behavior. Understanding territory, so do humans (Giger & Davidhizar, 2004; Leininger &
the essential characteristics and differences that give each com- McFarland, 2006).
munity its uniqueness and recognizing the different meanings Culture determines the amount of personal space an indi-
of some key concepts in different cultures is useful for nurses vidual requires. Some cultures are comfortable with very little
who practice in multicultural health care settings (Andrews & distance between people; others are more comfortable with a
Boyle, 2008; Galanti, 2004; Giger & Davidhizar, 2004; Leininger separation of several feet. When individuals from different
& McFarland, 2006; Purnell & Paulanka, 2008; Spector, 2008). cultures interact, one may violate the other's personal space.
Standing too close to another person can precipitate feelings of
Time and Space anger or fear in the person who feels that his or her space is
People perceive and use time in different ways: linear or circu- invaded. Hall (1963) identified four different relational spaces:
lar. A linear view sees time as a straight line with a beginning • Intimate distance ranges from 0 to 18 inches and is used
and an end. A circular view sees time as a never-ending unity when performing close physical assessments such as eye
that repeats itself and is part of a continuous whole. Western examinations.
health care providers tend to view time in a linear way, divided • Personal distance varies from 18 inches to 4 feet, the usual
into segments of minutes, hours, days, weeks, and so on. In the space within which communications between friends and
United States, we wear watches, and our watches are synchro- acquaintances, as well as certain aspects of the physical
nous with those of others. Our work day begins and ends at examination, occur.
a specific time. We keep appointments on time. Because time • Social distance is from 4 to 12 feet, the space in which small
is money and is in limited supply, we are urged to both work group interaction may occur.
and play rapidly, accurately, and smartly. We admire people who • Public distance is considered anything further than 12 feet and
make good use of their time and control their time well. is used in conducting workshops and community meetings.
The distance in each relational space varies widely, depend- All other (7.6%)
ing on the cultural group's spatial orientation. Spanish or
In some cultural groups, persons who own land mark their Spanish Creole
properties with fences to separate them from those of their (12.2%)
neighbors. Some cultures perceive land as belonging to every-
one and to no one in particular and would not think of put-
ting up fences. Some cultures value uniformity; others value
diversity. Although the United States places great emphasis
on individual freedom and creativity, many U.S. towns have
covenants that restrict the individual's right to alter his or her
property in any visible way that is unacceptable to the com- English (80.2%)
munity in general.
How people construct and use public space is an impor-
tant consideration when nurses conduct community meet- Note: Percentage distribution of persons 5 years and older.
ings. Various cultural groups perceive space as more or less Chart below indicates Other and Spanish expanded to show specific
formal, which can create problems among them. For example, languages spoken and frequency.
in one nursing home, Americans of African descent used the A
shared lobby on each floor as formal public space and dressed
accordingly. Americans of European descent, in contrast, used Spanish/Spanish Creole 62.0%
the shared space informally, wearing slippers, robes, and even French/French Creole 3.5%
hair curlers. Italian 1.4%
When in a client's home, the nurse is a guest and must be German 2.0%
aware of how space is structured and used in that home. Some Russian 1.5%
rooms in the house may be reserved only for family and close Polish 1.1%
friends, and the nurse must be aware of cues regarding public Chinese 4.4%
and private space. In working with people from a culture that is
Korean 1.9%
different from his or her own, the nurse has an obligation to dis-
Vietnamese 2.2%
cover how, in general, the client's cultural group perceives and
Tagalog 2.7%
uses space and how to recognize limit-setting cues.
Unspecified and Other 14.6%
Communication Arabic 1.4%
Communication is an essential component of any nurse–client African languages 1.3%
interaction. The effectiveness of communication depends on 0 5 10 15 20 25 30 35 40 45 50 55 60 65
each party's clear understanding of the meaning of each mes- B Percentage
sage. The process of communication includes both verbal and FIGUREÂ€10-3â•‡A, Language spoken at home, 2008; data in pie
nonverbal components and may be influenced by hierarchic chart form. B, Bar graph showing data as percentage speak-
relationships, gender, and religion. ing Spanish and other languages. (Data from U.S. Bureau of the
Census. [2010]. Detailed list of languages spoken at home for the popu-
Verbal Communication lation 5â•›years and over by state: 2010. Retrieved August 12, 2011 from
Language is an important tool in nursing and in establishing a http://www.census.gov/prod/cen2010/doc/sf3.pdf; and U.S. Census
Bureau. [2011]. Statistical abstract of the United States: 2011. TableÂ€53.
nurse–client relationship. The gathering of accurate information
Languages spoken at home. Retrieved September 26, 2011 from http://
related to health care beliefs, illness, and care measures is critical. www.census.gov/compendia/statab/2011/tables/11s0053.pdf.)
Ineffective communication may lead to misunderstandings. These
misunderstandings may result in failure to identify and access
existing health services; difficulty with appointment scheduling; Cultural and Linguistic Competence. Cultural and linguistic
inaccurate or incomplete information relevant to health status; competence refers to the ability of health care providers and
and inappropriate follow-up and follow through with recom- organizations to understand and respond to the cultural and lin-
mended treatment. Ineffective communication can result in client guistic needs of clients during health care encounters. Laws and
dissatisfaction with health care services and reluctance to return to federal guidelines pertaining to provision of language services,
the health care setting (cf. Andrews & Boyle, 2008; Galanti, 2004; means of accessing language services, and the appropriate use of
Giger & Davidhizar, 2004; Leininger & McFarland, 2006; Munoz language services are essential information for the community/
& Luckman, 2005; Purnell & Paulanka, 2008; Smedley etÂ€al., 2003; public health nurse. In response to the need to facilitate cultur-
Spector, 2008; Wilson-Stronks & Galvez, 2007). ally competent health care, the Office of Minority Health pub-
Language barriers are one of the greatest obstacles to health lished National Standards for Culturally and Linguistically
care among culturally diverse groups. In the United States, Appropriate Services (CLAS) to be implemented in health care
approximately 56 million people speak a language other than settings (USDHHS, 2001a). These standards provide a blueprint
English at home, and at least 39 different languages are in use for organizations to follow in building cultural and linguistic
(FigureÂ€10-3). Approximately 35 million are speakers of Spanish, competence in their workforces and organizations. BoxÂ€10-3
and of those, approximately 14 million report that they speak summarizes the sections relating to direct client–Â�provider con-
English less than very well (U.S. Bureau of the Census, 2010b; versations. The complete CLAS standards are available on the
U.S. Census Bureau, 2011b). book's website as Website Resource 10B.
BOXÂ€10-3â•…â•‡SAMPLES FROM THE Community/public health nurses who routinely care for
RECOMMENDED STANDARDS clients with English language difficulties should be prepared
in advance if no interpreters are available. The best strategy is
FOR CULTURALLY AND
for the nurse to become proficient in the language of the cli-
LINGUISTICALLY APPROPRIATE
ents. Another strategy is the use of a word board or index cards
SERVICES (CLAS) IN HEALTH with essential words or phrases in the client's own language. For
CARE example, “Where is your pain?” or “When did it start?” Hand
• Clients or consumers receive from staff effective, understandable, motions, miming, or simple touch may be the only available
and respectful care provided in a manner compatible with their cul- methods of communication; however, these methods are more
tural health beliefs and practices and preferred language. error prone than are cards or word boards.
• A diverse staff representative of the demographic characteristics of Using a considerate approach, addressing the client by for-
the service area is recruited, retained, and promoted. mal name, showing genuine warmth, and taking time to estab-
• Staff receives ongoing education and training in culturally and lin- lish trust are important. Clients from minority groups cite the
guistically appropriate service delivery. lack of time and attention given by health care professionals as
• Language assistance services are offered and provided at no cost to one of the most important reasons for their lack of trust in the
each client or consumer with limited English proficiency. health care system (Government Accountability Office, 2005;
• The competence of interpreters and bilingual staff providing lan- Kaiser Family Foundation, 2010). The nurse may wish to start
guage assistance is ensured. with safer topics, use open-ended formats, and elicit opinions
• Easily understood client-related materials are made available and and beliefs to begin the dialogue. Nonverbal clues and specific
signs are posted in the languages of the commonly encountered behavior during conversations should be noted. The diversity of
groups.
voice volume and tone used by different cultural groups should
Data from Federal Register, 65(247), 80865–80879. be appreciated. Anglo Americans and African Americans may
be perceived as loud and boisterous because of their voice vol-
ume. African Americans who speak black English, Gullah (a
Linguistic competence is addressed by four of the stan- Creole blend of Elizabethan English and African languages),
dards. CLAS standards require health care organizations to or other African dialects exclusively may be misunderstood
offer language assistance services free to each client or con- as being poorly educated or unintelligent (Campinha-Bacote,
sumer with limited English proficiency. Bilingual staff and 1998). Gypsy language tone is normally loud and argumenta-
interpreter service are preferred. Other options include face- tive, even in normal conversation. Arab Americans tend to use
to-face interpretation provided by trained staff or contract or an excited speech pattern that may be misunderstood as anger; a
volunteer interpreters. loud voice may merely indicate the importance of the message.
Community/public health nurses must establish an effec- The Chinese language is very expressive and may come across as
tive means of communication with individuals with limited loud and abrupt to others (Chin, 1996).
English proficiency. The use of interpreters and interpreter Health Literacy Skills. Health literacy skill refers to the ability
services is one means. However, the interpreter–client inter- to read and understand instructions on prescription and medi-
change may be affected by differences in dialects within the cine bottles, appointment slips, informed consent documents,
same regions; cultural, political, or religious rivalry between insurance materials, and client educational materials. Health
tribes, nations, regions, or states; and age, gender, and socio- illiteracy is a frequently overlooked and underemphasized bar-
economic status. For example, a client and an interpreter rier to health care in racial and ethnic minority populations
both come from Laos; however, one is Hmong and the other (Burroughs etÂ€al., 2002). An estimated 90 million American
is not. Because of their different tribal affiliations, each views adults possess low health literacy skills. Low literacy is more fre-
the other with suspicion, which makes the interpretation quently noted among persons of low socioeconomic status, the
process difficult. poorly educated, older adults, U.S.-born ethnic minority per-
Issues of status, age, gender, and privacy must be consid- sons, immigrants, and persons who are disabled. Low health lit-
ered when selecting an interpreter. For example, in some cul- eracy continues to be a barrier for racial and ethnic minorities.
tures, conversations between unrelated men and women are (See ChapterÂ€20 for ways to determine and reduce the reading
strictly regulated or forbidden. All attempts should be made to level of health materials.)
choose interpreters with characteristics as close as possible to The CLAS standards require that organizations provide edu-
those of the client. If a formal interpreter is not readily avail- cational materials and forms in the commonly encountered
able, telephone services are acceptable. Telephone services pro- languages. Community/public health nurses must ensure that
vide interpreters for most languages. The nurse and client speak materials in alternative formats are developed for individu-
into separate telephones, and the interpreter translates for each als who cannot read or who speak nonwritten languages (e.g.,
party. Accurate interpretation of client responses is critical. The sign language) and for persons with sensory, developmental,
CLAS standards require that organizations ensure the compe- or cognitive impairments. Title VI of the Civil Rights Act of
tence of interpreters. Family or friends should not be used as 1964 requires that all organizations that receive federal finan-
interpreters except in emergencies or at the specific request of cial assistance ensure that persons with limited English profi-
the client. Using family members or friends would cause breach ciency have meaningful linguistic access to the health services
of confidentiality, and these individuals may not give an impar- that these organizations provide (USDHHS, 2001a).
tial interpretation of the intended message. Minor children Community/public health nurses must perform an adequate
should not be used as interpreters, even in situations in which assessment of literacy skills to reduce the potential for medi-
the clients are their parents. cal errors caused by a client's language difficulties. Developing
Â�
client educational materials that are culturally congruent with done only with the permission of the parent. An alternative
the target population and at an appropriate reading level is method would be to make other observations to assess for
important. Many of the educational materials that are specifi- increased intracranial pressure or premature fontanel closure
cally targeted at minorities do not reflect the cultural values of while the parent holds the child on his or her lap. The nurse
the targeted groups, and few are written at a reading level suit- might place his or her hand over the mother's hand on the
able for persons with low literacy skills. Test of Functional Health fontanels while asking for a description for what the mother
Literacy in Adults (TOFHLA) is a tool that helps assess a cli- feels (Andrews, 2008).
ent's ability to perform health-related tasks that require reading Silence. Use of silence as a communication element varies
and computational skills, such as taking medications, keeping across cultures. Silence may indicate approval, disapproval, a
appointments, appropriately preparing for tests and proce- lack of understanding, respect, or disrespect. In Asian cultures,
dures, and giving informed consent. silence may indicate respect for elders. Silence and nodding
during the nurse–client interaction must be carefully evaluated
Nonverbal Communication because understanding or agreement of the message may or
Nonverbal communication patterns are important to the com- may not necessarily be conveyed. Silence and nodding may
munication process. Nonverbal communication patterns vary mean, “Yes, I hear you,” “Yes, we are interacting,” or some other
widely among cultures and ethnic groups. Understanding and message. For example, some American Navajos are comfort-
appropriate use of touch, silence, eye contact, greetings, and able with long periods of silence because active listening dem-
body language are vital to the nurse–client interaction. The onstrates an interest in what an individual is saying. Responding
nurse's capacity to assist the individual, family, and community with quick answers may suggest immaturity on the part of the
to reach the desired health outcomes may be impaired by his or client. Nurses need to provide ample time for older Navajos to
her inability to understand and accurately interpret the non- respond to questions and allow more silent time than the nurse
verbal patterns of the ethnic and cultural groups that he or she might ordinarily use in conversation (Still & Hodgins, 1998).
serves (cf. Munoz & Luckman, 2005; Purnell & Paulanka, 2008; Silence may indicate agreement or disagreement. For example,
Spector, 2008; Wilson-Stronks & Galvez, 2007). in French, Spanish, and Russian cultures, silence may be inter-
Touch. Use of touch in the communication process is cultur- preted as a sign of agreement; in Vietnamese cultures, in which
ally dependent and varies significantly from culture to culture. direct expressions of emotion are considered bad taste, silence
Some cultures seek bodily contact; others carefully avoid con- may mean “no” (cf. Andrews & Boyle, 2008; Galanti, 2004;
tact. For example: Munoz & Luckman, 2005).
• Greetings among many Americans include traditional hand-
shakes or hugging. An African American woman was being interviewed to
• Among Native American Navajos, touch is unacceptable determine suitable home health services. As the nurse ques-
except when one knows the person well or when it is part of tioned the client regarding support from her spouse, the
therapeutic treatments (Still & Hodgins, 1998). client remained silent. The nurse interpreted this silence as
• For Nigerian Americans, touching or casual hand holding indicating a possible situation of domestic disharmony. She
between members of the same or opposite sex usually signals continued the interview while assuring the client that she
friendship (Andrews & Boyle, 2008). could feel comfortable sharing any information relative to
• In some Middle Eastern cultures, women do not shake hands domestic problems. The client finally responded sharply,
with men, nor do men and women touch each other outside “That's none of your business,” indicating that she thought
of marriage (Andrews & Boyle, 2008). the discussion was inappropriate.
• Afghan and Afghan American extended family members and
close friends often touch each other on the shoulder or leg The preceding clinical example provides several points to
during conversations and greet with a kiss on each cheek or a ponder. Questions about interpersonal relationships are often
hug (Lipson etÂ€al., 2004). considered an intrusion into an individual's privacy. Spousal
Understanding the relevance of touch is important for the support (financial) may prevent families from accessing vari-
community/public health nurse because touch is part of the ous community and federal programs. If the nurse understands
process of providing health care. Nurses should be sensitive to these points, he or she can attempt to put the client at ease by
and accommodate, whenever possible, cultural and ethnic dif- opening the discussion with an explanation of the types of ques-
ferences in patterns of touch. For example: tions to be asked and the reason for asking them. For example,
• Examining the genitalia (and discussing reproduction) may “To better help you and your family, I will need to ask you a
be embarrassing to persons from some cultural groups, and list of questions to best determine which types of resources and
Chinese Americans, Hispanics, Muslims, and individuals supports are available to you.”
from other racial, ethnic, and/or religious groups may prefer Eye Contact. Eye contact is one of the most important non-
same-sex health care providers. verbal communication tools and can easily be misinterpreted.
• In some Arab and Hispanic cultures, male health care pro- Nurses use direct eye contact during interpersonal contact with
viders are prohibited from examining all or parts of the clients. Clients from different countries and different cultural
female body (Purnell & Paulanka, 2008; Spector, 2008). backgrounds may be less comfortable with direct eye contact,
Touching children is of particular concern. For example, depending on the degree of acculturation, length of time in
in Asian cultures, touching a child on the head may be inter- America, age, and education. For example:
preted as a sign of disrespect because the head is thought to • Many Asian Americans, Mexican Americans, Appalachians,
be the source of a person's strength. Examining the fontanels and American Indians consider eye contact rude and impolite
of a Southeast Asian infant should be avoided if possible or (cf. Giger & Davidhizar, 2004; Leininger & McFarland, 2006).
• Some Egyptian Americans think people who fail to maintain American gestures can often be devastating to clients, especially
eye contact or have shifty eye contact should not be trusted to recent immigrants (Giger & Davidhizar, 2004; Leininger &
(Meleis & Meleis, 1998). McFarland, 2006).
• Among the Irish, the absence of direct eye contact may
be interpreted as a sign of disrespect, guilt, or mistrust Rites and Rituals
(Wilson, 2003). Rites and rituals are markers of important events within a cul-
• Avoiding direct eye contact with elders, superiors, or per- ture. A rite is a ceremony or act that often marks an important
sons in authority is a sign of respect among many American event or life transition. A rite of passage is an event that marks
Indians, Hispanics, and Filipino Americans (cf. Cantos & a change in status from a lower to a higher level (Van Gennep,
Rivera, 1996; Munoz & Luckman, 2005). 1960). A ritual is a prescribed series of actions or process closely
related to a culture's ideology (Herberg, 1995). Each cultural
Preferred Greetings and Body Language group has defined rituals that may be related to both critical and
Greetings are important to all groups. A handshake is calendrical life events. Critical events include marriage, birth,
expected in first-time greetings among Americans. Among death, and graduation. Examples of calendrical events include
Vietnamese clients, shaking a female client's hand is con- Thanksgiving, Christmas, and Halloween. Rites and rituals can
sidered inappropriate for the nurse unless the woman offers indicate health and life in a community. For example, towns
her hand first. Ethiopians and Eritreans engage in hand- may have a carnival for a patron saint or an Independence Day
shakes only with persons who are unfamiliar. The standard parade every year. Residents are celebrating a calendrical rite of
greeting among familiar people in this culture is to kiss on identification. They are saying: “This is who we are; we rejoice
the cheek three to four times, and it is common for men in it.” Families that have ritual celebrations of Christmas or
to hug each other. Koreans greet with a bow of the head. Hanukkah are celebrating both their identity and the holiday.
Russians may shake hands or kiss on the cheek, depending Youths who are confirmed or “bar/bat mitzvahed” mark passage
on the relationship (Evanikoff, 1996). to a state of greater maturity.
Names are also an important part of the greeting and con- The community/public health nurse must have an under-
vey a sense of respect for the individual. In America, friends standing and appreciation of the various rites and rituals that
and relatives use first names. In the nurse–client interac- may influence the individual, family, and community health
tion, the formal use of a title (Mr., Mrs., or Ms.) is appro- behaviors. One of the most significant types of rituals relates to
priate. First names should be used only if the client permits childbirth and the care of the newborn and the mother. Cultural
it. In Cambodia, Korea, and the Philippines, name sequenc- practices surround pregnancy and labor care, parental roles
ing is reversed. AÂ€woman named Pak Yon is formally called during the birth process, breast-feeding, and recuperation after
Mrs.Â€Pak because the sequence of the names denotes that Pak childbirth. For example, American Indians’ labor practices vary
is the last name and Yon is the first name. Addressing the per- somewhat among tribes, but many include having the mother
son as Mrs. Yon is inappropriate. In both Appalachian and of the pregnant woman or other female kin in attendance dur-
African American cultures, a common practice of respect for ing the birth. Stoicism and self-control are encouraged, and
older adults is to address the person by the first name preceded pain control may include meditation or use of indigenous
by the title Miss or Mr., for example, Miss Alice or Mr. Jeremy, plants (Kramer, 1996).
whether Miss Alice is married or not. Names in most Spanish- During pregnancy, labor, and the postpartum period, there
speaking populations are more complex, and women's names are many prescriptive and restrictive taboo practices. For exam-
include the name of the father, the mother's surname, and the ple, among American Navajos, wearing two hats at one time
husband's surname, for example, Rachel Sanchez-Ramirez is considered taboo because one will then have twins (tradi-
Aldes (surnames of Rachel's father and mother followed by tionally undesirable and believed to be the work of a witch).
her husband's surname). Among American Navajos, elders American Navajos do not purchase clothing for an infant before
are addressed as “grandmother,” “grandfather,” “mother,” or birth and bury the placenta following birth as a symbol of the
“father,” by members of their clan. As a sign of respect, the child's being tied to the land (Still & Hodgins, 1998). Chinese
nurse may call an older Navajo client grandmother or grandfa- Americans may express the belief that going to the zoo dur-
ther; however, all clients should always be addressed in a for- ing pregnancy will cause the baby to take on the appearance of
mal manner and never by first names except on client request one of the animals (Chin, 1996). Postpartum practices among
(Andrews & Boyle, 2008; Galanti, 2004). Puerto Ricans, Mexican Americans, and Colombians may
Correct interpretation of body language and gestures is include avoiding any housework or strenuous activity from 7
important. The nurse may signal for someone to come by to 40â•›days after delivery; among the Vietnamese, avoiding a full
crooking the index finger, a common American gesture. Among shower for 2 to 4â•›weeks after delivery; and among West Indians,
the Vietnamese, however, this same signaling is a provocation, having ritual baths (Hill, 1996).
usually done to a dog. The OK gesture (thumbs up) given as a
response among Americans may have a different connotation
A community/public health nurse visits Mrs. Wong, a Chinese
for other cultural groups. In Latin American countries, the OK
American, who has just had a healthy infant boy. The nurse
gesture may mean that you are referring to the individual in a
advises Mrs. Wong to be attentive to diet, suggesting that a
derogatory manner. In the south of France, the sign may mean
healthy breakfast might include items such as orange juice,
worthless, and in the German culture, it is considered a rude
cold cereal, and milk. Startled, the client responds, “I can't eat
gesture. An important part of establishing rapport with clients
that.” For Mrs. Wong, postpartum practices are related to the
is knowledge of the different meanings of gestures and body
belief that imbalance occurs as a result of disharmony caused
language in different cultures. Misinterpretation of traditional
many to have originated because of health reasons such as fear

by the pregnancy and the childbirth. In this situation, beliefs
of trichinosis. Farb and Armelagos (1980) disagree; they see the
about pregnancy are based on the hot-cold theory of disease
prohibition in Genesis 9:3 as a reaction of the Israelites to their
causation. Because heat is lost during the birth process, the
Egyptian captors’ worship of swine rather than as a safeguard
postpartum period should be marked by a return to balance
against illness. This explanation, of course, does not account
and avoidance of cold food or cold air.
for the Muslim and Seventh-Day Adventist beliefs and prac-
tices that call for the avoidance of pork and pork derivatives.
Death-related rituals also vary. A great deal of symbolism Although it is sometimes difficult for community/public health
and ritual can be found surrounding the death or impending nurses to be familiar with the religious beliefs and practices
death of a family member. These symbols and rituals include, related to diet for all religions, they are encouraged to discuss
for example, reciting special prayers; using spiritual amulets, this matter with clients, especially those following special diets
religious medallions, or rosary beads; sitting by the window (low cholesterol, low carbohydrate, etc.) and to search for refer-
of a dying family member to keep out night spirits and chase ence sources pertaining to the major religious groups (Andrews
them away; or having all family members touch the body of the & Hanson, 2008).
deceased. The deceased's body may require special care such as In assessing dietary patterns among clients from diverse cul-
ritual washing of the body by family members. These practices tures, community/public health nurses should not only ask for
are of special significance to the family and should be respected a 24- or 48-hour diet recall but also be sure to ask about heavy
and facilitated by the health care provider, whenever possible. weekend or holiday eating patterns, which are customary among
most cultures and subcultures. Food customs are so deeply
Religion rooted in members of any cultural group that a kind of revul-
Religion and spirituality are linked strongly to our identity as sion can occur when they are presented with foods of other cul-
humans. Whenever possible, health care must fit into a client's tures. For example, what would a native-born American think
belief system. If clients do not believe that treatments are reli- of eating rats, cats, worms, or dogs? In France and Germany,
giously justified or morally acceptable, then the likelihood that corn is considered animal feed, whereas in the United States, it
they will comply with prescribed regimens is lessened. is popular for human consumption.
One question of critical importance for community/public The sharing of food often involves meaning and symbol-
health nurses is: How does religion influence health behaviors? ism (the use of something to point to something beyond itself).
Some religious groups fast or feast or have specific food or drink Wine, grape juice, bread, and cake are used in some Christian
regulations. Some religious ceremonies use alcohol or drugs as services and can stand for blood and body, life supported by
an integral part of the ceremony; other religions forbid their food and drink, the work involved in transforming grapes and
use. Religious beliefs may allow the use of faith healers. Some grain, or the unity of sharing. An understanding of the mean-
religions discourage participation in the modern medical sys- ings of food for various peoples and the context and manner in
tem. For example, Christian Scientists are more likely to rely on which food is shared (or not shared) is important for commu-
a Christian Scientist practitioner than they are to seek medi- nity/public health nurses who work with clients who belong to
cal care from a physician or nurse practitioner. Religion may different cultural groups.
also influence a person's willingness to participate in immuni-
zation, screening, and medical or nursing treatment. For exam-
ple, Jehovah's Witnesses are opposed to blood transfusions and
may be at greater risk during surgery if hemorrhage occurs.
They are also likely to refuse a surgery in which blood transfu-
sion is essential, such as some types of organ transplantation.
Electronic or printed religious calendars may also be useful to
alert community/public health nurses to upcoming religious
events or ceremonies during which time individuals, families,
groups, and communities might prefer to defer health-related
appointments and might have significant changes in diet, such
as fasting or feasting (Andrews & Hanson, 2008).
Role of Food
Food habits are inextricably linked to culture. The perceptions
and practices surrounding food provide important information
about a cultural group and are so deeply rooted that they may Asian family enjoying a traditional cultural meal eaten with
be difficult to change. The health care provider should care- chopsticks. (From Hockenberry, M. J., Wilson, D., Winkelstein, M. L.,
fully investigate and evaluate food preferences and eating habits etÂ€al. [2009]. Wong's nursing care of infants and children [8th ed.]. St.
for nutritional adequacy. Cultural food practices should not be Louis: Mosby.)
labeled as wrong simply because they do not conform to estab-
lished nutritional practices.
Food taboos are often linked to religious belief systems that Family and Kinship
are rooted in the history and culture of a people. Food customs Community/public health nurses look to the individual's fam-
can be so rooted in the past that people do not always know their ily members as important caregivers. Families provide, coor-
origins. For example, prohibitions against pork are thought by dinate, and influence much of the care in the home. To work
with Â�families, nurses need to identify family members and the drug therapy, and disease incidence. The biological models that
hierarchical structure of the family unit. Nurses often define use normative data based on white populations may not hold
the family as the next of kin or as the people living in the same true for members of other racial and ethnic populations.
household. This definition, however, may not match the percep- Community/public health nurses have a responsibility to
tion of an individual or family. understand normative differences among racial and ethnic
A family has many different forms and structures, depend- groups to perform an accurate physical assessment and sepa-
ing on individual and family selection and culture. The family rate normal from abnormal differences and reactions. Without
may be nuclear or extended. Family members may be related knowledge of differences, the nurse runs the risk of alarming
by blood, marriage, consensual union, or friendship (see people unnecessarily (in the event of a normal variation) or,
ChapterÂ€12). Members may include children who were given to more importantly, missing a cue to a serious health hazard.
an individual or couple to be reared and other individuals who, Normal variations in skin can be found between differ-
although not related by blood, are considered family members. ent racial and ethnic groups. For example, children of African,
For example, in many African American and Mexican American Asian, or Latin descent may have Mongolian spots. These irreg-
families, extended families and kin residence sharing is charac- ular areas of deep-blue pigmentation are usually located in the
teristic; and among the Amish people, the entire community is sacral and gluteal areas. Mongolian spots may resemble bruising
viewed as part of the extended family. and be mistakenly interpreted as signs of child abuse.
How a family defines itself and its members may be different Another issue encountered with skin assessments of cli-
from the definition of their family unit imposed by outsiders. ents from various cultures is correctly recognizing and inter-
People who are given children to rear may have no legal right preting jaundice, cyanosis, and pallor; erythema; petechiae;
to provide consent for hospitalization or surgical procedures. and ecchymosis. Persons with highly pigmented skin should
Gay partners may not have the legal right to hospital visits or to be assessed initially for baseline skin color. The surfaces with
consent to medical treatment for their partners. Complications the least amount of pigmentation (volar surfaces of forearms,
in providing nursing care can and do occur when the family soles of feet, palms of hands, abdomen, and buttocks) should
defines itself in a different way from how the nurse and the be checked. All skin, even in highly pigmented persons, has an
health care system does. Efforts must be made by both sides to underlying red tone, and its absence may indicate pallor. In
achieve a workable definition of the family that will best serve highly pigmented persons, jaundice may be observed in the
the family and take into account the family's view, however cul- sclera or the hard palate, and cyanosis, pallor, or petechiae may
turally different it may be from the nurse's view (Boyle, 2008). be assessed in the conjunctiva or the mouth. Pallor or cyano-
sis may also be detected by applying pressure to the nail and
Sexuality observing how rapidly the color returns to the nail beds.
Gender is more than a biological fact of life; it is also a cultural An increased incidence of certain diseases may be found in
construct with expectations about behaviors associated with select populations or ethnic groups. Some examples include
being a boy or a girl, a man or a woman. Sexual orientation glucose-6-phosphate dehydrogenase deficiency among MediÂ�
involves beliefs and practices about sexual behavior, as well as terranean people, African Americans, and Chinese; sickle cell
the social roles an individual assumes as a straight, gay, lesbian, disease in African Americans; cystic fibrosis in English popula-
bisexual, or transsexual person. Culture also determines how tions; and cleft lip or palate in Japanese people (cf. Andrews &
people define a sex-related health problem. Boyle, 2008; Giger & Davidhizar, 2004; Overfield, 1995).
Sexual beliefs and practices are emotionally charged issues in Biocultural variations may occur in some laboratory test
many cultures and serve as an arena for the airing of political, results. One of the most significant is serum transferrin lev-
religious, and scientific differences. Some areas for exploration els: the mean level is higher for African Americans than it is for
by community/public health nurses include how people learn whites. Because transferrin level increases in the presence of
about sexuality and how they are socialized into their sex roles. In anemia, it is a valuable marker for use in diagnosing and treat-
some cultures, little information regarding sexuality is provided ing children with anemia (Andrews & Boyle, 2008).
to children and adolescents. When this situation exists, the nurse Significant differences exist among racial and ethnic groups
needs to be sensitive to the problems associated with providing in the metabolism, clinical effectiveness, and side effects of dif-
sex education to children and teens. A clash may develop between ferent drugs. Racial and ethnic groups metabolize drugs for
the parents’ wishes and the delivery of sound health education diabetes, depression, and hypertension differently, and some
at school or the treatment of sexually related health problems in persons of African, Asian, or Hispanic descent metabolize drugs
children and adolescents. Issues surrounding circumcision, men- more slowly compared with the majority of the population. Few
struation, mate selection, sexual intercourse, conception and data are available on the differences in drug metabolism and
birth, contraception, menopause or climacteric, sexual taboos, effectiveness in subpopulations because few drug trials have
and sexual deviations from the norm are all areas for nonjudg- sufficient minority representation. Burroughs and colleagues
mental assessment, literature review, and verification. (2002) have identified some of the environmental, genetic, and
cultural factors underlying variations in responses among dif-
BIOLOGICAL VARIATIONS ferent population groups. BoxÂ€10-4 provides a few examples.
Nurses may encounter important biocultural (racial and ethnic) CULTURE-BOUND SYNDROMES
variations during physical examinations. Individuals may differ
in body structure, vital signs, general appearance, skin, enzyme Culture-bound syndromes are often referred to as disorders
levels, electrocardiographic patterns, nutritional deficiencies, restricted to a particular culture or group of cultures because
psychological characteristics, laboratory test values, response to of certain psychosocial characteristics of those Â� cultures.
BOXÂ€10-4â•…â•‡EXAMPLES OF VARIATIONS critically. Individuals, families, and communities have various

IN DRUG METABOLISM IN beliefs that influence their health seeking and acceptance of
care. Decisions are based on personal experiences, nationality,
SELECTED RACIAL AND
ethnicity, culture, and family background. To ensure culturally
ETHNIC GROUPS
competent care, nurses must understand and appreciate these
• African American and white clients have been shown to differ sig- differences.
nificantly in their responses to beta-blockers, angiotensin-Â�converting
enzyme inhibitors, and diuretics used either alone or in combination Culture's Relationship to Health and Health Beliefs
for the treatment of hypertension. Culture is related to health in that culture teaches us the mean-
• Some populations of Chinese are considerably more sensitive than ing of health and illness and the appropriate practices related to
whites to the effects of the beta-blocker propranolol on heart rate our beliefs. Wide variations exist in cultural belief systems and
and blood pressure. practices. In many cultures, concepts such as cause and effect
• African Americans and Chinese Americans metabolize nicotine may not be relevant. Cultural groups that adhere to the great
more slowly than do whites, and genetic variations associated with traditions of Buddhism, Confucianism, and Taoism accept the
slower metabolism are more common in some Asian populations. fate of an illness and may not necessarily seek to discover the
• Compared with some whites, certain Asian groups are more likely cause or cure. In fact, many cultural groups do not believe in
to require lower dosages of a variety of different drugs used to
natural causation (e.g., germs, stress, organic deterioration) but,
treat mental illness, including lithium, antidepressants, and
instead, hold theories of supernatural causation, allowing fate
antipsychotics.
to guide their lives and trying to live in simplicity and harmony
• Hispanic clients have been reported to require lower dosages of
antidepressants and to experience more side effects compared with nature. Many cultures also do not accept the germ theory.
with whites. Murdock (1980) describes 186 different cultural groups, only 31
of which have expressed theories concerning infection.
Data from Burroughs, V. J., Maxey, R. W., Crawley, L. M., etÂ€al. (2002). Andrews and Boyle (2008) describe three major health belief
Cultural and genetic diversity in America: The need for individualized systems that people embrace: magico-religious, scientific, and
treatment. Washington, DC: National Pharmaceutical Council and
holistic systems (TableÂ€10-3). Community/public health nurses
National Medical Association.
are likely to encounter individuals for whom the belief in health
and illness is tied to the religious belief that illness is a result
Community/public health nurses and other health care proof God's will. Individuals may also wear amulets (objects such
viders may encounter people with symptoms that are diffi- as charms worn on a string or chain) around the neck, waist,
cult to interpret or explain and must be understood within the or wrist to ward off evil spirits. A special amulet called a manu
context of the clients’ cultural beliefs. These very real symp- negro is placed on babies of Puerto Rican descent to prevent the
toms may have emotional or spiritual causes. For example, evil eye (Spector, 2004).
an individual who presents with vomiting, diarrhea, and hal- Some cultural groups may rely on the hot and cold theories
lucinations may believe that he or she has been conjured or of disease: four body humors—yellow bile, black bile, phlegm,
had a spell placed on him or her by persons who are skilled in and blood—must be balanced within the body for health. If
witchcraft. The individual who firmly believes that the under- imbalance occurs, the individual becomes ill. Imbalance is
lying cause of the illness is witchcraft is not likely to be recep- treated by consumption of prescribed foods or elements that
tive to treatments that do not involve casting out the spell (cf. are hot, cold, wet, or dry. Disease states, foods, beverages, and
Andrews & Boyle, 2008; Giger & Davidhizar, 2004; Purnell & drugs are thus classified as hot or cold. Treating disease is
Paulanka, 2008; Spector, 2008). accomplished by correcting the imbalance of hot or cold by
Some African Americans use the expression high blood, adding or subtracting the substances that affect the humors.
which means that the blood is too rich because of consump- For example, an illness attributed to a problem with blood
tion of too much red meat or other rich foods. Conversely, low (e.g., hot and wet) would require a cold and dry treatment to
blood is related to an insufficiency in the quantity of blood, reestablish and maintain equilibrium. The definitions of what
and treatment would be dietary supplements. Hispanics may are hot and cold entities vary with the cultural group. A com-
attribute a sudden onset of crying, fitful sleep, and diarrhea in munity/public health nurse may encounter people who refuse
children to mal ojo, or the evil eye. Anxiety—trembling from certain foods and drugs because of the belief that they will not
sudden fright—may be diagnosed as susto. In Western cultures, restore the body's imbalance.
anorexia nervosa is a syndrome that is linked to sociocultural
emphasis on body type and is an excessive preoccupation with Seeking Health Care
thinness, a self-imposed starvation. This syndrome is seen in An individual's decision to seek health care is influenced by
the United States, Europe, Japan, and Hong Kong, and among family, community, and culture. Typical patterns of behavior
certain Asian populations and immigrants under Westernizing such as when, where, why, and how to seek care are learned from
influence but not in other cultures. TableÂ€10-2 lists select cul- parents, neighbors, religion, and the health care system.
ture-bound syndromes found in various regions or cultures. The availability and acceptability of care and the ability to
reciprocate or pay in some way for the care received also influ-
CULTURAL PATTERNS OF CARE ence care-seeking decisions. In some countries, including the
United States, goods or services are exchanged in lieu of money
Leininger (1993) notes that one of the most significant chal- or health insurers’ reimbursement. Lack of health insurance
lenges for the health care professions is to study transcultural poses the most significant barrier to seeking care among racial and
health–illness patterns of caring and curing systematically and ethnic minorities.
TABLEÂ€10-2â•…â•‡SELECT CULTURE-BOUND SYNDROMES

SYNDROME GROUP OR REGION DESCRIPTION OF SYNDROME
Amok or mata elap Malaysia A dissociative episode characterized by a period of brooding followed by
outburst of violent, aggressive, or homicidal behavior directed at people
and objects
Anorexia nervosa North America, Western Europe An excessive preoccupation with thinness; self-imposed starvation; severe
restriction of food intake associated with morbid fear of obesity
Dhat India Semen-loss syndrome, characterized by severe anxiety and
hypochondriacal concerns with the discharge of semen, whitish
coloration of urine, and feelings of weakness and exhaustion
Falling out, blacking out, Southern United States, Episodes characterized by sudden collapse, dizziness, not enough blood or
or low blood Caribbean (blacks, Haitians) weakness of the blood that is often treated with diet; Individual's eyes
are usually open, but person claims inability to see; person usually hears
and understands what is occurring around him or her but feels powerless
to move and is unable to move
Ghost sickness Native Americans Preoccupation with death and the deceased, sometimes associated with
witchcraft; symptoms may include bad dreams, weakness, feelings of
danger, loss of appetite, fainting, dizziness, confusion, feelings of futility,
and a sense of suffocation
Hwa-byung or Korea Multiple somatic and psychological symptoms; pushing up sensation
Wool-hwa-bung of chest; palpitations, flushing, headache, epigastric mass, anxiety,
irritability, and difficulty concentrating
Koro Chinese, Southeast Asia, Malaysia An episode of sudden and intense anxiety that the penis (or in the rare
female cases, the vulva and nipples) will recede into the body and
possibly cause death
Locura Latin America A severe form of chronic psychosis, attributed to an inherited
vulnerability, the effect of multiple life difficulties, or a combination
of the two; symptoms include incoherence, agitation, auditory and
visual hallucinations, inability to follow rules of social interaction,
unpredictability, and possible violence
Pibloktoq or Arctic hysteria Greenland Eskimos An abrupt dissociative episode accompanied by extreme excitement of up
to 30 minutes’ duration and frequently followed by convulsive seizures
and coma lasting up to 12 hours; individual may be withdrawn or mildly
irritable for hours or days before the attack and will typically report
complete amnesia about the attack
Shenkui Chinese Marked anxiety or panic symptoms with accompanying somatic
complaints for which no physical cause can be demonstrated;
symptoms include dizziness, backache, fatigue, general weakness,
insomnia, frequent dreams, and complaints of sexual dysfunction;
symptoms are associated with excessive semen loss from frequent
intercourse, masturbation, nocturnal emissions, or passing of white
turbid urine believed to contain semen
Shin-byung Korea A syndrome characterized by anxiety and somatic complaints
(general weakness, dizziness, fear, loss of appetite, insomnia, and
gastrointestinal problems) followed by dissociation and possession of
ancestral spirits
Spell Southern United States A trance state in which individuals communicate with deceased relatives or
with spirits; at times is associated with brief periods of personality changes;
spells may be misconstrued as psychotic episodes in a clinical setting
Mal de ojo Spain and Latin America The Spanish term for the evil eye; used as a common idiom for disease,
misfortune, and social disruption throughout the Mediterranean, Latin
American, and Muslim worlds
Rootwork Southern United States and Idiom is described as a set of cultural interpretations that explain illness
Caribbean as the result of hexing, witchcraft, voodoo, or the influence of an evil
person
Susto Latinos in the United States Described as an illness that is attributed to a frightening event that causes
and Latin America the soul to leave the body, leading to symptoms of unhappiness and
sickness; symptoms are extremely variable and may occur months or
years after the supposedly precipitating event
Adapted from Andrews, M. M., & Boyle, J. S. (2008). Transcultural concepts in nursing care (5th ed.). Philadelphia: Lippincott, Williams & Wilkins;
and First, M. B., & Frances, A. (2002). DSM-IV-TR, Handbook of differential diagnoses. Washington, DC: American Psychiatric Association.
TABLEÂ€10-3â•…â•‡HEALTH BELIEF PARADIGMS

PARADIGM BELIEFS CULTURAL GROUPS THAT PRACTICE INTERVENTION
Magico-religious Supernatural forces are dominant. Many African American, Latino, and Healing is through magic or religion,
Fate of the individual depends on the Middle Eastern cultures are grounded in such as laying on of hands or
actions of God, or the gods, or other this belief. Christian Scientists believe anointing the sick with oil.
supernatural forces of good or evil. that physical healing can be effected
Gods also punish humans for their through prayer alone. Some West
transgressions. Illness is caused by Indians, Africans, and African Americans
sorcery, breach of taboo, intrusion of believe that sorcerers are the cause of
disease object or disease-causing many conditions. Mal ojo, or the evil eye,
spirit, loss of soul, and punishment common in Latino and other cultures can
from God, and may be initiated by a be viewed as a disease-causing spirit.
supernatural agent or another person.
Scientific Life (health and disease) is controlled Most western cultures, including the Healing is through physical or
by a series of physical and biological dominant cultural groups in the United chemical interventions specific to
processes that can be manipulated by States and Canada the identified cause (e.g., antibiotics
humans (e.g., infection, communicability for bacterial infection, chemotherapy
of a disease). Every disease has a or surgery for cancer, depending on
specific cause and a specific effect. type of cancer and body site).
Holistic Health is the natural balance of the North American Indian cultures and Asian Healing is through identifying
forces of nature (the laws of nature). cultures disharmonies (imbalance), restoring
Everything in the universe is a part of body functioning, and seeking
nature, including human life. Disturbing to reduce or eliminate the cause
the laws of nature creates imbalance, or causes. Great emphasis is on
chaos, and disease. Holistic theory preventive health and maintenance
incorporates the scientific or biological measures.
aspects of disease, but maintains that it
is not the only cause for the disease or
illness.
Adapted from Andrews, M. M., & Boyle, J. S. (2008). Transcultural concepts in nursing care (5th ed.). Philadelphia: Lippincott, Williams & Wilkins.
Other barriers to seeking health care for racial and ethnic Leininger & McFarland, 2006; Purnell & Paulanka, 2008;
minorities include attitudes of fear, fatalism, and pessimism; Spector, 2008):
mistrust of the system; poor availability of and access to services; • Curandero, espiritualista (spiritualist), yebero, and sanador
inconvenience such as office hours at difficult times; prejudice (Hispanic)
and discrimination; linguistic barriers; lack of cultural compe- • Old Lady, spiritualist, and voodoo priest or priestess (African
tence by providers; and low level of general health knowledge. American)
African American, Asian American, and Hispanic American • Herbalist and acupuncturist (Chinese)
adults are reported to be less likely than are white adults to have • Braucher or baruch-doktor and lay midwife (Amish)
a regular doctor, and fewer than one half of Hispanic and Asian • Magissa or magician, bonesetter, and orthodox priest (Greek)
Americans, when asked, feel confident in their ability to get • Shaman (Native American)
needed care (Collins etÂ€al., 2002).
Complementary and Alternative Therapies
Folk Medicine and Folk Healers Complementary and alternative medicine (CAM) is a growing
Folk healers are practitioners of lay medicine who work face to concept in health care. CAM is a collective of diverse medical
face with families and communities. Folk healers and their rem- and health care systems, practices, and products that are beyond
edies are indigenous to many cultures. Because folk healers are the realm of conventional Western medicine. Holistic health
present in both rural and urban communities, migrants to a dif- care practitioners incorporate CAM, recognizing that empirical
ferent or new locale can often find a healer from their own cul- science and technology do not necessarily have the answers to
tural group. The healer helps them link their new life to their every health concern.
former life and ties. Complementary medicines are therapies that are used
The folk healer's scope of practice and treatment vary together with conventional medicine (e.g., aromatherapy to
and may include diagnosis, prevention, and treatment of ill- lessen postsurgical discomfort). Alternative medicines are
ness; interpretation of signs and omens; prayer; use of amu- used in place of conventional medicine (e.g., a special diet
lets; witchcraft; assistance with personal, financial, spiritual, to treat cancer instead of conventional treatments such as
or physical problems; blessings; and exorcisms. The types surgery, radiation, or chemotherapy). Some clients combine
of healers seen in various communities include the follow- both mainstream medical therapies and CAM therapies to
ing (cf. Andrews & Boyle, 2008; Giger & Davidhizar, 2004; enhance wellness and quality of life. An increasing number
of major medical centers have large integrative health centers • Have a defined set of values and principles, and demonstrate
(IHCs). IHCs focus on the science and practice of combining behaviors, attitudes, policies, and structures that enable them
conventional and alternative therapies. The range of CAM to work effectively cross-culturally
therapies is expansive and changes as therapies are adopted • Have the capacity to (1) value diversity, (2) conduct self-Â�
into conventional treatments. This book's website
Â� provides a assessment, (3) manage the dynamics of difference, (4) acquire
detailed list of CAM therapies in Website Resource 10C. and institutionalize cultural knowledge, and (5) adapt to diver-
sity and the cultural contexts of the communities they serve
Meaning of Pain and Suffering • Incorporate the previously mentioned actions into all aspects
Both pain and suffering have cultural as well as physical aspects. of policy making, administration, practice, and service deliv-
Pain—whether physical, mental, or spiritual—is experienced, ery, and systematically involve consumers, key stake holders,
influenced, and handled by individuals and groups in the con- and communities
text of their cultures. How pain is interpreted and expressed var- Individual cultural competence refers to a complex integra-
ies across cultures. Some cultural groups minimize or emphasize tion of knowledge, attitudes, beliefs, skills, and encounters with
pain and the expression of pain. For example, some people see the those from cultures different from one's own that enhances
suffering associated with pain as redemptive, whereas others view cross-Â�cultural communication and the appropriateness and
suffering as punishment (just or unjust), as fate, or as plain bad effectiveness of interactions with others (American Academy
luck. An early anthropological study by Wissler (1921) reported of Nursing, 1992; Campinha-Bacote, 1998, 2007; USDHHS,
on the use of skewers inserted into chest incisions as part of the 2010a). Cultural competence has been defined as a process,
ritual sun dance performed by Plains Native Americans. Young as opposed to an end point, in which the nurse continuously
men who were able to complete the dance gained esteem and war- strives to work effectively within the cultural context of an indi-
rior status. Studies show that complaining, demanding behavior vidual, family, or community from a different cultural back-
is expected sick role behavior in American Jews and Italians; on the ground (Andrews & Boyle, 2008; Campinha-Bacote, 1998, 2007;
other hand, Asians and Native Americans with illnesses are quiet Campinha-Bacote & Munoz, 2001). Campinha-Bacote (2007)
and compliant (Ludwig-Beymer, 2007). defines cultural competence as an ongoing process in which the
When clients and families minimize or emphasize pain, health care professional continuously strives to achieve the abil-
unknowledgeable health care providers can misinterpret what is ity and availability to work effectively within the cultural con-
taking place. Clients who minimize pain can be viewed as resting text of the client (individual, family, community). This process
quietly and without pain, whereas those who emphasize pain can involves the integration of cultural desire, cultural awareness,
be viewed as nuisances, hypochondriacs, or malingerers. Nurses cultural knowledge, cultural skill, and cultural encounters
also tend to expect clients to handle pain in the same way the (Campinha-Bacote, 1998, 2002, 2007; Douglas etÂ€al., 2009).
nurse has learned to handle pain. If nurses are stoic, they tend to Given that community/public health nurses are likely to
expect clients to be stoic; if nurses are very verbal in expressing encounter clients from literally hundreds of different cultures and
pain, they usually expect clients in pain to be verbal rather than subcultures, as well as clients of mixed cultural heritage, it is virtu-
silent. Any of these inaccurate assessments can impede appro- ally impossible for them to know about the culturally based health-
priate diagnosis, referral, and treatment (Ludwig-Beymer, 2007). related beliefs and practices of them all. It is possible, however, to
master the knowledge and skills associated with cultural assess-
COMMUNITY/PUBLIC HEALTH NURSE'S ROLE ment and learn about some of the cultural dimensions of care for
IN A CULTURALLY DIVERSE POPULATION clients representing the groups most frequently encountered.
Culture and the values learned within a cultural group are critical to Cultural Self-Assessment
how people perceive health, health care, and nursing care providers. Before nurses provide culturally competent care to people from
Whether community/public health nurses focus on an individual, backgrounds different from their own, it is important for nurses
group, or community as the unit of care, these concepts must be to engage in cultural self-assessment. This includes developing
understood to provide the best possible nursing care. If community/ an awareness of one's own cultural values, attitudes, beliefs, and
public health nurses do not know what people believe about health practices. These insights also enable nurses to overcome eth-
and how they value health, then how can they change anything for nocentric tendencies and cultural stereotypes, which can lead
the better with regard to groups or individual members of society? to cultural imposition, prejudice, and discrimination against
Cultural competence should be a goal for every community/public members of certain groups.
health nurse (American Nurses Association [ANA], 2007). After engaging in a cultural self-assessment, community/
public health nurses should conduct a cultural assessment of
Culturally Competent Nursing Care others—individuals, families, groups, and communities.
When one nurse anthropologist recently conducted an Internet
search on cultural competence using the popular search engine Cultural Assessment of Individuals, Families, and Groups
Google, more than 27,700,000 results appeared. These fell into Cultural assessment is the foundation for culturally competent and
two major categories: (1) organizational cultural competence; culturally congruent nursing care; however, many nurses report that
and (2) individual cultural competence, usually in reference to they lack cultural knowledge and skill. This problem is compounded
nurses, physicians, social workers, or those in other health care, by the fact that the nursing profession fails to reflect the diversity of
education, or social services professions. the society at large (Sullivan Alliance, 2007; USDHHS, 2008).
According to the National Center for Cultural Competence Although the number of registered nurses has almost doubled
(n.d.) (http://www11.georgetown.edu/research/gucchd/nccc/), culÂ� during the past 24â•›years, nurses from racial and ethnic minorities
tural competence requires that organizations do the following: are still underrepresented in the United States (FigureÂ€10-4). Of the
Two or more races, non-Hispanic 1.5%

1.7%
American Indian/Alaska Native, 0.8%

non-Hispanic 0.3%
Asian or Native Hawaiian/ 4.5%

Pacific Islander, non-Hispanic 5.8%
Black/African American, 12.2%

non-Hispanic 5.4%
Hispanic/Latino, any race 15.4%

3.6%
White, non-Hispanic 65.6%

83.2%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
U.S. population RN population
FIGUREÂ€10-4â•‡ Distribution of registered nurses by racial/ethnic background, March 2008. (From
U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau
of Health Professions. [2010]. The registered nurse population: Findings from the 2008 National Sample
Survey of Registered Nurses. Retrieved August 2011 from http://bhpr.hrsa.gov/healthworkforce/rnsurveys/
rnsurveyfinal.pdf.)
three million registered nurses, 83% are white, non-Hispanic com- • Cultural knowledge—understanding of the beliefs and
pared with 65% of the total U.S. population (USDHHS, Health value systems of others developed through a scientific base
Resources and Services Administration, 2010). Seventeen percent of information about their similarities and differences
of registered nurses are from racial and ethnic minority groups. • Cultural skill—learning to collect cultural information by way of
Hispanics or Latinos still remain the most underrepresented group cultural assessments and culturally based physical assessments
among registered nurses compared with their representation in
the overall population. Although Hispanics or Latinos account for
14.1% of the population, only 2.2% of nurses are from this eth-
nic group. Such homogeneity reduces the chances for nurses to
learn about other cultures from members of their own profes- Cultural
Awareness
sion. Cultural competency in nursing care and public health can
be improved by actively recruiting members of minority racial and
ethnic groups to the profession and improving the cultural knowl-
edge of current nurses (Sullivan Alliance, 2007; USDHHS, 2008).
Cu es
ltu ire
D
ra
Cultural Frameworks and Assessment Tools

l
Knowledge
Cultural
Cultural
The existing body of information on cultural competency, as The Process

Skill
well as several models and frameworks, can assist nurses in of Cultural

Competence
delivering culturally competent care. Leininger (1978, 1988;
Leininger & McFarland, 2006) was an early pioneer in the field.
Other authors in this field include Murdock (1971), Tripp-
Reimer and colleagues (1984), Fong (1985), Kim-Godwin
and colleagues (2001), Campinha-Bacote (2002), Giger and
Davidhizar (2004), Purnell and Paulanka (2008), Spector
(2008), and Andrews and Boyle (2008). Cultural
Encounters
The model proposed by Campinha-Bacote (2002) recognizes
that achieving cultural competence is a continuous process in
which the health care provider constantly strives to work effectively
within the cultural context of the client (individual, family, and The Process of Cultural Competence in the
Delivery of Healthcare Services
community) (FigureÂ€10-5). This model has widespread applicabil- (Campinha-Bacote, 1998)
ity and outlines the integration or intersection of five processes: FIGUREÂ€10-5â•‡ Campinha-Bacote model of cultural competence.
• Cultural awareness—sensitivity to the values, beliefs, and cus- (From Campinha-Bacote, J. [2007]. The process of cultural competence
toms of others and examination of a person's own cultural in the delivery of healthcare services: The journey continues. Cincinnati,
values and beliefs, biases, and prejudices toward other cultures OH: Transcultural C.A.R.E. Associates.)
• Cultural encounters—engagement in cross-cultural interac- Building the trusting relationship acknowledges respect for the
tions with clients, including individuals and groups, so as to individual and the community and demonstrates the principle
explore the nurse's perceptions and knowledge about spe- of caring. Trust allows the client to become relaxed. The nurse
cific cultures and ethnic groups must master the skill of careful listening, recognizing that all
• Cultural desire—motivation on the part of the health care information has subjective and objective components and
provider, who wants to engage in the process of becoming should be validated. An equally important component of the
culturally competent rather than having to do so assessment process is providing clear information to the client
The Campinha-Bacote tool defines a continuum from simple regarding the purpose of the assessment, the expected process,
awareness to in-depth discovery of and competence in one or more the anticipated use of the data, and the choice to participate or
different cultures. The critical first step is cultural awareness. A not participate in the process. In some cultural groups, note
caregiver's lack of awareness about his or her own values, beliefs, taking is considered disrespectful, and terms such as okay or
and attitudes toward other cultures may lead to nursing care that is you guys may be unclear to the client. Use of words such as dear,
ethnocentric, or care planned for individuals with cultural beliefs honey, baby, mama, and papa is to be strictly avoided.
and values similar to his or her own (Leininger, 1978; Leininger & Assessing the cultural dimensions of the community involves
McFarland, 2006). For example, a nurse might value the impor- more than eliciting facts and data during one interview encoun-
tance of a baby's sleeping in his or her own bed. If the nurse comes ter. The systematic process suggests the need for continuity involv-
in contact with a family who thinks it is important for the baby ing numerous data points and numerous data sources. The data
toÂ€sleep with the parents, the nurse may label that act as bad par- gathering process is enhanced by holding community focus group
enting, rather than simply a different way of handling infant care. discussions, interviewing key community leaders, and identifying
The process of deliberately seeking out interactions with and listing community resources, organizations, and social outlets.
individuals and groups from diverse cultural backgrounds Leininger (1978) identified nine key areas in a cultural
is valuable because it provides an opportunity to explore the assessment:
nurse's perceptions and knowledge about a specific culture 1. Lifestyle patterns
with members of that group. These exchanges help nurses vali- 2. Cultural values and norms
date or negate their knowledge base and correct any misconcep- 3. Cultural taboos and myths
tions. This process helps to avoid generalizations, stereotyping, 4. The culture's world view and ethnocentric tendencies
and development of beliefs based on limited cross-cultural 5. The culture's perception of its similarities with and differ-
contact. Stereotyping is an exaggerated, usually negative, belief ences from other cultures
or image applied to both an entire category of people of a racial 6. Health care rites and rituals
or ethnic group and to each individual within it that is false or 7. Degree of culture change
greatly distorts the real characteristics of the group. It is impor- 8. Caring behaviors
tant to recognize that even within a specific culture, individual 9. Folk and professional health-illness systems being used
differences in values and beliefs can be found. The framework presented in TableÂ€10-4 is designed to
Two models are specifically proposed for delivering cultur- structure the assessment of families and communities within
ally competent community care: (1) the Bernal model (1993) a cultural perspective and incorporates most of Leininger's
and (2) the culturally competent community care model original suggestions. Answers are discovered from observing
(Kim-Godwin etÂ€al., 2001). Another model for use with fami- and participating with people in a caring context, as well as
lies and communities is introduced later in this chapter. Other interviewing people about their culture, family history, and
nursing scholars have developed cultural assessment tools beliefs and practices related to the health of individuals and
(Andrews & Boyle, 2008; Giger & Davidhizar, 2004; Leininger groups. Some general community assessment tools address
& McFarland, 2006; Purnell & Paulanka, 2008; Spector, 2008). culture. However, when health care providers recognize that
they are working with a cultural group that contrasts sharply
Cultural Assessment for the Community/Public with their own, a more extensive cultural assessment needs
Health Nurse to be conducted using a tool such as the one presented here.
The cornerstone of community/public health nursing is the con-
cept of community as client (Association of Community Health
Nursing Educators, 2000; 2010). Community/public health nurs-
ing practice must operate within a framework and structure that
focus on strategies for decreasing racial and ethnic disparities.
Because individuals comprise a community, the community is a
reflection of the characteristics of the community residents.
The cultural assessment is “a systematic appraisal or exami-
nation of individuals, groups, and communities as to their cul-
tural beliefs, values, and practices to determine specific needs
and interventions within the cultural context of the people being
evaluated” (Leininger, 1978, pp. 85-86). Cultural Â�assessment
helps the nurse understand from where clients derive their ideas
about disease and illness and helps determine beliefs, values, and
practices that may influence client care and health behaviors.
The first step of a cultural assessment, before collection of â•‡A nurse visiting a family at home. The nurse and family are of
any data, is to establish a rapport or beginning trust Â�relationship. different racial/ethnic origins. (Copyright CLG Photographics.)
TABLEÂ€10-4â•…â•‡COMMUNITY AND FAMILY CULTURAL ASSESSMENT GUIDE

CULTURAL CATEGORY QUESTIONS FOR COMMUNITY ASSESSMENT QUESTIONS FOR FAMILY ASSESSMENT
Definition of self How does the community view itself? What are its cultural How does the family view itself? Are there fictive kin?
groups? What are its calendrical events, and how are Does the family have more or fewer members than
they ritualized? What is the history of the community? the household? How do family members define the
What is the community's view of its future? role and status of each member? How does sex and
gender influence family roles? Do family members
live close by? How do they communicate? What are
the family's calendrical events, and how are they
ritualized? What critical events have occurred in the
family, and how are they marked? What is the history
of the family? What stories are told about the family?
What does the family see as its future? What does
the family tree (genogram) look like?
Definition of others Who are the helping agencies? Who are the key informal Who are the helping people? Who would help in a time
helpers? of need? What kind of help might be requested?
Definitions of health and What groups does the community identify as well, worried How does the family describe its health as a unit and
illness and well, early ill, or ill? How are well and ill groups the health of individuals within it? How and who
identified? What are the potential health problems of within the family determines when a member is sick
specific age and cultural groups? Who are the health and how? Who within the family decides when to
and illness care providers in the community? seek help for illness, and what type of help will be
sought?
Beliefs about health and How do cultural groups perceive health and illness in Does the family accept fate or use health-promotion
illness terms of accepting, adapting, and controlling? What are and illness-prevention strategies? How do they view
the prevailing illnesses? Do biocultural variations exist cause, diagnosis, and treatment? What illnesses or
that are important to the health of the community? How biological variation is the family susceptible to? Who
does theÂ€community view the cause, diagnosis, and do they view as health care practitioners? Do family
treatment? members practice folk medicine, traditional healers
or alternative and complementary therapies? What
are usual home treatments and nutritional remedies?
Life ways and meaning What are the major cultural values about life, nature, What is the meaning of life to the family? How does
and relationships? What are the cultural standards of the family live? What do the family members do
behavior? What is the prevailing meaning of life? each day?
How is life lived? What do people do each day?
Communication What is the major language and dialect spoken among What is the language and dialect spoken in the home
community members? What are common patterns and at social gatherings? How well do the family
related to verbal and nonverbal communication? What is members speak and write English? Is the use of an
the relationship of personal space to the communication interpreter necessary? What physical gestures do
process? Are interpreters available in the community and family members use during conversation? How much
health care settings? distance do family members place between each
other when speaking?
Time How is time structured? Is time viewed as a gift to be How is time structured? Is time viewed as a gift, a
appreciated, as a commodity to be used, or in some commodity, or in some other way? Are schedules
other way? Are people present, past, or future oriented? used? Are schedules valued? Is the family past,
present, or future oriented?
Space How is space structured in the community? Is open space How does the family structure space? Is the yard
available? Are public buildings welcoming? Where are fenced? Who makes most use of what space? Where
places of worship, shops, restaurants, bars, food stores, do family members eat and sleep? How close do
malls, public buildings, and health providers located? family members get? How is observable touch used?
Physical objects What visible objects represent the community? How What possessions are displayed? Does misplaced
are buildings characterized in terms of condition, matter exist? Is the house cared for? Is clothing
cleanliness, and access? How are public facilities clean, stylish, and in good condition? Does evidence
equipped and used? exist of conspicuous consumption (“keeping up with
the Joneses”)?
Food customs What kinds of eateries are present in the community? Does the family eat together? Does the family eat
How are eating places patronized and by whom? Is at a set time? What kinds of food are eaten? Who
some ethnic style of eating noted? How do people prepares the food? What and when do family
communicate during meals? members drink? What foods are adult foods? What
foods are children's foods? Are any foods or drinks
taboo? Do family members talk during meals? To
whom is food given and in what order?
(Continued)
TABLE 10-4â•…â•‡COMMUNITY AND FAMILY CULTURAL ASSESSMENT GUIDE—CONT'D

Religion How many churches, mosques, or synagogues are located Do family members participate actively in one
in the community? What denominations are represented? religion or more than one religion? Does church,
Do the organized religious groups provide any health care mosque, or synagogue membership provide
services? Are designated healers or nurses available in social support for the family now or if needed?
the churches? Do the churches sponsor health fairs or Do, or might, religious beliefs or practices affect
screenings? health? What are the rituals and taboos related
to birth, death, and illness?
Clubs What kinds of clubs are active in the community? What To what clubs do family members belong? Are clubs
political parties are active in the community? What available to which the entire family belongs? How
resources do the clubs have available? What kinds of active are family members at the present time in
people participate in clubs? Do separate groups for men, the club? What actual or potential resources can
women, and children exist? the club provide?
Work What occupations exist in the community? How many What family members work outside and inside the
people in the community work outside the home? How home? What potential or actual work hazards
many work inside the home? What work hazards exist are encountered by family members? What kind
in the major occupations? How many people cannot find of health insurance plans do family members
work? What employment support resources exist? Do have from their jobs? How do members prepare
people know about them? Are they accessible? What is for and cope with retirement, layoffs, or a
the value and meaning of work? company closing? What are the work duties in
the household? What is the value and meaning of
work?
Education What kinds of schools are located in the community? Do the children in the family attend school
Who attends these schools? What are the absence rates regularly? Is the family generally satisfied with
in the schools? Is health care provided in the schools? the schools the children are attending? Do the
What kind of health care is provided? What is the role parents or grandparents attend school? Are
of nursing with regard to school health? Does the school family members active in school activities? Is
play an active part in the community? school seen as a way to a good or better life?
Does the family identify specific problems with
the school?
Play What leisure activities are available in the community for How many hours do family members spend in
various age groups? Are recreation facilities being used? leisure activities? What kinds of activities do they
What groups use what kinds of resources? What is the enjoy as individuals and as a family? What is the
value and meaning of play? value and meaning of play?
Power How is official (formal) power structured in the community? How is power structured in the family? Who makes
Can informal power groups be identified? health decisions for family members?
Environment Does the community environment (physical and social) Does the family environment (physical and social)
foster health in the community? How? foster its own health and the health of other
community members? How?
In- and out-migrants and Who are the groups coming and going? How are in-migrant How does the family accept newcomers and the loss
in- and out-migration groups socialized to the community? How is out-migration of family members? Is the family open or closed to
justified? new groups in the community?
Deviance How is deviance handled in the community? Who are the Who are the deviants in the family? How does the
individual deviants and the deviant groups? family cope with deviance? Is the family itself a
deviant group within the community?
Change What major changes have occurred in the community? What major changes (anticipated and unanticipated)
How did the changes occur? Were the changes planned, have occurred in the family? How did the family
unplanned, valued, or disvalued? How did the community accept or attempt to control the changes? How
accept or attempt to control the changes? does the family view change?
Sick role Do ways of identifying the sick, the frail, those with chronic How is a family member identified as being
disabilities, and those with mental disorders exist in the sick? What are the behavioral expectations
community? How are these groups described? What are for members in the sick role? What are the
the expectations for sick role behavior among various behavioral expectations for chronically ill family
cultural groups? members? Who assumes the role of caregiver?
Who makes decisions for entry into a health care
system?
Death ways and meaning How are deaths marked by the community? Do variations How are deaths marked by the family? What is the
concerning the meaning of death among different groups meaning of death? What are the rituals enacted at
exist in the community? the time of a death? What are the expectations for
individual family members?
TABLE 10-4â•…â•‡COMMUNITY AND FAMILY CULTURAL ASSESSMENT GUIDE—CONT'D

Sexuality and sex roles How do schools and religious groups socialize children What are the sex role expectations across the
with regard to male and female roles? How, where, life span? How, when, and by whom is sexuality
and when is formal sex education taught? What are the discussed in the family? Who is responsible for
prevailing ideas in the community about sexual behavior? monitoring the sexual conduct of family members?
Who are the sexual deviants? How is sexual deviance What are the rules for sexual conduct? How are boys
handled? and men supposed to act? How are girls and women
supposed to act? When and how does a boy become
a man? When and how does a girl become a woman?
What are the sexual taboos?
Childbearing What are the shared practices of the community with How are family members involved in the birth
regard to pregnancy and childbirth? Who attends the prenatally and at delivery? What are the expected
mother during delivery? Is early nurturing and roles of family members surrounding the birth
mother–child bonding encouraged? Do purification rituals experience? Who cares for the infant immediately
exist for the mother? Is male (or female) circumcision after delivery? How is a newborn assimilated into the
practiced? What are the prevalent childbearing myths? family?
Child rearing What are community expectations with regard to child Who are the main child rearers and caregivers? What
rearing? Does the community play a part in disciplining is the expected role of siblings, other relatives, and
children? fictive kin with regard to child rearing? Who are the
gender role models? What are the privileges and
responsibilities of children? What are the rules for
child behavior? What are the patterns of discipline?
Growth and development How does the community provide resources for all age How does the family provide for the very old and the
across the life span groups? What health, education, and recreational very young? What are the expectations for behavior
resources are available for the needs of each age group? of each age group? How are life milestones marked?
Reciprocity and exchange What is the means of exchange in the community (e.g., When are gifts shared? Who purchases gifts, pays
money, goods, services)? How is debt perceived? bills or taxes, and so forth? What is the meaning of
money, debt, wealth, and poverty? When and how
does one give and receive?
Customs and laws What laws and customs are followed in the community? What are the implicit and explicit family rules? Who
Who are the law and customs enforcers? Who are the makes the rules? Who breaks the rules? What are
cultural heroes? the consequences of rule breaking?
Health care providers Who are the health care providers (traditional and folk) in What health care providers does the family use? How
the community? What is the perception concerning the does the family perceive health care providers?
various kinds of health care providers? How do cultural When (under what circumstances) does the family
groups differ in their perceptions of health care providers? use a health care provider? What does the family
know about the traditional health care delivery
system, including health insurance?
Developed by Judith Strasser, PhD, RN. Copyright Elsevier.
CULTURALLY APPROPRIATE STRATEGIES FOR THE materials and good cultural informants. Although most
COMMUNITY/PUBLIC HEALTH NURSE WORKING nurses know how to conduct a literature search, the criteria
WITH DIVERSE COMMUNITIES for selecting an informant may be new knowledge. Spradley
(1979) has delineated the following four characteristics of a
The diversity among communities is enormous, and local good informant:
community consultation is important to understand what is • Thoroughly acculturated—part of the group for a long
culturally appropriate and acceptable within each community. time
To promote health in diverse cultural groups, providers must • Currently involved in the culture—an active participant in
do the following: the culture
• Learn about the history of the culture, the traditional ways of • Capable of nonanalytic reporting—describes things in local
life, and the communication patterns terms rather than the way the informant thinks the nurse
• Spend time in the community attending community events wants to hear it
• Incorporate the community's input in planning • Willing to participate—willing to share his or her time and
• Incorporate many of the traditional values, beliefs, and ways knowledge about the culture
of life into program design and use of educational materials Informants should be historically and actively a part of the
Website Resource 10D provides a more detailed list culture. A good informant should be able to talk about what is a
of strategies to use in culturally diverse settings. Important typical belief or behavior of the cultural group in the language
resources for a thorough cultural assessment are library of the people.
CONTEMPORARY ISSUES AND TRENDS 2001, Â�

significantly affected the number of refugee approv-
als and admissions. Nonetheless, in 2005, a total of 1,122,373
A considerable number of important issues are of interest to immigrants were admitted for lawful permanent residence
community/public health nurses who wish to become cultur- in the United States, an increase of 17.2% over the previous
ally competent. The following discussion identifies some of the year; in 2010, the number was 1,042,625 (U.S. Department
most current issues. of Homeland Security, 2011). Since 2000, legal immigration
increased as a percentage of all immigration. FigureÂ€10-6 shows
Refugee and Immigrant Populations the proportion of legal immigrants to this country from various
People migrate both across national borders and within them, regions of the world.
doing so in official (legal) and unofficial ways and for a wide Data from a study conducted by the Pew Hispanic Center
variety of reasons. Migration involves hellos and good-byes. If a reveal that undocumented migrants represent about 29%
person migrates alone to a sharply contrasting culture, severe of foreign-born residents (Passel, 2005). In 2009, 10.8 mil-
culture shock may occur. Culture shock is associated with feel- lion undocumented residents lived in the United States;
ings of panic, anger, denial, and depression and a sense of sepa- 63% entered before 2000, and 62% were from Mexico (U.S.
ration from others and even from one's own self-identity. This Department of Homeland Security, 2010). Although the num-
experience can have serious health consequences. Culture shock ber of unauthorized immigrants increased between 2000 and
can lead to acts of aggression toward self or others, a loss of 2007, the number decreased by 7% in 2008, partly due to the
appetite and sleep, and general malaise that can result in death. economic recession and stricter enforcement of immigration
People who come to a country to take up permanent resi- laws. California, Texas, and Florida have the largest number of
dence are called immigrants. Illegal or undocumented immi- unauthorized immigrants.
grants are in a country without the appropriate documentation
and permission. Refugees are persons who migrate to escape Socioeconomic Status of Minority Populations
persecution based on race, religion, nationality, or political per- and Health
suasion and come to the United States under special legal pro- An increasing body of evidence suggests that risk factors for
cedures, usually requiring congressional action. Asylees are health outcomes are related to socioeconomic status and race.
individuals seeking political asylum from persecution in their Rabin (1993) and Williams and Collins (2002) suggested that
own countries. These classifications are of importance to the the root cause of observed racial and ethnic Â�differences in
community/public health nurse because they often determine health status is actually social factors such as lifestyle, Â�behavior,
the rights of individuals to health and social services. attitudes, and socioeconomic status, not racial or ethnic influ-
All immigrants are at considerable risk for health and social ences. Evidence indicates that socioeconomic inequalities in
problems because of language and employment difficulties, health are often larger than racial and ethnic inequalities in health
limited economic resources, and, often, past traumatic life and may be the single most important influence on health and
events. Existing studies suggest that youth and adults suffer a health disparities among racial and ethnic groups (Rabin,
disproportionate burden of mental health problems and disor- 1993; Williams & Collins, 2002).
ders, and the suicide rate is 50% higher among immigrants than
in the population as a whole (USDHHS, 2006). Immigrants dis-
proportionately lack health insurance coverage, receive fewer Caribbean
health services than do native-born citizens, and experience (13%)
other barriers, including linguistic issues and eligibility changes Asia (without
China and India)
that have limited their ability to qualify for Medicaid (Kaiser (27%)
Family Foundation, 2010; see also ChaptersÂ€4 and 21).
Newer immigrants are most in need of special care. These Mexico
families must cope with a bewildering array of new experiences, (13%)
including the health care system. Many of these individuals
have come from countries with different methods of health care
delivery and different ways of interacting with health care pro- Central
viders. Over time, many immigrant families adapt their health America
practices and lifestyles to accommodate their new country's China (4%)
patterns and practices, a process called acculturation. (6%)
Foreign-born individuals account for 12% (37 million) of South
America
the total U.S. population (U.S. Bureau of the Census, 2010c; U.S. India (8%)
Department of Homeland Security, 2011). Over 80% of legal (6%)
immigrants in 2010 came from countries in the Americas and Other*
Africa
Asia. The top 10 countries from which legal immigrants came (3%) Europe
(10%)
to the United States are Mexico, China, India, the Philippines, (9%)
the Dominican Republic, Cuba, Vietnam, Haiti, Colombia, and FIGUREÂ€10-6â•‡Immigrants admitted to the United States by
Canada. Host countries have various ways of controlling both region and country of last residence, 2010. N = 1,042,625 immi-
grants. (Does not add to 100% due to rounding.) *Canada,
in-migration and out-migration. In the United States, although
Oceania, and not specified. (Data from U.S. Department of
in-migration is limited by a quota system and by visa require- Homeland Security. (2011). 2010 Yearbook of immigration statistics.
ments, many people enter illegally without following the Retrieved September 24, 2011 from http://www.dhs.gov/xlibrary/assets/
Â�prescribed procedures. The terrorist attacks of September 11, statistics/yearbook/2010/ois_yb_2010.pdf.)
In the United States, minorities are at greater risk of pov- BOXÂ€10-5â•…â•‡SAMPLE COMMUNITY
erty and its associated problems: higher unemployment, STANDARDS OF PRACTICE
lower educational levels, and shorter life expectancy. The FOR PROVISION OF QUALITY
nation's official poverty rate rose from 12.6% in 2004 to 2005
HEALTH CARE SERVICES FOR
to 15.1% in 2010 (DeNavas-Walt etÂ€al., 2006; U.S. Census
GAY, LESBIAN, BISEXUAL, AND
Bureau, 2011a). People of limited economic means have fewer
resources to pay for food, clothing, and shelter and are fre- TRANSGENDERED CLIENTS
quently unable to access or pay for health care services and • Personnel—Agency provides a nondiscriminatory workplace
treatment (see ChaptersÂ€4 and 21). Many individuals forgo for gay, lesbian, bisexual, and transgendered (GLBT) employees,
medical care to purchase other necessities. Preventive care including equal benefits, compensation, and terms of employment.
is a luxury that few low-income people can afford. Poverty • Client's rights—Agency assures nondiscriminatory delivery of
is related to other stressors that also affect health: occupa- services to GLBT clients, staff use culturally appropriate language,
tional and educational opportunities are limited, housing is and agency has a policy to file and resolve grievances, and broadly
often substandard and hazardous, and neighborhoods are interprets the term family to include domestic partners.
not safe. These and other social conditions create a highly • Service planning and delivery—Staff are familiar with GLBT
stressful environment that affects the health of individuals. issues as they pertain to health care services, and direct care staff
Nonetheless, racial differences often persist even when socio- are competent to deliver appropriate care.
economic levels are equivalent. For example, at each socioeco- • Confidentiality of documents—Agency ensures the confidenti-
nomic level, African Americans generally have worse health ality of documents, including information about sexual orientation
status than do whites. and gender identity.
Data from Community standards of practice for the provision of quality
Sexual Orientation health care services for lesbian, gay, bisexual, and transgendered
Other subpopulations with special needs experience dispari- clients. Retrieved September 24, 2011 from http://www.glbthealth.org/
ties and barriers to care that result in unmet needs or lack of CommunityStandardsofPractice.htm.
appropriate care or both. The health and quality of life of les-
bian, gay, bisexual, transgendered, and intersexed (having a Racism and Discrimination
physically ambiguous gender with components of both male Racism and discrimination are important variables in the
and female anatomy) (LGBTI) individuals are too often over- health of individuals and communities. Both of these practices
looked. LGBTI populations experience significant disparities are added stressors for minority populations. Racism com-
in health status and health care. Barriers are related to sexual monly refers to institutional and individual practices that create
identity, sexual behavior, and gender identity, and most of the and reinforce oppressive systems of race relations that adversely
unique health care needs of this group have gone unmet within restrict the lives of individuals of certain races (Krieger, 2000).
the nation's mainstream health care system (Gay and Lesbian Discrimination is the “differential and negative treatment of
Medical Association, 2001). As a result, many LGBTI individu- individuals based on their race, ethnicity, gender, or other group
als avoid or delay care or receive inappropriate or inferior care membership” (Smedley etÂ€al., 2003, p. 95). Discrimination
because of perceived or real homophobia and discrimination by occurs in the broader context of American life and is evidenced
health care providers and institutions. in disparate practices in education, mortgage lending, housing,
Negative attitudes of nurses, as well as fear, ignorance, and employment, and criminal justice. In health care, discrimina-
homophobia, have served as obstacles to providing culturally tion is reflected in documented differences in care that result
competent care for LGBTI persons. As recently as 1998, a survey from biases, prejudices, stereotyping, and uncertainty in clinical
of nursing students showed that 8% to 12% “despised” lesbian, communication and decision making.
gay, and bisexual people; 5% to 12% found them “disgusting”; The experiences of minority clients with the health care sys-
and 40% to 43% thought that LGB people should keep their sex- tem are very different from those of white Americans. Many
uality private (Eliason, 1998). The health of the LGBTI popula- minority clients perceive higher levels of racial discrimination
tion involves a wide range of health care issues, not unlike that of in health care than do whites (LaVeist etÂ€al., 2000; Lillie-Blanton
their non-LGBTI counterparts; but they also have some LGBTI- etÂ€al., 2000). Studies suggest that discrimination and stereotyp-
specific health needs related to HIV infection and AIDS, mening are present in the health care system. In one experiment,
tal health problems (such as suicide), exposure to violence, and physicians treating black and white actors were less likely to
other serious public health challenges. What may perhaps be of recommend cardiac catheterization for the black actors than
most importance are the clinical encounter and the health care for white actors who were exhibiting the same symptoms
experience. (Schulman etÂ€al., 1999). In a review of actual clinical encoun-
The Gay and Lesbian Medical Association provides a wealth of ters, doctors rated black clients as less intelligent, less educated,
resources and guidance on providing culturally competent care more likely to abuse drugs and alcohol, less apt to comply with
to this population. BoxÂ€10-5 provides a summary of community medical advice, more likely to lack social support, and less likely
standards for quality health care services for the LGBTI popula- to participate in cardiac rehabilitation than were white clients
tion. The complete list of standards and suggestions for creating in spite of controlling for income, education, and personality
a safe clinical environment for this population are provided on characteristics (van Ryn & Burke, 2000).
the book's website as Website Resources 10E and 10â•›F. This Some studies suggest that racial bias, restricted socioeconomic
information is a useful resource to assist the nurse in develop- opportunities and mobility, residence in poor neighborhoods, the
ing culturally appropriate approaches and providing quality stress of experiences of discrimination, and the acceptance of the
nursingÂ€care. societal stigma of inferiority all have deleterious consequences for
health (Williams, 1999). Personal negative emotional and stress • Participate in continuing education or professional develop-
responses associated with discrimination are linked to hyperten- ment programs to increase knowledge regarding minority
sion, cardiovascular disease, and mental illness (Finch etÂ€al., 2001; groups
Karlsen & Nazroo, 2002; Williams & Williams-Morris, 2000). • Develop a philosophy of lifelong learning
Community/public health nurses must be aware of differ- The ANA position statement on discrimination affirms the
ences in health care perceptions among health care providers professional nurse's role in eradicating discrimination and rac-
and the impact this may have on minority clients and commu- ism in the profession of nursing, in the education of nurses,
nity attitudes toward health care services. Watts (2003) suggests and in the practice of nursing, as well as in the organizations in
a four-step process to focus nurses in this area: which nurses work (ANA, 1992). All nurses must work to ensure
• Conduct a comprehensive self-appraisal of racial and ethnic a level of cultural and linguistic competence in addressing the
heritage needs of our increasingly culturally diverse population.
• Launch a culture interest group, with a focus on the health
concerns of a specific racial and ethnic group
KEY IDEAS
1. The changing demographics of the United States and the ensure that clients receive optimal health care and care that
persistent health disparities among racial and ethnic groups is sensitive to clients’ cultural values and beliefs.
present both challenges and opportunities for community/ 6. Community/public health nurses need to be sensitive to the
public health nurses to improve the health of communities. diversity that exists in communities and populations with
2. Cultural and linguistic competence is essential for provid- regard to culture, ethnicity, race, age, health status, religious
ing appropriate health care for diverse racial, ethnic, and affiliation, language, physical size, disability, geographical
cultural groups. location, political orientation, economic status, occupa-
3. Concepts of health, illness, and wellness and treatments tional and educational orientation, gender, sexual orienta-
evolve from a cultural perspective and are a part of the total tion, and life experiences.
cultural belief system. 7. Nurses should seek to avoid labeling or stereotyping and
4. Cultural competence is an ongoing process that involves assuming that all members of a culture are alike. Different
cultural awareness, cultural knowledge, cultural skill, cul- individuals within a specific culture will demonstrate varia-
tural encounters, and cultural desire. tions in their beliefs and behaviors.
5. Nurses need to explore the use of formal Western medical
practices and other formal and informal health Â�practices to
1. Caring for Miss Geraldine: an individual or group exercise in clinical nutrition assessment and intervention that is to
culturally competent care include weight reduction and client education (the usual
Miss Geraldine, an African American older woman, comes to treatment for hypertension is a course of diuretics and a
the clinic complaining of shortness of breath. On initial cur- beta-blocker for most clients).
sory examination, you find that she is obese, is in moderate Given your cultural and clinical knowledge:
respiratory distress, has moderately elevated blood pressure, • Is it likely that the nurse practitioner is demonstrating
and complains of tiredness. She tells you that she “has been incompetence in the treatment protocol by ordering a
big, like my family, all my life”; was “born with a veil over her different course of therapy?
face”; and has had “high blood” all her life. She says her blood • What information do you have regarding African
is very “thin.” She has frequent blackout spells as a result of American cultural practices that would be relevant to
her “high blood.” She has obvious large, irregularly patchy, this assessment?
unpigmented areas of skin over her face and neck. Her skin 2. Group exercise
appears to have a yellowish hue. Form two groups. Sue Toms and John Adams (fictitious
a. From your knowledge of cultural variations, answer the names) are the two study subjects. Each group selects one
questions below. What additional important questions of these individuals and specifies a cultural or ethnic group
will you ask Miss Geraldine? of their choice for the individual. The other group selects a
• What is the relevance of her sharing with you that she cultural or ethnic group for their individual that is different
was “born with a veil over her face”? from the first group's selection. (For example, Sue may be an
• What are the probable unpigmented areas over her face American Piscataway and John may be a Hispanic from El
and neck? Salvador.) With Sue designated as a member of cultural or
• How will you determine whether the yellowish tint is ethnic group No. 1 and John as a member of cultural or eth-
caused by jaundice? nic group No. 2, answer the following questions on the basis
b. After conducting an extensive physical examination of your knowledge and research of the two cultures. The two
and interview, the nurse practitioner prescribes a single groups should come back together to share what they learned
Â�antihypertensive drug for Miss Geraldine and orders a from their discussion, questions, and concerns.
L E A R N I N G BY E X P E R I E N C E A N D R E F L E C T I O N — C O N T ' D
a. Describe characteristic cultural phenomena that may be d. Discuss the correlation between Sue Toms's health/illness
associated with each individual (e.g., time orientation, and her race, culture or ethnicity, and class.
space relations). Discuss the health care beliefs, practices, e. Discuss the initiative to eliminate racial and ethnic dis-
and behaviors commonly associated with the cultural parities in health care as it may relate to John Adams.
group for each individual. f. Identify any biocultural variations that may be of sig-
b. List two reasons for learning about the cultural health nificance in the cultural assessment of both Sue and
care practices of each individual. John.
c. Describe one cognitive, one affective, and one behavioral
strategy in overcoming communication barriers with
each individual.

The Access Project http://www.accessproject.org/new/pages/index.php Transcultural Nursing Society http://www.tcns.org/
American Medical Student Association http://www.amsa.org/ The following sites provide cultural tools and other resources
AMSA/Homepage.aspx related to cultural care:
Center for Cross-Cultural Health http://www.caringcommunity. Compendium of Cultural Competence Initiatives in Health Care
org/node/view/361 http://www.kff.org/uninsured/6067-index.cfm
Cross Cultural Health Care Program http://www.xculture.org/ Multilingual Glossary of Medical Terms http://users.ugent.
EthnoMed http://ethnomed.org/ be/~rvdstich/eugloss/welcome.html
Gay and Lesbian Medical Association http://www.glma.org/ Multicultural Pavilion http://www.edchange.org/multicultural/
Multicultural Mental Health Australia http://www.dhi.gov.au/ index.html
Multicultural-Mental-Health-Australia/home/default.aspx Provider's Guide to Quality and Culture http:// erc.msh.org/mainpage.
National Center for Cultural Competence http://nccc.georgetown. cfm?file=1.0.htm&module=provider&language=English
edu/ U.S. Department of Health and Human Services, Office
National Council of La Raza's Institute for Hispanic Health of Minority Health, Center for Linguistic and Cultural
http://www.nclr.org/ Competence http://minorityhealth.hhs.gov/templates/browse.
National Multicultural Institute http://www.nmci.org/ aspx?lvl=2&lvlid=107
Transcultural C.A.R.E. Associates http://www.transculturalcare.net/
http://evolve.elsevier.com/Maurer/community

and assessment materials: also found on the Evolve site:
• NCLEX Review Questions 10A: Summary of Recommendations for Elimination of Health
• Critical Thinking Questions and Answers for Case Studies Disparities
• Care Plans 10B: Recommended Standards for Culturally and Linguistically
• Glossary Appropriate Services in Health Care
10â•›C: Complementary and Alternative Medicine Categories
10D: Working with Culturally Diverse Communities: Strategies
for the Community/Public Health Nurse
10E:Â€Community Standards of Practice for Provision of Quality
Health Care Services for Gay, Lesbian, Bisexual, and TransÂ�
gendered Clients
10â•›F: Guidelines for Creating a Welcoming Clinical Environment
for Gay, Lesbian, Bisexual, Transgendered, and Intersex
Patients
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U N I T
3
Family as Client
11 Home Visit: Opening the Doors for Family Health
12 A Family Perspective in Community/Public
HealthÂ€Nursing
13 Family Case Management
14 Multiproblem Families
297
CHAPTER
11
Home Visit: Opening the Doors
forÂ€Family Health
Claudia M. Smith
FOCUS QUESTIONS
Why are home visits conducted? How can a nurse's family focus be maximized during a typical
What are the advantages and disadvantages of home visits? home visit?
How is the nurse–client relationship in a home similar to What promotes safety for community/public health nurses?
and different from nurse–client relationships in inpatient What happens during a typical home visit?
settings? How can client participation be promoted?
CHAPTER OUTLINE
Home Visit Promoting Nurse Safety
Definition Clarifying the Nurse's Self-Responsibility
Purpose Promoting Safe Travel
Advantages and Disadvantages Handling Threats during Home Visits
Nurse–Family Relationships Protecting the Safety of Family Members
Principles of Nurse–Client Relationship with Family Managing Time and Equipment
Phases of Relationships Structuring Time
Characteristics of Relationships with Families Handling Emergencies
Increasing Nurse–Family Relatedness Promoting Asepsis in the Home
Fostering a Caring Presence Modifying Equipment and Procedures in
Creating Agreements for Relatedness the Home
Increasing Understanding through Communication Skills Postvisit Activities
Reducing Potential Conflicts Evaluating and Planning the Next Home Visit
Matching the Nurse's Expectations with Reality Consulting and Collaborating with the Team
Clarifying Nursing Responsibilities Making Referrals
Managing the Nurse's Emotions Legal Documentation
Maintaining Flexibility in Response to Client Reactions The Future of Evidence-Based Home-Visiting
Clarifying Confidentiality of Data Programs
KEY TERMS
Agreement Family focus Presence
Collaboration Genuineness Referral
Consultation Home visit
Empathy Positive regard
Nurses who work in all specialties and with all age groups can be practiced in any setting. However, a family's residence pro-
practice with a family focus, that is, thinking of the health of vides a special place for family-focused care.
each family member and of the entire family per se and consid- Community/public health nurses have historically sought to
ering the effects of the interrelatedness of the family members promote the well-being of families in the home setting (Zerwekh,
on health. Because being family focused is a philosophy, it can 1990). Community/public health nurses seek to promote health;
298
CHAPTER 11â•… Home Visit: Opening the Doors forÂ€Family Health 299
prevent specific illnesses, injuries, and premature death; and members may be called on to support an individual fam-
reduce human suffering. Through home visits, community/ ily member's adjustment to a chronic illness as well as take on
public health nurses provide opportunities for families to tasks and roles that the ill member previously performed. This
become aware of potential health problems, to receive antici- adjustment occurs over time and often takes place in the home.
patory education, and to learn to mobilize resources for health Community/public health nurses can assist families in making
promotion and primary prevention (Kristjanson & Chalmers, these adjustments.
1991; Raatikainen, 1991). In clients’ homes, care can be person- Since the late 1960s, deinstitutionalization of mentally ill cli-
alized to a family's coping strategies, problem-solving skills, and ents has shifted them from inpatient psychiatric settings to their
environmental resources (see ChapterÂ€13). own homes, group homes, correctional facilities, and the streets
During home visits, community/public health nurses can (see ChapterÂ€33). Nurses in the fields of community mental
uncover threats to health that are not evident when family mem- health and psychiatry began to include the relatives and sur-
bers visit a physician's office, health clinic, or emergency depart- rogate family members in providing critical support to enable
ment (Olds etÂ€al., 1995; Zerwekh, 1991). For example, during a the person with a psychiatric diagnosis to live at home (Mohit,
visit in the home of a young mother, a nursing student observed 1996; Stolee etÂ€al., 1996).
a toddler playing with a paper cup full of tacks and putting The hospice movement also recognizes the importance of
them in his mouth. The student used the opportunity to dis- a family focus during the process of a family member's dying
cuss safety with the mother and persuaded her to keep the tacks (American Nurses Association [ANA], 2007a). Care at home or
on a high shelf. The quality of the home environment predicts in a homelike setting is cost effective under many circumstances.
the cognitive and social development of an infant (Engelke & As the prevalence of acquired immunodeficiency syndrome
Engelke, 1992). Community/public health nurses successfully (AIDS) increases and the number of older adults continues to
assist parents in improving relations with their children and in increase, providing care in a cost-effective manner is both an
providing safe, stimulating physical environments. ethical and an economic necessity.
All levels of prevention can be addressed during home Â�visits. Nurses in any specialty can practice with a family focus.
Research has demonstrated that home visits by nurses dur- However, the specific goals and time constraints in each health
ing the prenatal and infancy periods prevent developmental care service setting affect the degree to which a family focus can
and health problems (Kitzman etÂ€al., 2000; Norr etÂ€al., 2003; be used. A home visit is one type of nurse–client encounter that
Olds etÂ€al., 1986). Olds and colleagues demonstrated that fami- facilitates a family focus. Home visiting does not guarantee a
lies who received visits had fewer instances of child abuse and family focus. Rather, the setting itself and the structure of the
neglect, emergency department visits, accidents, and poisonings encounter provide an opportunity for the nurse to practice with
during the child's first 2â•›years of life. These results were true for a family focus.
families of all socioeconomic levels but greater for low-income
families. The health outcomes for families who received home
visits were better than those of families that received care only
in clinics or from private physicians. Furthermore, the favor-
able results were still apparent 15â•›years after the birth of the first
child (Olds etÂ€al., 1997), and the home visits reduced subsequent
pregnancies (Kitzman etÂ€al., 1997; Olds etÂ€al., 1997). The U.S.
Advisory Board on Abuse and Neglect advocates such home-
visiting programs as a means to prevent child abuse and neglect
(U.S. Department of Health and Human Services, 1990). Other
research shows that home visits by nurses can reduce the inci-
dence of drug-resistant tuberculosis and decrease preventable
deaths among infected individuals (Lewis & Chaisson, 1993).
This goal is achieved through directly observing medication
therapy in the individual's home, workplace, or school on a
daily basis or several times a week (see ChapterÂ€8).
Several factors have converged to expand opportunities for
nursing care to adults and children with illnesses and disabili-
ties in their homes. The American population has aged, chronic
diseases are now the major illnesses among older persons, and
attempts are being made to limit the rising hospital costs. As the
average length of stay in hospitals has decreased since the early
1980s, families have had to care for more adults and children with
acute illnesses in their homes. This increased demand for home
health care has resulted in more agencies and nurses providing
home care to the ill and teaching family members to perform the
care (see ChapterÂ€31).
The degree to which families cope with a member with a
chronic illness or disability significantly affects both the indi-
vidual's health status and the quality of life for the entire family A nurse visiting a client in his home listens to the man's heart
(Burns & Gianutsos, 1987; Harris, 1995; Whyte, 1992). Family while his daughter looks on.
300 CHAPTER 11â•… Home Visit: Opening the Doors forÂ€Family Health
Nurses who graduate from a baccalaureate nursing pro- (3)Â€patternsÂ€and knowledge of health maintenance, and
gram are expected to have educational experiences that prepare (4)Â€family dynamics and structure (Simmons, 1980). Home vis-
them for beginning practice in community/public health nurs- its are one means by which community/public health nurses
ing. Family-focused care is an essential element of community/ can address these problems and achieve goals for family health.
public health nursing. One of the ways to improve the health
of populations and communities is to improve the health of Advantages and Disadvantages
Â�families (ANA, 2007b). Advantages of home visits by nurses are numerous. Most of the
Home visits may be made to any residence: apartments for disadvantages relate to expense and concerns about unpredict-
older adults, group homes, boarding homes, dormitories, domi- able environments (BoxÂ€11-1).
ciliary care facilities, and shelters for the homeless, among oth-
ers. In these residences, the family may not be related by blood,
but, rather, they may be significant others: neighbors, friends,
acquaintances, or paid caregivers. TABLEÂ€11-1â•…â•‡FAMILY HEALTH-RELATED
Nurses who are educated at the baccalaureate level are one PROBLEMS AND GOALS
of a few professional and service workers who are formally
taught about making home visits. Some social work students, PROBLEM* GOAL
especially those interested in the fields of home health and pro- Lifestyle and resources Promote support systems and use of
tective services, also receive similar education. The American health-related resources
Red Cross and the National Home Caring Council have devel- Health status deviations Promote adequate, effective family
oped training programs for homemakers and home health care of a member with an illness or
aides; not all aides have received such extensive training, how- disability
ever. Agricultural and home economic extension workers in the Patterns and knowledge Encourage growth and development
United States and abroad also may make home visits (Murray, of health maintenance of family members, health
1968; World Health Organization, 1987). promotion, and illness prevention
Promote a healthful environment
Family dynamics and Strengthen family functioning and
HOME VISIT structure relatedness
Definition *Problems from Simmons, D. (1980). A classification scheme for client
A home visit is a purposeful interaction in a home (or resi- problems in community health nursing (DHHS Pub No. HRA 8016).
dence) directed at promoting and maintaining the health of Hyattsville, MD: U.S. Department of Health and Human Services.
individuals and the family (or significant others). The service
may include supporting a family during a member's death.
Just as a client's visit to a clinic or outpatient service can be
viewed as an encounter between health care professionals and BOXÂ€11-1â•…â•‡ADVANTAGES AND
the client, so can a home visit. A major Â�distinction of a home DISADVANTAGES OF HOME
visit is that the health care professional goes to the client VISITING
rather than the client coming to the health care professional.
Advantages
Purpose • Home setting provides more opportunities for individualized care.
• Most people prefer to receive care at home.
Almost any health care service can be accomplished on a
• Environmental factors impinging on health, such as housing condi-
home visit. An assumption is that—except in an emergency—
tion and finances, may be observed and considered more readily.
the client or family is sufficiently healthy to remain in the
• Collecting information and understanding lifestyle values are easier
community and to manage health care after the nurse leaves in family's own environment.
the home. • Participation of family members is facilitated.
The foci of community/public health nursing practice in the • Individuals and family members may be more receptive to learn-
home can be categorized under five basic goals: ing because they are less anxious in their own environments and
1. Promoting support systems that are adequate and effective because the immediacy of needing to know a particular fact or skill
and encouraging use of health-related resources becomes more apparent.
2. Promoting adequate, effective care of a family member who • Care to ill family members in the home can reduce overall costs by
has a specific problem related to illness or disability preventing hospitalizations and shortening the length of time spent
3. Encouraging normal growth and development of family in hospitals or other institutions.
members and the family and educating the family about • A family focus is facilitated.
health promotion and illness prevention
4. Strengthening family functioning and relatedness Disadvantages
5. Promoting a healthful environment • Travel time is costly.
• Home visiting is less efficient for the nurse than working with
The five basic goals of community/public health nursing
groups or seeing many clients in an ambulatory site.
practice with families can be linked to categories of family prob-
• Distractions such as television and noisy children may be more dif-
lems (TableÂ€11-1). A pilot study to identify problems common
ficult to control.
in community/public health nursing practice settings revealed • Clients may be resistant or fearful of the intimacy of home visits.
that problems clustered into four categories: (1) lifestyle and • Nurse safety can be an issue.
living resources, (2) current health status and Â� deviations,
NURSE–FAMILY RELATIONSHIPS
How nurses are assigned to make home visits is both a phil-
osophical and a management issue. Some community/public
health nurses are assigned by geographical area or district. The
size of the geographical area for home visits varies with the pop-
ulation density. In a densely populated urban area, a nurse might
visit in one neighborhood; in a less densely populated area, the
nurse might be assigned to visit in an entire county. With geo-
graphical assignments, the nurse has the potential to work with
the entire population in a district and to handle a broad range
of health concerns; the nurse can also become well acquainted
with the community's health and social resources. The poten-
tial for a family-focused approach is strengthened because the
nurse's concerns consist of all health issues identified with a
specific family or group of families. The nurse remains a clinical
generalist, working with people of all ages.
Other community/public health nurses are assigned to work
with a population aggregate in one or more geopolitical com-
munities. For example, a nurse may work for a categorical pro- A nurse enters the home of a client with a young child.
gram that addresses family planning or adolescent pregnancy,
in which case the nurse would visit only families to which the All Levels of Prevention
category applies. This type of assignment allows a nurse to work Through assessment, the community/public health nurse
predominantly with a specific interest area (e.g., family plan- attempts to identify what actual and potential problems or con-
ning and pregnancy) or with a specific aggregate (e.g., families cerns exist with each individual and, thematically, within the
with fertile women). family (see ChapterÂ€13). Issues of health promotion (diet) and
specific protection (immunization) may exist, as may undiag-
Principles of Nurse–Client Relationship with Family nosed medical problems for which referral is necessary for fur-
Regardless of whether the community/public health nurse is ther diagnosis and treatment. Home visits also can be effective
assigned to work with an aggregate or the entire population, in stimulating family members to seek appropriate services such
several principles strengthen the clarity of purpose: as prenatal care (Bradley & Martin, 1994) and immunizations
• By definition, the nurse focuses on the family. (Norr etÂ€al., 2003). Actual family problems in coping with illness
• The health focus can be on the entire spectrum of health or disability may require direct intervention. Preventing sequelae
needs and all three levels of prevention. and maximizing potential may be appropriate for families with a
• The family retains autonomy in health-related decisions. chronically ill member. Health-related problems may appear pre-
• The nurse is a guest in the family's home. dominantly in one family member or among several members.
A thematic family problem might be related to nutrition. For
Family Focus example, a mother may be anemic, a preschooler may be obese,
To relate to the family, the community/public health nurse and a father may not follow a low-fat diet for hypertension.
does not have to meet all members of the household person-
ally, although varying the times of visits might allow the nurse Family Autonomy
to meet family members usually at work or school. Relating A few circumstances exist in our society in which the health of
to the family requires that the nurse be concerned about the the community, or public, is considered to have priority over
health of each member and about each person's contribution the right of individual persons or families to do as they wish.
to the functioning of the family. One family member may be In most states, statutes (laws) provide that health care workers,
the primary informant; in such instances, the nurse should including community/public health nurses, have a right and
realize that the information received is being filtered by the an obligation to intervene in cases of family abuse and neglect,
person's perceptions. potential suicide or homicide, and existence of communicable
The community/public health nurse should take the time diseases that pose a threat of infection to others. Except for these
to introduce herself or himself to each person present and three basic categories, the family retains the ultimate authority for
address each person by name. Building trust is an essen- health-related decisions and actions.
tial foundation for a continued relationship (Heaman etÂ€al., In the home setting, family members participate more in their
2007; McNaughton, 2000; Zerwekh, 1992). The nurse should own care. Nursing care in the home is intermittent, not 24 hours
use the clients’ surnames unless they introduce themselves in a day. When the visit ends, the family takes responsibility for their
another way or give permission for the nurse to be less formal. own health, albeit with varying degrees of interest, commitment,
Interacting with as many family members as possible, identify- knowledge, and skill. This role is often difficult for beginning
ing the family member most responsible for health issues, and community/public health nurses to accept; learning to distin-
acknowledging the family member with the most authority are guish the family's responsibilities from the nurse's responsibilities
important. The nurse should ask for an introduction to pets involves experience and consideration of laws and ethics. Except
and ask for permission before picking up infants and children in crises, taking over for the family in areas in which they have
unless it is granted nonverbally. demonstrated capability is usually inappropriate.
For example, if family members typically call the pharmacy PHASES OF A HOME VISIT
to renew medications and make their own medical appoint-
ments, beginning to do these things for them is inappropriate 1. Preplanning 5. Post home visit
for the nurse. Taking over undermines self-esteem, confidence, and preplanning
and success.
Nurse as Guest
Being a guest as a community/public health nurse in a fam- 4. Termination 2. Initiation
ily's home does not mean that the relationship is social. The
social graces for the community and culture of the family must
be considered so that the family is at ease and is not offended.
However, the relationship is intended to be therapeutic. For 3. Implementation
example, many older persons believe that offering something FIGUREÂ€11-2â•‡Phases of a home visit. (Redrawn from Smith, C.
to eat or drink is important as a sign that they are being cour- [1980]. Phases of a home visit [Unpublished manuscript]. Baltimore,
teous and hospitable. Because your refusal to share in a glass of MD: University of Maryland School of Nursing.)
iced tea may be taken as an affront, you may opt to accept the
tea. However, you certainly have the right to refuse, especially if Preplanning each telephone call and home visit is helpful.
infectious disease is a concern. BoxÂ€11-2 lists activities in which community/public health
Validate with the client that the time of the visit is conve- nurses usually engage before a home visit. The list can be used
nient. If the client fails to offer you a seat, you may ask if there is as a guide in helping novice community/public health nurses
a place for you and the family to sit and talk. This place may be organize previsit activities efficiently.
any room of the house or even outside in good weather. The visit begins with a reintroduction and a review of the
plan for the day; the nurse must assess what has happened with
Phases of Relationships the family since the last encounter. At this point, the nurse may
Relatedness and communication between the nurse and the renegotiate the plan for the visit and implement it. The end
client are fundamental to all nursing care. A nurse–client rela- of the visit consists of summarizing, preparing for the next
tionship with a family (rather than an individual) is critical to encounter, and leave-taking. BoxÂ€11-3 describes the commu-
community/public health nursing. The phases of the nurse–Â� nity/public health nurse's typical activities during a home visit.
client relationship with a family are the same as are those with
an individual. Different schemes have been developed for nam- Characteristics of Relationships with Families
ing phases of relationships. All schemes have (1) a preinitiation Some differences are worth discussing in nurses’ relationships
or preplanning phase, (2) an initiation or introductory phase, with families compared with those with individual clients in
(3) a working phase, and (4) an ending phase (Arnold & Boggs, hospitals. The difference that usually seems most significant to
2011). Some schemes distinguish a power and control or con- the nurse who is learning to make home visits is the fact that the
tractual phase that occurs before the working phase.
The initiation phase may take several visits. During this
phase, the nurse and the family get to know one another and BOXÂ€11-2â•…â•‡PLANNING BEFORE A
determine how the family health problems are mutually defined. HOMEÂ€VISIT
The more experience the nurse has, the more efficient she or he â•‡1. Have name, address, and telephone number of the family, with
will become; initially, many community/public health nursing directions and a map.
students may require four to six visits to feel comfortable and to â•‡ 2. Have telephone number of agency by which supervisor or faculty
clarify their role (Barton & Brown, 1995). can be reached.
The nursing student should keep in mind that the relation- â•‡ 3. Have emergency telephone numbers for police, fire, and emer-
ship with the family usually involves many encounters over gency medical services (EMS) personnel.
time—home visits, telephone calls, or visits at other ambulatory â•‡ 4. Clarify who has referred the family to you and why.
sites such as clinics. Several encounters may occur during each â•‡ 5. Consider what is usually expected of a nurse in working with
phase of the relationship (FigureÂ€11-1). Each encounter also has a family that has been referred for these health concerns (e.g.,
its own phases (FigureÂ€11-2). postpartum visit), and clarify the purposes of this home visit.
â•‡ 6. Consider whether any special safety precautions are required.
â•‡ 7. Have a plan of activities for the home visit time (see BoxÂ€11-3).
PHASE
â•‡ 8. Have equipment needed for hand-washing, physical assessment,
Initiation Working Ending
OF and direct care interventions, or verify that client has the equip-
RELATIONSHIP: ment in the home.
â•‡ 9. Take any data assessment or permission forms that are needed.
10. Have information and teaching aids for health teaching, as
appropriate.
ENCOUNTER: Phone Home Home Home Home Phone Home Home 11. Have information about community resources, as appropriate.
call Visit Visit Visit Visit call Visit Visit 12. Have gasoline in your automobile or money for public
FIGUREÂ€11-1â•‡A series of encounters during a relationship. transportation.
(Redrawn from Smith, C. [1980]. A series of encounters during a 13. Leave an itinerary with the agency personnel or faculty.
relationship [Unpublished manuscript]. Baltimore, MD: University of 14. Approach the visit with self-confidence and caring.
Maryland School of Nursing.)
BOXÂ€11-3â•…â•‡NURSING ACTIVITIES DURING THREE PHASES OF A HOME VISIT

Initiation Phase of Home Visit 12. Conduct physical assessment, as appropriate, and perform direct
â•‡1. Knock on door, and stand where you can be observed if a peephole physical care.
or window exists. 13. Identify household members and their health needs, use of commu-
â•‡ 2. Identify self as [name], the nurse from [name of agency]. nity resources, and environmental hazards.
â•‡ 3. Ask for the person to whom you were referred or the person with 14. Explore values, preferences, and clients’ perceptions of needs and
whom the appointment was made. concerns.
â•‡ 4. Observe environment with regard to your own safety. 15. Conduct health teaching as appropriate, and provide written
â•‡ 5. Introduce yourself to persons who are present and acknowledge them. instructions. Include any safety recommendations.
â•‡ 6. Sit where family directs you to sit. 16. Discuss any referral, collaboration, or consultation that you
â•‡ 7. Discuss purpose of visit. On initial visits, discuss services to be pro- recommend.
vided by agency. 17. Provide comfort and counseling, as needed.
â•‡ 8. Have permission forms signed to initiate services. This activity may
be done later in the home visit if more explanation of services is Termination Phase of Home Visit
needed for the family to understand what is being offered. 18. Summarize accomplishments of visit.
19. Clarify family's plan of care related to potential health emergency
Implementation Phase of Home Visit appropriate to health problems.
â•‡9. Complete health assessment database for the individual client. 20. Discuss plan for next home visit and discuss activities to be accom-
10. On return visits, assess for changes since the last encounter. plished in the interim by the community/public health nurse, indi-
Explore the degree that family was able to follow up on plans from vidual client, and family members.
previous visit. Explore barriers if follow-up did not occur. 21. Leave written identification of yourself and agency, with telephone
11. Wash hands before and after conducting any physical assessment numbers.
and direct physical care.
nurse has less control over the family's environment and health- discussing the possibilities the family declines either overtly or
related behavior (McNaughton, 2000). The relationship usually through its actions, the nurse has provided an opportunity for
extends for a longer period. A more interdependent relationship informed decision making and has no further obligation.
develops between the community/public health nurse and the
family throughout all steps of the nursing process. Goals of Nursing Care Are Long Term
A second major difference in nurse relationships with families is
Families Retain Much Control that the goals are usually more long term than are those with indi-
The family can control the nurse's entry into the home by vidual clients in hospitals. Clients may be in hospice programs
explicitly refusing assistance, establishing the time of the visit, for 6â•›months. A family with a member who has a recent diagnosis
or deciding whether to answer the door. Unlike hospitalized cli- of hypertension may take 6â•›weeks to adjust to medications, diet,
ents, family members can just walk away and not be home for and other lifestyle changes. A school-aged child with a diagnosis
the visit. One study of home visits to high-risk pregnant women of attention deficit disorder may take as long as half the school
revealed that younger and more financially distressed women year to show improvement in behavior and learning; sometimes,
tended to miss more appointments for home visits (Josten etÂ€al., a year may be required for appropriate classroom placement.
1995). Being rejected by the family is often a concern of nurses For some nurses, this time frame is judged to be slow and
who are learning to conduct home visits. As with any relation- tedious. For others, the time frame is seen as an opportunity to
ship, anxiety can exist in relation to meeting new, unknown know a family in more depth, share life experiences over time, and
families. Families may actually have similar feelings about see results of modifications in nursing care. For nurses who like to
meeting the nurse and may wonder what the nurse will think of know about a broad range of health and nursing issues, relation-
them, their lifestyle, and their health care behavior. ships with families stimulate this interest. Having had some expe-
A helpful practice is to keep your perspective; if the clients are rience in home visiting is helpful for nurses who work in inpatient
home for your visit, they are at least ambivalent about the meet- settings; it allows them to appreciate the scope and depth of prac-
ing! If they are at home to answer the door, they are willing to tice of community/public health nurses who make home visits
consider what you have to offer. as a part of their regular practice. These experiences can sensitize
Most families involved with home care of the ill have requested hospital nurses to the home environments of their clients and can
assistance. Because only a few circumstances exist (as previously result in better hospital discharge plans and referrals.
discussed) in which nursing care can be forced on families, the Because ultimate goals may take a long time to achieve, short-
nurse can view the home visit as an opportunity to explore vol- term objectives must be developed to achieve long-term goals.
untarily the possibility of engaging in relationships (Byrd, 1995). For example, a family needs to be able to plan lower-Â�calorie
The nurse is there to offer services and engage the family in a menus with sufficient nutrients before weight loss is possible; a
dialogue about health concerns, barriers, and goals. As with all parent may need to spend time with a child daily before unruly
nurse–client relationships, the nurse's commitment, authenticity, behavior improves.
and caring constitute the art of nursing practice that can make a Nursing interventions in a hospital setting become short-
difference in the lives of families. Just as not all individuals in the term objectives for client learning and mastery in the home set-
hospital are ready or able to use all of the suggestions made to ting. In an inpatient setting, giving medications as prescribed is
them, families have varying degrees of openness to change. IfÂ€after a nursing action. In the home, the spouse giving medications as
prescribed becomes a behavioral objective for the family; the the family situation. For example, a young mother with a healthy
related nursing action is teaching. newborn may not have thought about how to determine when
Human progress toward any goal does not usually occur at her baby is ill. A spouse caring for his wife with Alzheimer disease
a steady pace. For example, you may start out bicycling faith- may not know what safety precautions are necessary. Community/
fully three times a week and give up abruptly. Similarly, clients public health nurses seek to enhance family competence by shar-
may skip an insulin dose or an oral contraceptive. A family may ing their professional knowledge with families and building on the
assertively call appropriate community agencies, keep appoint- family's experience (Reutter & Ford, 1997; SmithBattle, 2009).
ments, and stop abruptly. Families can be committed to their Flexibility is a key. Because visits occur over several days to
own health and well-being and yet not act on their commitment months, other events (e.g., episodic illnesses, a neighbor's death,
consistently. Recognizing that setbacks and discouragement are community unemployment) can impinge on the original plan.
a part of life allows the community/public health nurse to be Family members may be rehospitalized and receive totally new
more accepting of reality and have the objectivity to renegotiate medical orders once they are discharged to home. The nurse's
goals and plans with families. BoxÂ€11-4 includes evidence-based clarity of purpose is essential in identifying and negotiating
ways to foster goal accomplishment. other health-related priorities after the first concerns have been
Changes are sometimes subtle or small. Success breeds suc- addressed (Monsen, Radosevich, Kerr, & Fulkerson, 2011).
cess, at least motivationally. The short-term goals on which
everyone has agreed are important to make clear so that the INCREASING NURSE–FAMILY RELATEDNESS
nurse and the family members have a common basis for eval-
uation. Goals can be set in a logical sequence, in small steps, What promotes a successful home visit? What aspects of the
to increase the chance of success. In an inpatient setting, the nurse's presence promote relatedness? What structures provide
skilled nurse notices the subtle changes in client behavior and direction and flexibility? The nursing process provides a gen-
health status that can warn of further disequilibrium or can sig- eral structure, and communication is a primary vehicle through
nal improvement. Similarly, during a series of home visits, the which the nursing process is manifested. The foundation for
skilled nurse is aware of slight variations in home management, both the nursing process and communication is relatedness
personal care, and memory that may presage a deteriorating and caring (ANA, 2003; McNaughton, 2005; Roach, 1997;
biological or social condition. SmithBattle, 2009; Watson, 2002; Watson, 2005).
Nursing Care Is More Interdependent with Families Fostering a Caring Presence

Because families have more control over their health in their Nursing efforts are not always successful. However, by being
own homes and because change is usually gradual, greater concerned about the impact of home visits on the family and
emphasis must be placed on mutual goals if the nurse and fam- by asking questions regarding her or his own motivations, the
ily are to achieve long-term success. nurse automatically increases the likelihood that home visits
Except in emergency situations, the client determines the will be of benefit to the family. The nurse is acknowledging that
priority of issues. A parent may be adamant that obtaining the intention is for the relationship to be meaningful to both the
food is more important than obtaining their child's immuni- nurse and the family.
zation. A child's school performance may be of greater con- Building and preserving relationships is a central focus of
cern to a mother than is her own abnormal Papanicolaou (Pap) home visiting and requires significant effort (Heaman etÂ€al.,
smear results. Failure of the nurse to address the family's pri- 2007; McNaughton, 2000, 2005). The relatedness of nurses in
mary priority may result in the family perceiving that the nurse community health with clients is important (Goldsborough,
does not genuinely care. At times, the priority problem is not 1969; SmithBattle, 2009; Zerwekh, 1992).
directly health related, or the solution to a health problem can
Involvement, essentially, is caring deeply about what is hap-
be handled better by another agency or discipline. In these
pening and what might happen to a person, then doing
instances, the empathic nurse can address the family's stress
something with and for that person. It is reaching out and
level, Â�problem-solving ability, and support systems and make
touching and hearing the inner being of another… . For a
appropriate referrals. When the nurse takes time to validate and
nurse–client relationship to become a moving force toward
discuss the primary concern, the relationship is enhanced.
action, the nurse must go beyond obvious nursing needs and
Families are sometimes unaware of what they do not know. The
try to know the client as a person and include him in plan-
nurse must suggest health-related topics that are appropriate for
ning his nursing care. This means sharing feelings, ideas,
beliefs and values with the client… . Without responsibil-
BOXÂ€11-4â•…â•‡BEST PRACTICES IN ity and commitment to oneself and others…[a person] only
FOSTERING GOAL exists. It is through interaction and meaningful involvement
with others that we move into being human (Goldsborough,
ACCOMPLISHMENT WITH
1969, pp. 66-68).
FAMILIES
Mayers (1973, p. 331) observed 16 randomly selected nurses
1. Share goals explicitly with family.
during home visits to 37 families and reported that “regardless
2. Divide goals into manageable steps.
of the specific interaction style [of each nurse], the clients of
3. Teach the family members to care for themselves.
nurses who were client-focused consistently tended to respond
4. Do not expect the family to do something all of the time or perfectly.
5. Be satisfied with small, subtle changes. with interest, involvement and mutuality.” A client-focused
6. Be flexible. nurse was observed as one who followed client cues, attempted
to understand the client's view of the situation, and included
the client in generating solutions. Being related is a contribution a characteristic of a helping relationship with spirituality or “a
that the nurse can make to the family, independent of specific sense of connection to life itself ” (Haber etÂ€al., 1987, p. 78).
information and technical skills, a contribution that students Empathy is a necessary pathway for our relatedness.
often underestimate. However, what does understanding another person's experi-
Although being related is necessary, it is inadequate in itself ence mean? More than emotions are involved. A person's expe-
for high-quality nursing. A community/public health nurse rience includes the sense that she or he makes of aspects of
must also be competent. Community/public health nursing human existence (SmithBattle, 2009; van Manen, 1990). Being
also depends on assessment skills, judgment, teaching skills, safe understood means that a person is no longer alone (Arnold,
technical skills, and the ability to provide accurate information. 1996). Being understood provides support in the face of stress,
As a community/public health nurse's practice evolves, tension illness, disability, pain, grief, and suffering. When a client feels
always exists between being related and doing the tasks. In each understood in a nurse–client partnership (side-by-side rela-
situation, an opportunity exists to ask, “How can I express my tionship), the client's experience of being cared for is enhanced
caring and do (perform direct care, teach, refer) what is needed?” (Beck, 1992).
Barrett (1982) and Katzman and colleagues (1987) reported To understand another person's experience, you must be
on the differences that students actually make in the lives of able to imagine being in her or his place, recognize common-
families. Barrett (1982) demonstrated that postpartum home alities among persons, and have a secure sense of yourself
visits by nursing students reduced costly postpartum emer- (Davis, 1990). Being aware of your own values and boundar-
gency department and hospital visits. Katzman and co-workers ies is helpful in retaining your identity in your interactions
(1987) considered hundreds of visits per semester made by 80 with others. To understand another individual's experience,
students in a southwestern state to families with newborns, well you must also be willing to engage in conversation to nego-
children, pregnant women, and members with chronic illnesses. tiate mutual definitions of the situation. For example, if you
Case examples describe how student enthusiasm and involve- are excited that an older person is recovering function after a
ment contributed to specific health results. stroke, but the person's spouse sees only the loss of an active
Everything a nurse has learned about relationships is impor- travel companion, a mutual definition of the situation does
tant to recall and transfer to the experience of home visiting. not exist. Empathy will not occur unless you can also under-
Carl Rogers (1969) identified three characteristics of a helping stand the spouse's perspective.
relationship: positive regard, empathy, and genuineness. These As human beings, we all like to perceive that we have some
characteristics are relevant in all nurse–client relationships, and control in our environment, that we have some choice. We avoid
they are especially important when relationships are initiated being dominated and conned. The nurse's genuineness facili-
and developed in the less-structured home setting. Presence tates honesty and disclosure, reduces the likelihood that the
means being related interpersonally in ways that reveal positive family will feel betrayed or coerced, and enhances the relation-
regard, empathy, genuineness, and caring concern. ship. Genuineness does not mean that you speak everything that
How is it possible to accept a client who keeps a disorderly you think. Genuineness means that what you say and do is con-
house or who keeps such a clean house that you feel as if you sistent with your understanding of the situation.
are contaminating it by being there? How is it possible to have The nurse can promote genuine self-expression in others
positive feelings about an unmarried mother of three when you by creating an atmosphere of trust, accepting that each person
and your partner have successfully avoided pregnancy? Having has a right to self-expression, “actively seeking to understand”
positive regard for a family does not mean giving up your own others, and assisting them to become aware of and understand
values and behavior (see ChapterÂ€10). Having positive regard themselves (Goldsborough, 1969, p. 66). When family mem-
for a family that lives differently from the way you do does not bers do not believe that being genuine with the nurse is safe,
mean you need to ignore your past experiences. The latter is they may tell only what they think the nurse would like to hear.
impossible. Rather, having positive regard means having the This action makes developing a mutual plan of care much
ability to distinguish between the person and her or his behav- more difficult.
ior. Saying to yourself, “This is a person who keeps a messy The reciprocal side of genuineness is being willing to under-
house” is different from saying, “This person is a mess!” Positive take a journey of self-expression, self-understanding, and
regard involves recognizing the value of persons because they growth. Tamara, a recent nursing graduate, wrote about her
are human beings. Accept the family, not necessarily the fam- growing self-responsibility:
ily's behavior. All behavior is purposeful; and without further
information, you cannot determine the meaning of a particular “Although I felt out of control, I felt very responsible. I took
family behavior. Positive regard involves looking for the com- pride in knowing that these families were my families, and
mon human experiences. For example, it is likely that both you I was responsible for their care. I was responsible for their
and client family members experience awe in the behavior of a health teaching. This was the first semester where there was
newborn and sadness in the face of loss. no a faculty member around all day long. I feel that this will
Empathy is the ability to put yourself in someone else's help me so much as I begin my nursing career. I have truly
shoes and to be able to walk in her or his footsteps so as to felt independent and completely responsible for my actions
understand her or his journey. “Empathy requires sensitivity in this clinical experience.”
to another's experience…including sensing, understanding,
and sharing the feelings and needs of the other person, seeing This student, who preferred predictable environments, was
things from the other's perspective” according to Rogers (cited able to confront her anxiety and anger in environments in which
in Gary & Kavanagh, 1991, p. 89). Empathy goes beyond self much was beyond her control. A mother was not interested in
and identity to acknowledge the essence of all persons. It links the student's priorities. A family abruptly moved out of the state
in the middle of the semester. Nonetheless, the student was able be most helpful, why they are willing to work with a nurse or
to respond in such circumstances. She became more responsi- student again, and what goals they have in mind. Other fami-
ble, and she was able to temper her judgment and work with the lies who have had no prior experience with community/Â�public
mother's concern. When the family moved, the student experi- health nurses may not have specific expectations. Asking is
enced frustration and anger that she would not see the “fruits of important.
her labor” and that she would “have to start over” with another A contract is a specific, structured agreement regarding the
family. However, her ability to respond increased because of her process and conditions by which a health-related goal will be
commitment to her own growth, relatedness with families, and sought. In the beginning of most student learning experiences,
desire to contribute to the health and well-being of others. the agreement usually entails one or more family members con-
In a context of relating with and advocating for the family, tinuing to meet with the nursing student for a specific num-
the relationship becomes an opportunity for growth in both the ber of visits or weeks. Initially, specific goals and the nurse's
nurse's and the family's lives (Glugover, 1987). Imagine stand- role regarding health promotion and illness prevention may be
ing side-by-side with the family, being concerned for their well- unclear. (If this role was already clear, undergoing a period of
being and growth. Now imagine talking to a family face-to-face, study and orientation would be unnecessary.)
attempting to have them do things your way. The first image is a Initially, the agreement may be as simple as, “We will meet
more caring and empathic one. here at your house next Tuesday at 11:00â•›am until around noon
to continue to discuss what I can offer related to your family's
Creating Agreements for Relatedness health and what you'd like. We can get to know each other bet-
How can communications be structured to increase the par- ter. We can talk more about how the week has gone for you
ticipation of family members? Without the family's engage- and your family with your new baby.” These statements are
ment, the community/public health nurse will have few positive the nurse's oral offer to meet under specific conditions of time
effects on the health behavior and health status of the family and place. The process of mutual discussion is mentioned. The
and its members. goals remain general and implicit: fostering the family's devel-
Nurses are expert in caring for the ill; in knowing about ways opmental task of incorporating an infant and fostering family–
to cope with illness, to promote health, and to protect against nurse relatedness. For the next week's contract to be complete,
specific diseases; and in teaching and supporting family mem- the family member or members would have to agree. The most
bers. Family members are experts in their own health. They important element initially is whether agreement about being
know the family health history, they experience their health present at a specific time and place can be reached. If 11:00â•›am
states, and they are aware of their health-related concerns. is not workable for the family, would another time during the
Through the nurse–family relationship, a fluid process takes day when you both are available be mutually agreeable? For
place of matching the family's perceived needs with the nurse's families who do not focus as much on the future, a commu-
perceptions and professional judgments about the family's nity/public health nurse needs to be more flexible in schedul-
needs. Paradoxically, the more skilled the nurse is in forgetting ing the time of each visit.
her or his own anxiety about being the good nurse, the more The word contract often implies legally binding agreements.
likely the nurse is to listen to the family members, validate their This is not true of nurse–client contracts. Nurses are legally and
reality, and negotiate an adequate, effective plan of care. ethically bound to keep their word in relation to nursing care;
One study of home visits revealed that more than half of the clients are not legally bound to keep their agreements. However,
goals stated by public health nurses to the researcher could not establishing a mutual agreement for relating increases the clarity
be detected, even implicitly, during observations of the home of who will do what, when, where, for what purposes, and under
visits. Therefore, half the goals were known only to the nurse what conditions. Because of some people's negative response to
and were, therefore, not mutual. The more specifically and con- the word contract, agreement or discussion of responsibilities
cretely the goals were stated by the nurse to the researcher, the may be better.
greater would be the likelihood that the clients understood the An agreement may be oral or written. For some families,
nurse's purposes (Mayers, 1973). To negotiate mutual goals, the written agreements, especially early in the relationship, may
client needs to understand the nurse's purposes. be perceived as a threat. For example, a family that has been
The initial letter, telephone call, or home visit is the time to conned by a household repair scheme may be very suspicious
share your ideas with the family about why you are contacting of written agreements. Family members who are not legal citi-
them. During the first interpersonal encounter by telephone or zens may not want to sign an agreement for fear that if it is not
home visit, explore the family members’ ideas about the pur- kept they will be punished. Do not push for a written agree-
pose of your visits. This phase is essential in establishing a mutu- ment if the family is uncomfortable. If you do notice such dis-
ally agreed on basis for a series of encounters. As a result of her comfort, this may be a good opportunity to explore their fears.
qualitative research study of maternal-child home visiting, Byrd Written agreements are required when insurance is paying for
(2006, p. 271) stated that “people enter…relationships with the the care provided by nurses working with home health agen-
expectation of receiving a benefit” that may be information, cies and to comply with the Health Insurance Portability and
status, service, or goods. Byrd asserted that it is important for Accountability Act (HIPAA).
nurses to create client expectations through previsit publicity Helgeson and Berg (1985) describe factors affecting the con-
about (marketing) home-visiting programs. Also it is essential to tracting process by studying a small convenience sample of
understand the expectations of the specific persons being visited. 15 community/public health nursing students and 12 client
Family members may have had previous relationships with responses. Of the 11 students who introduced the idea of a con-
community/public health nurses and students. Family members tract to clients, all did so between the second and the fourth vis-
may be able to share such information as what they found to its of a 16-week series of visits; 9 students did so orally rather
than in writing. No specific time was the best. Eight clients were have a working relationship because of the absence of Â�caring.
very receptive to the idea because they liked the idea of estab- Mayers (1973) reported that each of the community/public
lishing goals to work toward and felt the contract would serve as health nurses studied had her or his own interactional style:
a reminder of their responsibility. The very process of develop- some were nondirective listeners, calm, and relatively quiet; oth-
ing a draft agreement to present to families provides the novice ers were more verbally active and directive. Most nurses did not
practitioner with an increased focus of care, clarity of nurse and demonstrate a balanced use of communication techniques, yet
family responsibilities and activities, and a basis from which to those who were unable to be with the families had a successful
negotiate modifications in client behaviors (Helgeson & Berg, relationship in spite of their imperfect techniques.
1985; Sheridan & Smith, 1975). Communication techniques do have their place as skills for
The Home Visiting Evaluation Tool in FigureÂ€11-3 lists nurse community/public health nurses. Through communication,
behaviors that are appropriate for home visits, especially initial the nurse discovers the meanings of particular things to fami-
home visits and those early in a series of home visits. Nurses can lies and validates these meanings. Through communication, the
use this list as a preplanning tool to identify their readiness to nurse comes to understand the family and their circumstances,
conduct a specific home visit. Additionally, students and com- goals, and preferences.
munity/public health nurses have used the tool to evaluate ini- Leitch and Tinker (1978) discuss clusters of communication
tial home visits and identify their behaviors that were omitted skills and their purposes and guidelines for use. Listening, lead-
and needed to be included on the second home visits. The tool ing, reflecting, and summarizing are important communication
also has been used jointly as an evaluation tool by nurses and skills. Listening skills assist nurses in clarifying and validating
supervisors and students and faculty. messages. Leading skills assist nurses in focusing and question-
ing for the purposes of expanding the scope and depth of fac-
Increasing Understanding through tual and emotional messages and reducing confusion. These
Communication Skills skills are basic to all nursing relationships, and they are espe-
The nurse's ability to be with family members determines the cially important to community/public health nurses because
success of the nurse–family relationship. A nurse can employ the nurse is probably the sole collector of information. Time
techniques of speaking and listening appropriately and still not passes between home visits, during which events occur in the
FIGUREÂ€11-3â•‡ Home Visiting Evaluation Tool. (From Chichester, M., & Smith, C. [1980]. Home visiting evaluation tool [Unpublished manuscript].
Baltimore, MD: University of Maryland School of Nursing.)
Continued
FIGUREÂ€11-3,â•‡ Cont'd
family's life. Unlike in a hospital setting, in which records or In working with families and individuals over time, the
reports are given from nurses on previous shifts, on home opportunity to identify themes of communication emerges.
visits the nurse must update the assessment based mainly on Analytic skills can be of assistance. When themes become clearer,
what the family says. Reflecting skills allow community/public the family and nurse can work on more basic issues rather than
health nurses to understand the family's frame of reference and on piecemeal episodes. For example, during week 2 of a series of
the meaning of its concerns. Reflecting also allows the family home visits, a young mother had missed a well-child appoint-
members to know that they have been understood. ment; during week 4, she missed her own Â�appointments to a
Â�general practitioner to monitor the blood levels of her antisei- How does a nurse manage her or his own anxiety or self-
zure medications and to the dentist to treat her related gum absorption in a home that is likely very different from the
problems. By week 6, she had not made any new appointments. nurse's own home? Expectations, role insecurity, value interfer-
The student, Juanita, was able to recognize a theme of unkept ence, and the client's reaction to the nurse are potential sources
appointments and summarize the past weeks with the mother. of conflict (Friedman, 1983).
When Juanita confronted her own feelings, she realized that Matching the Nurse's Expectations with Reality
she was frustrated and angry that the mother had not kept Surprises often shock or unnerve and reduce a person's abil-
her word and had not made progress toward what Juanita ity to feel in control. Have you ever attempted to use a piece of
believed had been mutual goals. Juanita expressed the inten- medical equipment that you have never seen before? Did you
sity of her own feelings to faculty and peers rather than wonder how to make it work? Did you feel anxious that you
directly to the client. She did not want to blame or attack might do something foolish? Were you thinking that other peo-
the mother with her own anger. Rather, she expressed herself ple were watching you and thinking that you were an incom-
calmly to the mother by describing the pattern of making, petent nurse? If someone had described the machine to you
missing, and not remaking appointments. ahead of time, talked you through the procedure, and warned
When Juanita asked the mother to explain, the mother you of the machine's idiosyncrasies, might you have felt more
agreed that the infant's shots were important, that she prepared, more in control, and less anxious? For many of you,
had been “worried about her living arrangements and felt the answer is yes.
tired,” and that she would make and keep the infant's future Similarly, learning about a neighborhood and a family before
appointments. She explained that because she had suf- your home visit can allow you to anticipate what you will find,
fered from seizures for so long, she knew to go to the physi- reduce surprises, and promote your feelings of calmness and
cian when she was seriously ill but would not go routinely. self-control. In such a state, you are much more likely to be
Although Juanita did not like the mother's response about attentive in your relationship with family members.
her own health, she accepted it as the mother's own frame Learning about the family before the home visit can be
of reference. Juanita pointed out that more frequent medi- accomplished by gathering as much information as possible.
cal appointments might help to prevent seizures. The mother These data may be obtained by calling the person who initi-
still said she would not go to the physician. ated the referral to you, by having the liaison nurse or discharge
Juanita returned from the home visit no longer angry. She planner obtain the information from the hospitalized fam-
expected that the mother would have her son immunized ily member, by calling the family, and by looking at the family
before the end of the semester (twelfth visit) and that she identification information if you are working in a health main-
would not obtain medical care for herself at this time. Her tenance organization or health department.
expectations were fulfilled. 1. Who is in the family? What are their ages? Who is likely to be
at home during your visit? If you know that three preschoolers
The efficiency of identifying themes usually increases with the are at home, you can be mentally prepared for relating with
nurse's experience. Discussing families with your peer group and children and for the possible exuberance of their presence.
faculty or supervisor allows you to identify others’ perceptions 2. What are the related developmental tasks of the family mem-
of family themes, while maintaining confidentiality. Expanding bers? Anticipating these tasks can suggest possible situations in
possible meanings provides you more flexibility and depth of the family that are timely topics for discussion. For example, if
interpretations. You have an opportunity to return to the fam- it is autumn, is a child adjusting to kindergarten or first grade?
ily with renewed ability to validate the meaning of behavior with 3. How receptive might this family be to your visit? Has the fam-
the family. This process may result in the family having a clearer ily initiated the request for service? If not, what have they been
understanding or interpretation of their own behavior. told about the referral to you? Has the family been visited pre-
viously by community/public health nurses or nursing stu-
REDUCING POTENTIAL CONFLICTS dents? What is the family's past or current relationship with
the agency with which you are affiliated? Does the family usu-
Acknowledging that the nurse can feel uneasy because of reduced ally keep outpatient office and clinical appointments? Nurses
control during home visits, how is mutuality facilitated? Because previously involved with the family may be able to describe
coercion has little place in public health and nursing, how can a the family members’ usual way of presenting themselves.
nurse exert influence over the health of family members? 4. With what other health and social service agencies and pro-
The truth is that the one person you can change is yourself. viders is the family involved? Are all of the relationships vol-
Changing yourself is under your direct control. Through changes untary, or are some of them court ordered? This information
in yourself, you may be able to affect your relationship with a cli- assists you in clarifying part of the family's support system,
ent so that a shift in her or his being and behavior may take place. as well as to initiate discussion about persons already known
A paradox of relationships is that the more you focus on chang- to the family.
ing, fixing up, or making another person “better,” the more likely 5. What will the environment be like? In some neighborhoods,
that person is to feel dominated and to resist change. Through predicting what the inside of a home looks like based on the
managing your own anxiety and your degree of self-attention, exterior of the building is misleading.
you may shift your being and behavior sufficiently to provide the A disadvantage of collecting information about the family
family members with openness and self-expression. By attuning before your initial home visit is that the information may bias your
to their perception of reality, you have a basis for dialogue, thera- point of view about the family. Some nurses prefer to visit first and
peutic relationship, and practical problem solving. then validate their perceptions with data from other sources.
Clarifying Nursing Responsibilities emotional responses are often automatic and certainly color
The purpose of the visit constitutes another category of data to our perceptions, they are usually not rational. What seems to
be collected in the preinitiation phase of the relationship before be the only feeling possible at the moment is really one of many.
the home visit. Another person may associate the environmental cue with an
• What has the family been told about the purpose of your entirely different meaning and thereby have an entirely different
visit, and what are the family's expectations? emotional response.
• If the family initiated the request for services, what specifi- Although community/public health nurses are confronted
cally do they want? by a variety of home settings, lifestyles, family types, and cul-
• What is the goal of the agency or program for whom you tures, possibly triggering strong emotions, family members may
are working? end the relationship if nurses are judgmental. One goal in thera-
• What is the job description for you and your peers? peutic nursing relationships is to be open to possible interpreta-
Uncertainty and ambivalence are common responses of nurses tions of the situation other than your initial, automatic one. For
who have little experience in home visiting. Talk about your anxi- example, if on an initial home visit a mother does not maintain
eties with faculty, supervisors, or more experienced nurses. eye contact with the nurse and the preschoolers shelter them-
For registered nurses who are skilled at providing nursing selves behind her, the nurse might automatically conclude that
practice in inpatient settings, home visiting adds complex- she or he is not wanted and act accordingly, by leaving the visit
ity. The reduced control, increased focus on family, expanded prematurely. Perhaps the mother has low self-esteem or is rela-
teaching, adaptation of care to the home, and increased pri- tively shy with strangers. Not making eye contact may also be a
mary prevention add complexity to the already-established respectful gesture in some cultures, especially toward author-
role (see ChapterÂ€1). ity figures. Considering these possible meanings of the family's
Once you have contacted the family by telephone or at their reaction to the home visit will at least remind the nurse that the
home, listen actively to the specifics and themes of what is com- meaning of the mother's behavior is not known. Not knowing
municated. What is not talked about may be as important as provides an opportunity for further discussion of the purpose
what is mentioned. Following up on cues can provide impor- of the visit and of the mother's perception of that purpose, as
tant information for you. For example, when reviewing the well as of the mother's concerns and possible ambivalence.
health of household members with the nurse during a home
visit, a mother spoke positively about all of her children except Maintaining Flexibility in Response to Client Reactions
Patti. When the mother did not even mention Patti, the nurse The nurse should not assume that a client's behavior is a reac-
specifically commented, “We haven't talked about Patti yet.” tion rationally linked to the nurse's behavior. Her or his culture,
The mother hesitantly said they did not get along and changed family values, and personal experience influence the way a par-
the subject. The nurse now knew more about the meaning of ticular individual behaves at a given moment. In the example
the mother's omission. given previously, the mother may rarely maintain eye contact
The desire to have families be appreciative and cooperative with anyone except a close friend or sister. Because the nurse–
can backfire. Families may test what the nurse is willing to do, family relationship is in the initiation stage, some testing behav-
or they may be so overwhelmed and looking for help that they ior may automatically occur regardless of the nurse's behavior.
make inappropriate or unrealistic demands. Families sometimes The client may subconsciously ask, “Is the nurse sufficiently
ask for time, money, rides, or assistance with tasks that they can interested to continue caring for me?”
accomplish themselves. Other families are so emotionally dis- Conversely, do not assume that your behavior has no effect
traught that they seek relief from their uncomfortable feelings by on the client's responses and behavior during the home visit.
placing unrealistic hopes on the nurse. The nurse tries to develop By definition, communication is interactive. How you present
a relationship with a family that inspires their trust. Limit setting yourself with family members makes a difference with them.
on the part of the nurse helps establish trust. For example, if a
client asks for a loan to pay the rent, you might reply, “I will not Clarifying Confidentiality of Data
loan you money, but I will help you think about other plans for If both the nurse and the family members are clear about who is
paying your bills.” Agreeing to demands that are unrealistic or working with the family and what information is being shared,
uncomfortable for the nurse will eventually erode the relation- the potential for conflict will be far less. The nurse and family
ship. The nurse needs to learn to be comfortable identifying and expectations about shared information will be aligned.
stating limits to the family starting at the very first visit. Furthermore, nurses must follow the privacy regulations of
You would not have come this far in your nursing educa- the 1996 federal Health Insurance Portability and Accountability
tion and practice were you not committed to being a success- Act (HIPAA) that became effective in April 2003 (Frank-
ful nurse and contributing to the well-being of other persons. Stromberg & Ganschow, 2002). These regulations cover any
Rather than worry about your success in a new environment, health care information that can be used to identify an individ-
attempt to experience your home visits as the next step in your ual. The regulations address privacy rights, confidentiality, and
nursing journey. who should and should not have access to client information.
Clients have a right to know what information is being entered
Managing the Nurse's Emotions in the legal health record and with whom the nurse is sharing
As with all relationships in nursing, our emotions can get in the that information. Remember that individual clients have the right
way of our providing client-centered care. Anxiety has already to read their own health records and the records of their chil-
been mentioned; sadness, disgust, anger, joy, and fear can also be dren and of those under their guardianship. Keep the following
evoked during interactions. Our emotions are linked through in mind when recording: objective data, not inferences or gener-
associations to events and situations in our lives. Although our alizations, should be recorded. Describe client behaviors, but do
not attribute motivation. For example, note that the “client spoke most accustomed. Practicing as a community/public health
rapidly,” and the client stated, “They can't make me give my child nurse will probably expand these boundaries.
medicine.” Do not record that the “client doesn't like health pro- As the incidence of violence in our society has increased,
viders,” which is an invalidated, overgeneralized conclusion. concerns about safety in general have grown. This increase has
Other health care providers employed by your health care become especially true in neighborhoods in which drug traffick-
agency may have access to the legal record if they are involved in ing, gang activity, and violent crimes occur. Having acknowl-
providing direct care, consulting with you, or supervising your care. edged all these potentially dangerous circumstances, putting the
Identifying with the client the specific health care providers with potential threats in perspective is necessary. Community/public
whom you will share information routinely is honest and fair. For health nurses are generally known in communities and acknowl-
example, “I will share this information about your child with my edged as having special skills and relationships that contribute
supervisor, the nurses who work in the clinic, and the physician(s) to the residents’ well-being. Community/public health nurses
there. Sometimes I may speak with Dr. X, your pediatrician.” collectively have been seen as caring, helpful, constructive per-
Written permission of the client or of the parent or guard- sons throughout their history. As a visitor who represents nurs-
ian of a minor is required to obtain or release written informa- ing, you have the protection of this general community attitude.
tion from other agencies or disciplines in private practice (see Community/public health nurses are also usually perceived
ChapterÂ€6). With the client's knowledge, you may share and seek differently in a community than are police and social workers
information orally to collaborate in providing care. As discussed because nurses’ roles are perceived to have less threat of law.
earlier, some situations are such that the nurse is required by law As discussed elsewhere, community/public health nurses are
to share information without client consent. Even when you are usually invited in, or families at least have the opportunity to
initiating a referral for suspected abuse or neglect, discussing decline nursing services. Consequently, nurses are seen as being
your problem solving with the available family members would helpful rather than threatening.
be appropriate. Though these family members may be unhappy What is done to promote the safety of community/public
or angry, you have acknowledged them by providing informa- health nurses? In very high-risk neighborhoods, some nurses are
tion. Remember that the right of minors to sign for permission accompanied by police, neighborhood volunteers, or paid secu-
for their own treatment varies from state to state. rity escorts (Nadwairski, 1992) (BoxÂ€11-5). Almost universally,
Before the home visit, clarify your state's laws that govern
consent of minors and mandatory reporting of selected circum- BOXÂ€11-5â•…â•‡SAFETY AND HOME VISITING
stances (such as child abuse) by health care providers. With your
supervisor or faculty, identify the usual and customary people 1. If possible, obtain the family's permission to work with them by
within the agency with whom you will be sharing information. telephone before home visiting.
2. Ask for directions to their road, driveway, building, or apartment.
3. Always leave an itinerary with the agency for each clinical day
PROMOTING NURSE SAFETY that includes the name of the family to be visited, their address
The safety of community/public health nurses is critical. The and telephone number, and the license plate number and make of
the automobile you are driving.
purpose of the home visit is to offer or provide nursing services
4. Consider whether certain times of day are safer for visits in cer-
that make a contribution to the family's health and to do so
tain areas.
while maintaining your safety. The purpose of a home visit is 5. Do not carry purses or wear jewelry other than engagement or
not to provide care at all costs. Assertiveness, not abandonment wedding rings. Do not wear rings with large gems.
of your own needs, is required, which is especially true when 6. Wear the appropriate dress (uniform or street clothes) determined
you are learning to be a community/public health nurse and by the agency.
testing yourself and the boundaries of your professional role. 7. Carry coins for telephone calls or a cell phone and a small amount
of money for emergencies.
Clarifying the Nurse's Self-Responsibility 8. Carry an identification badge and wear a name pin.
Nurses will encounter some clients who are hostile, angry, vola- 9. Avoid secluded areas such as stairwells, alleys, basements, and
tile, or potentially violent. This type of encounter is true of indi- empty buildings or obtain an escort.
viduals in an acute inpatient setting and in their homes (e.g., 10. Avoid areas where persons are loitering, or arrange to be escorted.
a person with dementia who is combative). Therefore, why do 11. Use discretion about visiting a family. If you feel unsafe, do not visit.
many nurses who are beginning home visits (as well as their 12. In the residence, sit between the client and the exit.
families) express anxiety and fear? The reason is largely because 13. Consider asking for pets to be removed from the room.
the nurse has less control over the environment on a home visit. 14. If approached on the street by someone requesting a home visit,
The experience of home visiting is new and unknown. There refer them to the office of the public health or home health agency.
are no hospital or agency walls within which to practice, no 15. Consider whether an escort is needed to avoid visiting a lone man
backup personnel immediately available, no receptionist, and, if you are a woman or visiting a lone woman if you are a man.
often, no security guards. The community/public health nurse 16. Request a nurse partner or escort to a home visit, if needed.
often visits alone. 17. Avoid entering a home in which fights, drug use, or drug sales are
Community/public health nurses visit in every type of in progress.
18. Always report back to the agency in person or by telephone at the
household and neighborhood. Each nurse has grown up in a
end of the clinical day.
specific family constellation and neighborhood, with particu-
19. Visit only during your scheduled work hours. If you must make an
lar socioeconomic, ethnic, religious, and racial compositions. exception to this time, permission from your supervisor must be
We are more comfortable with people who are similar to our- obtained.
selves and with environments similar to those to which we are
nurses may request that another nurse or their supervisor accom- you can use communication and crisis intervention to alter the
pany them on visits to neighborhoods and homes in which they family's self-expression. All of your knowledge and experience
are uncomfortable. In some agencies, the ethical decision has in psychiatric and mental health nursing is of value in such cir-
been made to forbid nursing visits to selected neighborhoods, cumstances. In some agencies, psychiatric nursing consultants
apartment developments, or families for the nurse's protection. are available to coach you in responding to family members
Family members can be invited to more neutral territory such who exhibit anger. Psychiatric emergency teams are available
as a school, clinic, or library for an interaction. Telephone visits for home visits in some communities.
may at times be substituted for some home visits. Families generally present a more reserved, formal social self
to nurses, especially at first. Consequently, any illegal behav-
Promoting Safe Travel ior is often hidden from the nurse. As a beginner, do not probe
All community/public health nurses can benefit from basic your speculations about illegal behavior. For example, if several
crime prevention courses that local or state police provide different people are coming in and out of a house during each
regarding safety on the street and in automobiles. Knowing of your visits, you might suspect that drug trafficking is taking
that she or he is incorporating basic self-protection behaviors place. However, you usually would not ask, “Is someone here
is especially helpful for a community/public health nurse. For dealing drugs?” Seek consultation from your faculty or supervi-
nurses driving in remote areas, having cellular telephones or sor instead. In some households, members may be intoxicated
citizens-band radios and knowing what to carry for weather from consuming alcohol or may be using illicit drugs during
emergencies are especially important. Some community health your visit. Such individuals are likely to be cognitively impaired
agencies supply nurses with telephones or radios. and will not benefit from your visit. You should indicate that
you will return at another time, and leave the home. If a family
Handling Threats during Home Visits member is at risk of harm, such as an infant who is not being
Actual and potential threats can occur during home visits. supervised and is being cared for by the intoxicated person,
What should a community/public health nurse do if the fam- you should follow the policies and procedures for notifying the
ily is engaged in an altercation or fight when the nurse arrives? appropriate authorities.
What if family members appear to be intoxicated or under the If clients have weapons that are unsafely displayed in the
influence of drugs? What if someone in the family displays a home, requesting that weapons be put away during or before
weapon? Although no single, absolutely correct response exists, your visits is your right. For example, an older man kept a
some guiding principles may be helpful. The first rule is to pro- loaded pistol with him for protection in his efficiency apart-
tect your own safety because you are of no assistance if you ment. Because he knew when she was coming, the nurse
become entangled in an altercation or are harmed. If you are requested that he put his gun away before he answered the door
feeling sufficiently fearful or anxious that your functioning is for her. When he refused, he was given a choice between keeping
compromised, or if you perceive that your presence is further his gun out and having nursing visits. After some discussion, the
aggravating the circumstances, then do not enter the home, or man chose to store his gun when the nurse visited.
leave the home if you have already entered. Ethically, you need to encourage family safety related to
You can ask the family whether another time to visit would proper storage of weapons, especially when children or adults
be better; or you can announce that you will not stay and that with compromised cognition or proneness to violence are pres-
you will call or come at another time. Sometimes when the focus ent. Some states or local jurisdictions have legislation governing
is shifted by the presence of an outsider, the situation is tempo- safe gun storage in homes.
rarily defused. Always notify your supervisor or faculty as soon
as possible. Remember, though, as a beginning community/ MANAGING TIME AND EQUIPMENT
public health nurse, you may feel less confident than someone
with more experience. Erring on the side of being too cautious The community/public health nurse's effectiveness depends
with regard to your own safety is acceptable. If, however, you are on planning the day for the efficient use of time and other
finding that most home visits seem threatening, you must speak resources. Physical resources are often limited to equipment
with your faculty, preceptor, or supervisor to help identify the carried by the nurse, or provided by the family at the home,
sources of perceived threats and ways to deal with them. or both. Consequently, making do with what is at hand and
doing this consistent with basic principles of safety and infec-
Protecting the Safety of Family Members tion control are the hallmarks of a skilled community/public
The second principle is to protect the safety of all family mem- health nurse, although more specialized equipment is being
bers. How can you accomplish this task if you are no longer used in the home to care for sicker individuals (see ChapterÂ€31).
in their house? If you believe that someone is in imminent BoxÂ€11-2 discusses the activities for planning a home visit that
physical danger or is being injured, you need to call the polic- will increase efficiency.
ing authority that responds to domestic violence. If someone
has been injured, you should call for both the police and the Structuring Time
emergency medical services (EMS). If you believe that depen- The time devoted to a home visit may vary; an hour is often
dent children or adults are being neglected or abused, you need used as a basis for planning. As many as seven visits per day
to contact your faculty or supervisor and follow your school's may be expected of nurses in some home health agencies.
or agency's policies and procedures. Beyond these priorities, the Geographical location, travel time, and client priorities help
Â�community/public health nurse is not legally bound to respond. establish the order of visits. Visits to persons with infected
After you have gained experience with a specific family or wounds should be scheduled after home visits to healthy or
are more experienced in dealing with family anger in general, immunosuppressed individuals.
Some visits may last only the few minutes required to deter- As presented in CPR classes, the priorities in physiological
mine that a family either is absent from the home or is engaged emergencies are the ABCs—airway, breathing, and circulation.
in other activities that make home visiting inappropriate at that In these three emergencies, appropriate use of CPR is required,
time. Other visits may approach 2 hours in length, especially an which includes activating the EMS.
initial visit to a family with a member who is being admitted Poisoning is usually considered the fourth most important
to the services of a home health agency. In such a case, consent life-threatening emergency. Nurses should always carry their
forms must be signed, assessments must be performed, envi- state's poison control telephone number; nurses are to call this
ronmental evaluations must be done to determine equipment number to verify the importance of any suspected poisoning
needs, and direct care techniques must be demonstrated to fam- and to ascertain the need for any immediate treatment before
ily members. For novices, an hour usually proves to be suffi- medical treatment.
cient time to accommodate some inefficiencies in interviewing, Other physical emergencies include acute deficits in hydra-
relating, and performing nursing care. If family members are tion or nutrition and environmental safety hazards that may
especially anxious or upset, visits may take longer. If equipment be life threatening. Of similar magnitude are the psychological
must be improvised or modified, or if a health-related emer- emergencies of potential suicide, homicide, and abuse, which
gency exists, more time will probably be needed. have been discussed previously.
Conversely, the duration of the home visit may need to be Community/public health nurses often encounter family
shortened when the stamina of the client is compromised. An members who exhibit signs or symptoms that have not yet been
interview with a person with shortness of breath, for example, diagnosed by a physician or nurse practitioner. Are these signals
needs to be paced so that the person does not become tired. of normal variations that bother the family member? Is a refer-
Some family members tend to think concretely rather than ral for medical diagnosis appropriate? Are these signals of an
abstractly; thus, short, frequent visits allow the nurse to focus unstable condition or an impending emergency that requires
on one or two items at a time. Shorter visits result in greater immediate referral? These are distinctions that community/
clarity and in timely correction and/or reinforcement of the public health nurses assist families to make.
family's health-related behaviors.
Other Family Emergencies
Handling Emergencies Families, in addition to individual family members, also have
Emergencies in the family may extend the length of the home emergencies. Unexpected situations requiring immediate action
visit and are always to be handled before the nurse leaves unless do constitute emergencies for families. Emergencies often relate
the safety of the nurse is threatened. If the nurse were not mak- to an unhealthy environment such as loss of heat, potable water,
ing the home visit, the family would probably handle the emer- or refrigeration for food. Families may have insufficient funds to
gency without the nurse unless the nurse was one of the resources pay heating bills or repair a refrigerator, or community disasters
that the family contacted. More likely, the family would contact such as storms or fires may have interrupted the supply of utilities.
other family members, their private physician, the emergency A family may be experiencing an impending or actual eviction.
department of a hospital, an ambulatory emergency center, or Food, water, clothing, shelter, and safety are basic requirements
the EMS. However, once the nurse is made aware that an emer- for survival, and their loss usually constitutes an emergency.
gency exists, the nurse's professional and legal responsibility is Families may also experience crises in which the stressors
to address the emergency within the scope of nursing and to exceed their coping skills. A birth, death, job loss, or chronic ill-
support the family to obtain appropriate resources. ness may tax their coping. Stress may manifest as acute physical
or psychiatric illness in one or more family members.
Medical Emergencies How does a community/public health nurse relate to such
Responding to a medical emergency in the home is similar to emergencies? What does the nurse do? Referrals are appropri-
responding to a client's emergency in the hospital in that in both ate for emergency food, clothing, and shelter. The local or state
circumstances the nurse has knowledge of basic assessment skills, department of social services has some resources for emergency
cardiopulmonary resuscitation (CPR), asepsis, and nursing inter- food stamps and shelter. Agencies such as the Salvation Army
ventions to reduce client anxiety, conserve client energy, promote and the Red Cross as well as religious and civic organizations
comfort, and prevent further dysfunction. However, the nurse in supply emergency provisions. Members of the extended family,
the home does not have the equipment and team members that are neighbors, or volunteers may be mobilized to stay with the fam-
available to the hospital nurse. Equipment in the home is probably ily for support during the crisis.
limited to what the nurse brings—soap, clean gloves, a sphygmo-
manometer, a stethoscope, thermometers, and clean dressings. The Promoting Asepsis in the Home
only medications available would be those of the family members. The goals of infection control in the home are to prevent the
The medical orders are those of the family member's physician or spread of communicable organisms from one family member to
nurse practitioner, which may be known to the nurse from writ- another and from one household to another, to protect individ-
ten medical orders to the nurse or from written and oral instruc- ual family members who are especially susceptible to infection,
tions to family members. Many agencies also have written policies and to protect the nurse from infection. The Centers for Disease
and procedures for handling a variety of emergencies. Knowledge Control and Prevention (CDC) (Siegel etÂ€al., 2007) has pub-
of basic and advanced first aid is appropriate for any nurse making lished infection-control standards for the hospital and other
home visits (American Red Cross, 2007). In addition to knowing settings. The community health nurse adapts these standards to
what family members are taught to do in emergencies, a nurse who the circumstances of each household and to the specific needs
starts with first-aid skills and incorporates basic nursing practice of the family. BoxÂ€11-6 lists some ways to promote asepsis dur-
and agency policy will be functioning on a firm foundation. ing home visits.
BOXÂ€11-6â•…â•‡ASEPSIS DURING A HOME VISIT

1. Air-borne organisms can be transmitted to and from you and among as a Â�protection to yourself and so as not to transmit any organisms
family members, even without direct contact. Observing respiratory from your clothing to the bedding.
symptoms among family members offers an opportunity to teach 4. When you remove your coat, either continue to sit on it, or remove it
family members about managing coughs and sneezes and perform- completely and fold it with the outside out; the outside is considered
ing hand-washing and other infection-control measures. less clean to you. Washing uniforms in hot water (55â•›°C or 131â•›°F for
2. If you have a respiratory illness yourself, you need to identify the 20 minutes) or dry cleaning or driers set on the “hot cycle” promotes
likely degree of communicability; as in the hospital, nurses need infection control (Heymann, 2009).
to distinguish their allergies from colds, manage their symptoms, 5. Direct physical contact and using equipment introduce the neces-
and avoid clients with compromised immunity. In community/public sity for medical asepsis or clean technique by the community/public
health nursing, the nurse may wear a mask and be fastidious about health nurse. Take as little equipment into the home as you anticipate
hand-washing, postpone the visit until another day, or have another you will need; do not carry purses, knapsacks, extra records, or books.
nurse act as a substitute. If you travel by car, you can stock extra supplies and resources there.
3. Lice and scabies can be transmitted from clothing, bedding, Usually, it is sufficient to take a pen, paper, permission forms to be
and upholstered furniture. In some households, the furniture is signed, health records to be completed, emergency telephone num-
Â�multipurpose—for sleeping and for sitting. When this situation bers, educational materials, and a nursing bag (with hand-washing
occurs, sitting in un-upholstered furniture, if available, such as a equipment and basic physical assessment equipment) into the home.
wood or plastic chair is best. Routinely avoid sitting on beds, both Some agencies also provide small policy and procedure handbooks.
Some visits will be entirely talking visits and involve no direct Handling Equipment
physical care. For example, you might be making a home visit Proper handling of equipment prevents the spread of commu-
to a mother of school-aged children when they are in school. If nicable organisms. Each agency usually specifies the standard
your initial purposes are to introduce yourself, obtain the moth- equipment each nurse is to have on a home visit; minimally,
er's agreement to work together, and collect identifying infor- equipment for physical assessments is included. When sterile
mation and health history for the record, no direct physical equipment is needed, the family usually obtains it from a sup-
contact may occur. Unless the mother herself is ill and requires ply company. Cleansing equipment in the home is sometimes
some physical assessment or she exhibits risk factors that indi- needed to prevent contamination of the nursing bag and sub-
cate the need for screening (e.g., high blood pressure), you need sequent transmittal of organisms to other households and indi-
not wash your hands and use equipment from the nursing bag. viduals. Website Resource 11A provides a procedure for
Your hands are clean from having washed them before leaving cleaning equipment in the home.
the agency or the previous home visit. The CDC has recommended that all individuals receive care
as though they are potentially positive for human immunodefi-
Hand-Washing ciency virus (HIV) and other blood-borne infections. All health
Hand-washing is as an essential component of infection con- agencies adopt universal precautions when handling blood
trol in homes as it is in all other settings of practice. In the and body fluids, needles, and other materials (see ChapterÂ€8).
hospital, nursing home, or clinic, the sink with water, soap, Infection-control guidelines for people living with infectious
and paper towels is an expected part of the environment. diseases (including AIDS) in the community also are included.
Running water will not always be available in homes. The Waste material contaminated with blood or body fluids should
water may be temporarily shut off while the pipes or hot be double-bagged in plastic before disposal (Trotter, 1996).
water heater is being fixed. In one instance, a family's condo-
minium had faucets that leaked excessively. Rather than pay Modifying Equipment and Procedures in the Home
for a plumbing bill, the Â�family turned the water off under From its inception, district nursing involved teaching families in
each sink until it was needed. Some homes have well or cis- the home about the care of the ill and preventive hygiene prac-
tern water that must be carried in from outside, sometimes tices. The nurse assisted the family in using available equipment,
over a great distance. in modifying household items for health-related purposes, and
All sinks in homes are considered dirty. This determination in making equipment. How can a family make bed tables and
is not meant as a judgment of the family's house-cleaning skills; bed rails? How can a drawer become an infant bed?
rather, it is a basic principle of medical asepsis. The community/ The need to modify home equipment has been reduced by the
public health nurse does not know what else has touched the availability of durable medical equipment for purchase and rent
sink or how the sink has been used. (such as hospital beds and commodes) and disposable equipment
Some homes will have sinks, running water, liquid soap, and (such as dressing trays). Medicare and some other health insurance
separate hand towels for guests. Unless a known infection exists and assistance plans often pay for such equipment. However, many
in the home, the nurse may use these family supplies for hand- people are not eligible for reimbursement because they are not
washing. Other homes will have sinks and running water but eligible for skilled home health care (see ChapterÂ€31). Therefore,
will have a bar of soap and towel that everyone in the house- improvised equipment is a cost-effective means of assisting fam-
hold uses. In this case, neither the soap nor the towel is clean ilies to care for such individuals. Some home health books for
enough for the nurse to use. Sometimes, no waste receptacle nurses discuss equipment modifications (Humphrey, 1998).
may be available. Consequently, the nurse must always include While en route to homes, the nursing bag is to be kept
soap, paper towels, and bags for waste as a part of the standard clean and safe from theft. Always keep the bag in your sight,
equipment for home visiting (BoxÂ€11-7). or have it locked in the vehicle's trunk or covered hatch or in
BOXÂ€11-7â•…â•‡HAND-WASHING PROCEDURES
A. Hand-Washing Procedure with Running Water which may present a poisoning hazard to a confused family Â�member or
Equipment a child. If you have any doubts, take the soap with you, replace it in the
1. Liquid soap in squeeze bottle (Antimicrobial soap is needed only bag before going to the sink, or assign a responsible person to guard the
when contact precautions are required, a client is severely immu- equipment. Other procedures involve taking the soap to the bathroom.
nosuppressed, or invasive procedures will be done [Rhinehart &
Friedman, 1999].) B. Hand-Washing Procedure with Poured Water
2. Paper towels Substitute the previous step 5 with the following:
3. Trash receptacle (paper or plastic bags) 5. Have another person pour a small amount of water from a clean
pitcher, glass, jar, or other utensil over your hands. (To warm the
Procedure water, water may be heated in a small saucepan on a stove, burner,
1. Remove the soap and paper towels from nursing bag. or fire, and then cooled with additional water, as needed.)
2. Place one paper towel down as a clean field.
3. Squeeze soap into the palm of one hand, and place the soap container C. Hand-Washing Procedure without Water
on the clean field. Germicide liquids and aerosols are commercially available for hand-
4. Carry the remaining paper towels to the sink area. Place paper washing without water and can be carried in the nursing bag. Avoid
towels under one arm, and hold them against your side. This action scented products, which may act as asthma triggers.
prevents them from getting wet or being placed on the dirtyÂ€sink. Equipment
5. Turn on the water, adjust temperature to warm, and wash and rinse 1. Bottle or can of waterless, antimicrobial hand-washing product
hands.
6. Dry hands with paper towels. Procedure
7. Turn off water with paper towels. 1. Squeeze or spray small amount onto hand.
8. Dispose of paper towels in household receptacle or return to nursing 2. Rub germicide onto all surfaces of hands, fingers, and fingernails
bag, and use the receptacles provided. for 30 seconds. The germicide evaporates, and no towel is needed
A major advantage of this procedure is that the equipment does not (Trotter, 1996).
have to be taken to the dirty sink where it can get wet and contaminated. 3. Hand-washing with a germicide is only effective for four cleansings.
The disadvantage is that the soap may be left out of sight of the nurse, Water must be used for the fifth washing.
a Â�covered box. For example, do not drive to a restaurant for POSTVISIT ACTIVITIES
lunch, open the trunk, and place the bag in the trunk. Rather,
immediately before leaving a home, put the bag in the trunk, You have prepared yourself for a home visit, considered your
and then drive away. The bag is safe and out of sight until it is own safety, and conducted a home visit. You have considered
needed at another home visit. your relatedness with the family and management of time and
Just as the floor in a hospital is considered dirty, so too equipment. You have a right to feel successful and pleased with
are streets, sidewalks, the ground, vehicle floors, and floors in yourself. What comes next?
homes. Do not place a nursing bag on any of these surfaces. Postvisit activities provide a time for your evaluation and work
Newspapers are considered clean and provide an appropriate on behalf of the family: collaboration, referral, and document-
field on which to place your nursing bag. ing. This conclusion of one visit becomes the beginning or preini-
Modifications in using assessment equipment may also be tiation for the next encounter. A plan of care is derived from the
needed. For example, infant scales are not always available. An information you have assessed. The initial home visit, the first of
alternative procedure is to weigh a parent on the bathroom few or many visits in your nurse–family relationship, is complete.
scale, weigh the parent with the infant, and then subtract the
first value from the second value. The parent should be dressed Evaluating and Planning the Next Home Visit
similarly at each visit to reduce variation; however, this proce- How does a community/public health nurse determine whether
dure provides only a gross estimate of infant weight. the home visit has been successful? What criteria are used to deter-
Teaching family members to assess their own health status mine the success of any nurse–client encounter? The nurse usually
is often a responsibility of community/public health nurses. By looks at the scope and specificity of the nursing process, the degree
using the family's equipment, the procedures can be tailored of client satisfaction, the quality of the nurse–client relationship,
to specific circumstances. For example, using the thermometer and the health behavior and status of the client (Smith, 1987).
that is available in the home and assisting the family members How can these criteria be applied to evaluating a specific
in effective, safe, clean use may be more appropriate. Cool water home visit? BoxÂ€11-8 lists questions that were derived from the
can be used as a lubricant for taking rectal temperature if clean criteria; you may wish to develop more.
petroleum jelly is not available. Family members can be taught
that it is unhygienic to insert thermometers into a jar of petro- Consulting and Collaborating with the Team
leum jelly that is also used for chapped hands and lips. Consultation is seeking the advice or opinion of an expert.
When families give medications, especially liquids, validating Community/public health nurses may consult with a wide array
the type and size of spoons and droppers used is important to of practitioners in other disciplines such as medicine, physical
ensure that the doses given match the doses prescribed. Alarm therapy, and environmental hygiene. Nurses with specialties are
clocks and prefilled medication boxes can be used to assist fami- also available. For example, psychiatric nurses can assist in formu-
lies in remembering medication schedules. lating a plan of care for an interpersonally intense family Â�situation;
BOXÂ€11-8â•…â•‡DETERMINING THE SUCCESS OF YOUR HOME VISIT

Preinitiation • What cues indicate that the interactions were appropriate to the
• Was your preplanning adequate in scope to assist you in anticipating phase of the relationships?
the needs of the family? • What health care behaviors did one or more family members agree
• How did a review of nursing literature before the home visit to initiate or modify? What information did they indicate they better
strengthen your knowledge base, promote evidence-based practice, understood?
and foster your role security? • Can you identify any changes in the health status of one or more fam-
ily members?
Home Visit
• To what degree were you able to express your purpose for the home Postvisit Activities
visit and to elicit the perception of family members? • How complete was your documentation? Were gaps in your database
• How were you able to address the purpose? revealed? If so, what plans are necessary for collecting the missing
• Did any major issues arise for which you were not prepared? If so, data?
how did you handle them? • What activities are necessary to complete any referrals?
• What data do you have to support your inferences about the family's • What consultation with your faculty, supervisor, or other members of
satisfaction with the home visit? To what degree did you validate the the health care team would be helpful?
accuracy of your inferences with the family members? • What plans are evolving for your next home visit in the areas of data
• How satisfied were you with your visit? What contributed to your collection, teaching, other direct care, and referral?
satisfaction? • What changes, if any, in equipment, asepsis, or safety require plan-
• What cues indicate that you and the family are engaged in the ning before the next home visit?
relationship?
Adapted from Smith, C. (1987). Determining the success of your home visit (unpublished manuscript). Baltimore, MD: University of Maryland
School of Nursing. Used with permission.
pediatric nurses in regional neonatal intensive care units can dem- problem is not within the scope of your responsibility and capa-
onstrate the use of monitoring equipment to you and the parents bility (or that of your team), making a referral may be necessary.
before an infant who is at risk for sudden infant death syndrome Referrals may be indicated for the following reasons: screen-
(SIDS) is discharged from the hospital. Your supervisor and peers ing procedures; medical diagnostic consultations, laboratory
are also available to share opinions about family care in formal and tests, or procedures; emergency services; nursing home place-
informal conferences. ment; educational, vocational, and social services; or consulta-
Even if you are just beginning community/public health nurs- tions with medical, nursing, and other disciplines regarding the
ing practice, you are the individual who has made the home visit treatment and care regimen (Smith, 1972).
and experienced meeting the family in their environment. You Referral always consists of communication among three
are, therefore, in a position to collaborate with nursing and mul- individuals: the client, the person making the referral, and the
tidisciplinary teams. You are in a position to share assessment person or persons to whom the client has been referred. The
information, determine what it means to the family, and discuss most short-term goal is that the family member or members
nursing inferences you have derived. You are also able to contrib- and the person to whom they are referred make contact. The
ute ideas for realistic goals and time frames. Developing a plan intermediate goal is for the family to receive the desired treat-
on which the entire team has agreed helps prevent duplication ment, aid, or information. The ultimate goal is that the fam-
and gaps in care. For example, will home visits be made jointly ily's needs will be met because of the relationship with the third
by disciplines to prevent family confusion, or will home visits be person. Staying involved with the family until connections have
made separately to promote intermittent reinforcement? been made between the family and the third person is ideal for
Consultation and collaboration may occur via the telephone the nurse. The nurse can evaluate the degree to which the family
(or other telecommunications, such as fax), by mail, or in per- and agency are satisfied with the referral. At times, the original
son, depending on the complexity and urgency of the situation. referral proves to be inappropriate for family needs, and addi-
Emergencies are best handled with telephone calls or citizens- tional referrals are necessary.
band radio followed by written communications. Complex situ- The nurse initiating the referral must have prior knowledge
ations are best handled by face-to-face conferences (including of both the family and the agency or specialist to whom the
teleconferencing), in which all disciplines can hear the same family is being referred. The nurse must then decide what infor-
information simultaneously. One participant can be designated mation about the family needs to be shared with the agency and
to write and circulate a meeting summary. what information the family needs to be given about the agency.
As a beginner, reporting to your supervisor about changes In many cases, it may take up to 6â•›months for a community/pub-
in family health status and functioning, emergencies, threats to lic health nurse to learn the details about health and social agen-
your safety, and situations that you do not understand clearly cies and private practitioners in the specific geographical area
is always the safest course of action. This process is considered of practice. Because personnel and policies frequently change,
necessary for sound legal practice. keeping up to date is a continual process (see ChapterÂ€19).
Making Referrals Legal Documentation

Referral is the act or instance of sending or directing someone for All home visits are to be documented on the legal record.
treatment, aid, information, or a decision. If the family members Telephone calls from and to the family and with other disci-
have needs that cannot be satisfied with available resources and the plines involved are also to be recorded. Ineffective telephone
calls and home visits are recorded to show effort and timeliness Olds’ Nurse–Family Partnership program has produced con-
of nursing attempts to provide care. sistent effects in three different trials, including white, African
Most community/public health agencies use some version American, and Hispanic populations; it has been partially rep-
of the problem-oriented recording (POR) system, which con- licated in the United Kingdom (Barlow etÂ€al., 2006). Similar
sists of forms for databases, including identifying informa- programs show promise of improving infant attachment and
tion; problem lists; selected flow sheets; progress notes; and behaviors (Olds, 2004), as well as reduced criminal and antiso-
discharge summaries. In agencies that do not use POR, nar- cial behavior in adolescents (Olds etÂ€al., 1998). Compared with
rative progress notes and flow sheets are used. Computerized paraprofessionals, nurses have been shown to produce larger
record systems are becoming more prevalent (Martin, 2005; effects (Olds etÂ€al., 2002).
USDHHS, 2011). SectionÂ€2951 of The Patient Protection and Affordable
Care Act of 2010 (Public Law 111-148) describes a provi-
THE FUTURE OF EVIDENCE-BASED HOME-VISITING sion establishing evidence-based home-visiting programs to
improve health and development outcomes for at-risk children
PROGRAMS (USDHHS Administration for Children and Families, 2010).
At the beginning of this chapter, we discussed populations for States and tribal organizations may apply for funds to establish
whom home-visiting programs exist. Given the trend of increased evidence-based programs with a proven record of success, such
numbers of frail older adults and those with chronic diseases and as the Nurse–Family Partnership, to improve maternal child
disabilities, the demand for home visiting is expected to increase health, prevent childhood injuries, promote school readiness,
for these populations. Home visiting for care of the frail older reduce crime or domestic violence, and/or increase family self-
adults, the ill, and the disabled has proved to be cost effective when sufficiency. Baccalaureate prepared community/public health
compared with providing care in hospitals and nursing homes. nurses are managing and implementing these home-visiting
Other home-visiting programs seek to empower families programs to improve child and family well-being.
with children, especially those that live in poor communi- Community/public health nurses will continue to demon-
ties with health disparities (Donovan etÂ€al., 2007; Wisconsin strate the cost-effectiveness of programs of home visiting for
Department of Health and Family Services, 2007). Evaluations health promotion and primary prevention to reduce dispari-
of some prenatal and postnatal home-visiting programs that ties among various aggregates/populations. Community/public
target low-income, unmarried women demonstrate improved health nurses are exploring creative models of nursing care that
pregnancy outcomes, reductions in child abuse and neglect, reintegrate care of the sick with health promotion and primary
and improved maternal life course (Olds, 2004). The David prevention within families.
KEY IDEAS
1. Home visiting is a traditional and evidence-based activity of Families retain more control over the environment; the
community/public health nurses for providing health pro- relationship may extend over weeks, months, or years; and
motion and all levels of illness prevention to individuals and goal achievement depends more on an interdependent
families. partnership between the nurse and the family.
2. Home visits provide opportunities for family-focused care, 7. Nurses can reduce potential conflicts in their relationships
for personalizing care within the environment in which the with families by clarifying the purpose of the visits, care-
care will actually be implemented, and for modifying care to fully negotiating contracts/agreements with family mem-
family preferences. Home visits also provide an opportunity bers, being aware of their own feelings and values, and
for detecting health threats that the family may be unaware of. honoring confidentiality.
3. Practice and research indicate that positive preventive 8. Maintaining nurse and family safety and appropriately
health outcomes result from home visits by community/ handling emergencies are important responsibilities when
public health nurses. Although the health results obtained making home visits. Promoting personal hygiene and a
from home visits can exceed those obtained by visits to clin- clean home environment reduces the likelihood of the
ics and private physicians, research continues regarding the transmission of communicable diseases among family
cost-effectiveness of home visiting by nurses for health pro- members and between households.
motion and primary prevention. 9. Postvisit activities include evaluating the visit and the plan
4. Home visiting involves a process of initiating relation- of care, collaborating with other team members, conduct-
ships with family members, negotiating and implementing ing referrals, documenting in the legal health record, and
a family-focused plan of care, and evaluating health out- planning for future contacts with the family.
comes and family satisfaction. 10. Community/public health nurses need to continue to
5. Each home visit involves several phases or steps: preplan- demonstrate the cost-effectiveness of home visits for
ning the visit, traveling to the home and initiating the visit, health promotion and primary prevention to reduce dis-
accomplishing the interventions, evaluating and summa- parities among various populations. Home visiting for care
rizing the visit with the family, ending the visit and leav- of the ill and the disabled has proved to be cost effective
ing the home, and conducting postvisit activities. Efficiency when compared with providing care in hospitals and nurs-
is increased when community/public health nurses wisely ing homes. Community/public health nurses are exploring
manage their time and equipment. creative models of nursing care that reintegrate care of the
6. Relationships with families within their homes are differ- sick with health promotion and primary prevention within
ent from nurse–client relationships in inpatient settings. families.
CASE STUDY
Home Visiting
A community/public health nurse employed by a suburban county Initiating the Home Visit
health department in a maternal–child health program received a refer- As the nurse drove to the home, she noticed a “for sale” sign on the
ral from the local hospital for a young mother and her newborn daugh- farm property and tall grass and weeds in the field. A relatively new
ter. The nurse who initiated the referral was employed by the health mobile home sat next to a farmhouse that was in disrepair. The yard
department and the hospital for the express purpose of interviewing around the mobile home was mowed and contained a plastic swim-
and identifying families at risk for child health problems. ming pool and several children's bikes. No animals were to be seen.
As she parked her car and approached the mobile home, a woman
Planning for the Home Visit appeared at the door and called, “Are you the nurse?” The nurse replied
The community/public health nurse reviewed the referral for identi- that she was and introduced herself by name. The woman introduced
fying information, information about the family, and the purpose of herself, stated that her cousin and the cousin's infant were inside, and
the referral. The referral included the parents’ and infant's names, motioned for the nurse to come in.
address, and telephone number; a brief delivery history (normal, On entering the mobile home, the nurse noticed three preschool-
5-lb, 7-oz female infant delivered vaginally); the results of screening ers playing on the floor and a young woman sitting with an infant on
tests for illicit drugs and sexually transmitted diseases (negative); a sheet-covered sofa. The nurse introduced herself, and so did the
the method of infant feeding (breast-feeding); and a description of mother. The nurse said hello to the children as well. The chairs were
mother–infant interactions (anxiety regarding breast-feeding and piled with clothes, and there was nowhere in the room to sit. The nurse
living arrangements) observed by the hospital nurse. The mother noticed the dinette chairs and asked if she might move one to the living
had agreed to be contacted by a community/public health nurse for room for herself; the cousin agreed.
home visits. The nurse repeated that she was from the health department and was
The referral further stated that the mother had moved to the county there to be of assistance to the mother and her newborn. The nurse sat
2â•›months ago, which interrupted her prenatal care. She was staying quietly, looking at the mother and the newborn, waiting for the mother
with her cousin while her husband traveled to a neighboring state to speak. The mother smiled faintly and asked if the nurse would like to
in search of employment. Therefore, the nurse inferred that further hold her infant. The mother was dressed in nightclothes, her hair was
assessment of the mother's support systems, knowledge of health care uncombed, and she had dark circles under her eyes. The nurse stated
resources, and finances would be especially important. that she would be delighted to hold the infant but that she would like
When the community/public health nurse telephoned the home to to wash her hands first.
make an appointment for a home visit, she heard the voices of children
in the background; their volume made hearing the mother difficult. The Implementing the Home Visit
nurse introduced herself by name, stated that she worked for the health After washing her hands, the nurse held the infant, looked into her face,
department, and indicated that she had been notified by the hospital and spoke softly about how alert she was. She asked what the infant's
that the mother had delivered a baby girl. The nurse asked how the name was. The nurse noticed that the infant's respirations were regular
mother and infant were doing. The mother replied that she was very and her color was good; her fontanels were not depressed or bulging,
tired and was not sure that her infant was getting enough to eat; she and her mucous membranes were moist; her umbilical cord was drying
was giving her infant formula from a bottle and trying to breast-feed without exudate; she did not appear to be in any distress. Therefore,
at alternate feedings. Yes, she was eager to have the nurse visit in her the nurse focused on the mother.
cousin's home. The nurse arranged a visit for the next day at a time The mother stated that she was tired because the infant did not yet
when the infant was usually being fed. sleep through the night. She was sleeping on the couch, and the infant
The nurse determined that the family lived in a mobile home behind slept in an infant car seat that belonged to her cousin. She was disap-
an old farmhouse near a new housing subdivision. The nurse found the pointed that her husband had not yet come to see his daughter. He had
address on her county map and decided that she believed that the area telephoned about his job interviews and had wired her some money
was adequately safe to visit alone. from his unemployment check. Yes, she was able to purchase some
After completing the telephone call, she reflected that the purpose diapers and had a few bottles. Her cousin had loaned her some infant
of the maternal–child health program was to promote the well-being clothes.
of families with infants, to prevent problems such as infant failure to When asked specific questions about her postpartum status, the
thrive and injuries, to ensure that family members received appropriate mother replied that her vaginal bleeding was getting lighter and did
immunizations and health care, and to promote positive parent–child not contain any clots. She did not have any bothersome pains in her
relationships and child development. Her focus would be on the infant, abdomen or her legs. Her blood pressure was 130/76â•›mm Hg. She was
the mother, and other household members. eating two meals a day but wondered what to eat to “help make my
In preparation for the visit, the nurse obtained the appropriate milk.” Her breasts were engorged, and she reported difficulty getting
agency forms for recording postpartum and newborn care in the the infant to latch onto her nipples.
home and obtaining the mother's written permission for services. The infant began to fret and root as if she were hungry. The mother
She restocked her nurse's bag with soap, towels, disposable tape noticed the infant's behavior and stated it was time for her to eat. The
(used to measure infant head circumference), thermometers, sphyg- nurse stated she would like to observe the breast-feeding so she might
momanometer, and stethoscope. She obtained an infant scale. To be make suggestions; the mother eagerly agreed. The nurse used the
prepared for teaching the mother, the nurse collected pamphlets on opportunity to demonstrate several positions for holding the infant dur-
postpartum care, care of a newborn, breast-feeding, infant safety, ing breast-feeding and how to use the rooting reflex and position her
and community resources. Before leaving the office, the nurse left nipples to assist her daughter. The nurse explained that the more the
an itinerary of her visits for the next day; she would go directly from infant sucked and emptied the breasts, the more milk would be pro-
her home to her first visit. duced. The nurse suggested that the mother empty one breast before
CASE STUDY
Home VisitingÂ�—Cont'd
going to the second. The nurse affirmed what the mother was doing La Leche League. The nurse reinforced that she was doing well caring for
correctly and worked with the mother to improve her technique. The her infant and had a plan for obtaining medical care when she needed it.
nurse discussed how to check for wet diapers to ensure that the infant The nurse left her name, agency address, and telephone number in writ-
was receiving enough breast milk. ing. The nurse stated that she would telephone the next day to see how
As the infant fell asleep, the nurse had the mother sign the permis- the breast-feeding was working and whether the mother's breast engorge-
sion form for home-visiting services. Most of the visit was devoted ment had decreased. A second home visit was planned for the next week.
to teaching related to breast-feeding because this was the immedi-
ate concern of the mother and was also essential for the hydration Postvisit Activities
and nutrition of the infant. The nurse assessed that the mother had During the evaluation of her home visit, the community/public health nurse
completed high school and had worked in an office for a while. The was pleased that she had been able to establish a relationship with the
nurse reviewed the written pamphlets on breast-feeding, postpartum mother and to offer information related to breast-feeding that was imme-
changes in mothers, safety for newborns, and medical emergencies. diately helpful. No additional referrals or consultations were needed.
She gave the mother the telephone numbers of a local church that sup- The community/public health nurse completed her legal documen-
plied infant clothes and equipment and the local La Leche League group tation on the client identification form, postpartum assessment form,
that provided information and support for breast-feeding women. newborn infant assessment form, and progress note. She identified
The nurse further assessed the mother's living arrangements, finan- the problems as altered breast-feeding, potential for growth related
cial circumstances, and plans for obtaining a postpartum examination to care of firstborn, knowledge deficit related to community resources,
for herself and well-child care for the infant. The mother had no health and income deficit related to unemployment.
insurance but had initiated application for medical assistance while in The family strengths included the father's motivation to seek employ-
the hospital. She had applied for Women, Infants, and Children (WIC) ment, the mother's education and readiness to learn, the mother's
vouchers to help obtain nutrition for herself while she breast-fed. She attentiveness to her newborn, and the support from her extended fam-
would return to the hospital for a postpartum visit, but she did not know ily. The nurse concluded that she needed more information about the
where to obtain care for her infant. The nurse provided a list of pediatri- social situation before she was able to predict how long she would
cians who participated in medical assistance managed care, as well as need to continue the home visits. Her assessment priorities for the next
the health department's immunization clinics. home visit included information about the spousal relationship and the
The cousin and the mother both confirmed that the mother planned to mother's coping skills, more information about the cousin's family and
stay for a “couple of months,” until her husband returned for her. Yes, their health needs, a home safety assessment, and a developmental
it was crowded in their mobile home, but “families need to help each assessment of the infant.
other out and I know a lot about caring for babies,” the cousin asserted. The community/public health nurse would start her next home visit by
inquiring about how the week had gone, how the mother was feeling,
Ending the Home Visit and whether breast-feeding had improved. She would also evaluate
The nurse stated that it was almost time for her to leave. The mother whether the mother had contacted the church and La Leche League and
volunteered that she felt much more confident with her breast-feeding the degree to which these resources had been helpful.
and that she understood that she did not have to feed both formula and See Critical Thinking Questions for this Case Study on the
breast milk. She would call the church for more infant clothes and call the book's website.
1. Describe experiences you have had with visits to homes in 5. After a home visit to a family, describe several behaviors of
which you did not know anyone (e.g., selling newspapers, a family member or members that you believe to have been
collecting money for charities). Recall your feelings. What in response to your interactions. Speculate on at least three
did you do that was usually effective? Share your ideas with possible meanings of the behaviors. Create a plan to validate
others. which of the meanings is most accurate.
2. Describe your own home, and compare it with another home 6. Write an agreement that you desire to negotiate with a family
that is much different. Note what categories you use for com- on the first home visit. Role-play how this might be expressed
parison: (a) What are the themes in your comparison (e.g., verbally to the family members; be certain to validate with
did you compare the level of activity in the home, or did you the clients what they actually agree to.
compare the amount and type of furniture)? (b) Which of 7. Discuss how a family focus can be fostered during a home
your senses are represented in your comparison, in addition visit when only one household member is present.
to sight? 8. After an initial home visit, use the Determining the Success of
3. After an initial home visit to a family, describe the physical Your Home Visit guide (see BoxÂ€11-8) or the Home Visiting
features of the home without including value judgments or Evaluation Tool (see FigureÂ€11-3) to help preplan for your
generalized conclusions such as, “The furniture was in good second visit.
shape.” 9. Create an artistic expression of what relating with a family
4. Have another person critique how successful you were in and being concerned for their well-being and growth means to
answering question 3. Note which of your values or biases you. (You might work with drawing, painting, music, prose,
were revealed. dance, or poetry, for example.)

Association for Professionals in Infection Control and EpiÂ� Nurse-Family Partnership: http://www.nursefamilypartnership.
demiology, Inc.: http://www.apic.org//AM/Template.cfm? org/
Section=Home1 The Pew Center on the States, Home Visiting Campaign:
Center for Home Visiting (University of North Carolina): http:// http://www.pewcenteronthestates.org/initiatives_detail.aspx?
www.unc.edu/~uncchv/Center_for_Home_Visiting.htm initiativeID=52756
Centers for Disease Control and Prevention: http://www.cdc. Visiting Nurse Association of America: http://vnaa.org/vnaa/
gov/ siteshelltemplates/homepage_navigate.htm
National Association for Home Care and Hospice: http://www.
nahc.org/
WEBSITE

Visit the Evolve website for this book to find the following study 11A: Cleaning Equipment in the Home
• NCLEX Review Questions
• Care Plans
• Glossary
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Paulist Press. Care, 13(2), 84-91. Government Printing Office.
CHAPTER
12
A Family Perspective in Community/Public
Health Nursing
Claudia M. Smith*
FOCUS QUESTIONS
Why use a family perspective in community/public health How can these approaches be integrated?
nursing? What is family nursing?
How do families differ? How are they the same? How is the family perspective used in the practice of
What different family approaches have been proposed in theÂ€past? community/public health nursing?
CHAPTER OUTLINE
A Family Perspective Bowen's Family Systems Theory
Family as Client Family Structure and Function
Why Choose a Family Perspective? Family Interaction and Communication
What Is a Family? Distinctive Characteristics of Families
Definition of Family Family Coping with Stress
How Are Families Alike and Different? How Can These Approaches Be Integrated?
Historical Frameworks Family Perspectives in Nursing
Family Development What Is Family Nursing?
Family as a System How Is Family Nursing Practiced?
KEY TERMS
Anxiety Hierarchy Stages
Appraisal Interactional style Strengths
Boundary Level of differentiation Structure
Coping Metacommunication Style
Developmental tasks Needs Subsystems
Double-bind communication Process Transition
Dysfunctional Resilience Triangle
Family Resources Values
Function Roles
A FAMILY PERSPECTIVE to pretend that they do not have a family; but ultimately, the
person that one becomes is a reflection of the family from which
All nurses can and should practice family nursing. People are born one came.
into and grow, live, and die within their families. Everyone has a
family. Families have different structures and sizes, have different Family as Client
levels of connection and ways of operating with each other, and The family as a unit of care has been a focus in community/Â�
may be geographically close or distant. Families can offer Â�support public health nursing since its beginning (Whall, 1993). Nurses
and love and can also bring their members Â�disappointment and and other workers in the community recognized that the Â�family
grief. People grow older, may move away, or may sometimes try was a major source of support and influence in many Â�situations.
*This chapter updates material written for the first four editions by Marcia L. Cooley.
322
CHAPTER 12â•… A Family Perspective in Community/Public Health Nursing 323
The community/public health nurse learned to include the A problem can be viewed in many ways. In the past, science
Â�family in nursing care whether the issue was a family member
Â� has often used a cause-and-effect way of thinking: Germ A causes
with an Â�illness, a change in the family (e.g., birth, death), or sickness B. Applying medicine C cures the sickness. This example is
health promotion and disease prevention. People's lifestyles a type of cause-and-effect thinking that became popular in the
and, consequently, their health are intimately tied to the culture, medical field after medications and inoculations proved to be
values, beliefs, practices, and socioeconomic status they share successful in combating specific infectious illnesses.
with their families. Real life, however, is more complex than what simple cause-
Appreciation of the family as a unit of care evolved naturally and-effect thinking implies. Not every person exposed to a
as community/public health nurses worked within the com- certain pathogen becomes ill. Becoming infected depends on
munity. With this work came a recognition that not all Â�families variables such as general level of health, stress level at the time,
are able to provide all their members with what they need to previous antibody development, and genetic susceptibility. Many
reach optimal levels of health. Community/public health different events occur at the same time. When the organism con-
nurses have a unique position because they are broadly edu- fronts these events while various factors are in balance, health is
cated and able to integrate different perspectives that contribute usually maintained. When Â�imbalance exists, illness or dysfunc-
to an Â�understanding of family functioning. Nurses also have a tion may occur—not because of any one event but because of a
unique role within the community that offers them access to combination of factors. This Â�recognition of the complexity and
family Â�situations. Focusing on the family is a helpful step to interconnectedness of a living organism is a Â�systemic, rather
take in working toward a broader perspective of caring for the than a cause-and-effect, way of thinking.
Â�individual, the family, and the entire community. Individuals in a family can be thought of as a living system.
Can a difference be found in using a family rather than an Each person is one of the elements that are interrelated with one
individual perspective? Consider the following example. another. A boundary or imaginary wall exists around the fam-
ily, similar to the thin membrane of a cell wall. This boundary
Michelle, a 13-year-old girl, has been referred to the com- can vary; it can be rigid and impenetrable, or it can be a perme-
munity/public health nurse by administrators at her middle able membrane that allows exchange in and out of the system.
school. Her attendance has been very poor, she is Â�irritable Each member, although only a part of the system, has the poten-
and rebellious in class, her previously good grades are drop- tial to change the patterns and organization of the entire system.
ping, and she has recently gained so much weight that the Together, the individuals within the family make up something
school nurse wonders if Michelle is pregnant. Depending on new that is different from and greater than the simple sum of
the Â�professional's point of view, many different ideas may be its members.
formulated about her problem. The school system views her Living systems have parts that undergo growth and change.
behavior as truancy, the school psychologist wonders about At any given point in time, the individuals in the family will
depression, and her teacher views her as one with a behavior be undergoing change themselves. The members are growing,
problem. Repeated attempts to involve her mother have had developing, learning, and changing, usually on trajectories or
little success. paths that are recognizable as part of the life cycle. Thus, the
Suppose that the community/public health nurse has been family as a living system is constantly changing.
alerted to the need to visit and assess the family. During the The boundaries of the system permit some exchange of
visit, the nurse realizes that Michelle is staying home from information between the inside and the outside. The family
school to watch her younger brother and sister on days her is one system; the community outside the family is another.
grandmother goes to work and no other baby-sitter is avail- Bronfenbrenner (1979), while studying children in families,
able. Michelle is unhappy about having to miss school but does proposed the idea of different levels of systems that Â�constitute
not want anyone to know the situation at home. Her mother is broader and broader environmental contexts in which the
addicted to drugs and is not a reliable person to care for them. child will grow. A phenomenon can be viewed from genetic,
The younger children, aged 6 and 8â•›years, have had repeated Â�biochemical, individual, family, community, and Â�societal per-
throat infections during the winter. No one has been able to spectives. These various levels of analysis can be used when
take them to the clinic. Michelle is not Â�pregnant, but she has thinking about family nursing care. Note that family is not
been so unhappy that she is overeating and Â�gaining weight. the only perspective but is one piece in an ever-broader
Â�ecological context of conceptualizing the appropriate target of
The opportunity to look at a bigger picture gives a perspec- intervention.
tive that is very different from the one presented by an individ-
ual view of Michelle. Viewing the situation solely as Michelle's Why Choose a Family Perspective?
problem is difficult. The community/public health nurse may • Family thinking gives a broader picture. Viewing an individ-
still choose to focus only on Michelle's Â�difficulties but realizes ual in a smaller framework may narrow the information and
that these difficulties are connected to other issues and to the the understanding of the problem. This view assumes that
health of other people. Not only is Michelle's health a concern, individuals act independently and in an isolated way when
but the health of other family
Â� members and the entire family they are actually intimately connected with larger systems.
is also at risk. The Â�family can either be supportive of Michelle When a family member is being assessed, that person may
or block attempted Â�interventions. Community/public health be completely understood only if he or she is viewed within
nursing recognizes the Â�importance of the family and defines the context of the gestalt—the whole situation. Assessment
the entire family as the unit of treatment. Michelle will be using an individual perspective may miss important interre-
involved, but the whole family will become the focus for nurs- lated aspects of the problem or resources that can be used to
ing care. promote health and alleviate distress.
324 CHAPTER 12â•… A Family Perspective in Community/Public Health Nursing
• The family is a unit of care. People often live in households

The Johnson family had been very successful early on, but
as families. Families are organized in a structure with iden-
this changed when the father, Mike, became ill. Mike and his
tified roles and leadership, and society expects families to
wife Jennifer had worked hard to put themselves through
assume some responsibility for each of their members. The
college and later graduate school. Mike worked as an accoun-
family divides its economic resources. Family members also
tant, and Jennifer was a teacher. Their two children, Stephanie
have emotional ties to each other. Even though society has
and Chad, had typical ups and downs during their teenage
assumed some of the family's functions (i.e., education), the
years. Stephanie is now married and expecting a child. Chad
family remains a workable unit.
is working hard at starting a computer business.
• The family assumes a crucial role in maintaining health.
Jennifer and Mike had been planning a happy retirement
Such a strong relationship exists between the Â�family and
until 6â•›months ago. Then a second mortgage was taken
health care that the role of the family becomes para-
out on the house to help Chad start his business. Mike had
mount in maintaining health. Health beliefs, values, and
found out 2â•›months ago that he needed bypass surgery,
behaviors are learned and supported in the family.
at about the same time that his company laid off work-
Health Â�promotion activities are taught and implemented.
ers, including him. He now has health coverage that will
Denham (2003) developed the Family Health Model after
pay for only Â�approximately 50% of the cost of the surgery.
finding that the mother plays a key role in transmitting
HeÂ€Â�cannot work for at least 3â•›months. Jennifer cannot cover
health beliefs about issues such as food choice and prepa-
the Â�mortgage with just her salary. She had planned to baby-
ration, exercise, rest, and sleep patterns to children. The
sit for Stephanie, but now she must keep her teaching job.
family is also a critical resource in the delivery of health
The worry about finances and Mike's health has caused
care. How decisions are made about when to seek care, how
Jennifer to have migraines and is adding to Mike's stress and
health care is paid for, and how the recommended treat-
his high blood pressure. Both Chad and Stephanie are very
ment regimens are carried out are all enacted within the
concerned about asking their parents for the help that was
family. The family is sometimes the primary care provider
previously planned.
for its members who are ill and dependent. Changes in
lifestyle are often required of the whole family if the level
of wellness of one of the members is affected. Research • Family and intimate relationships are important for track-
evaluating the effectiveness of service delivery validates ing the occurrence and incidence of disease. To community/
a family-centered approach. Families that form a part- public health nurses who are attempting to prevent, track,
nership with care providers who recognize the parents as and record disease processes, the relationships within fami-
experts on their children's needs have more positive out- lies and with other intimate partners are clearly significant.
comes for their children (Law etÂ€al., 2003). This approach Family information is used in assessing needs, determining
is considered as the best practice for families with children health care priorities, finding cases, tracking and preventing
with disabilities (King etÂ€al., 2002). the spread of communicable diseases, educating for preven-
• Dysfunction in one member may be related to disturbance tive purposes, and organizing the delivery of care to special
in the whole family. Because a family operates as a system, and large populations. The family is an essential piece of
a symptom in one member may be a signal that some- these epidemiological health care functions.
thing is happening in the family as a whole. The family • The unique goals of family nursing—individual health,
will sometimes work hard on one health problem, with Â�supportive interpersonal relationships, and an effective fam-
some good results, only to have another health problem ily unit—can be achieved only by using a family perspective.
present in a second family member. A familiar example of Hanson (2005) suggests that family is the umbrella under
this concept is a family with the problem of alcoholism, in which all other nursing should be practiced. Family Â�nursing
which one spouse stops drinking, only to have the mar- is a movement in nursing that is coming into its own identity.
riage break up or the healthy spouse become ill. Physical, By definition, all nursing practice is oriented toward achiev-
emotional, and social problems are considered to be ing goals that are beneficial to the health and Â�well-being of
related to the degree of anxiety and emotional imma- individuals within society. The goals that are put forth in
turity present and shared among family members in the family nursing—goals for individuals, relationships, and
entire system. the family unit—can be addressed only by using a family
• Dysfunction in one member may lead to added stress and perspective.
depletion of resources for a family. Some believe that
any family member who has impaired functioning will WHAT IS A FAMILY?
Â�ultimately affect the health of the entire system. Caring
for a member who is ill or dependent can deplete finan- Definition of Family
cial resources, physical energy, and other sources of Thus far, this text has talked about families as if all families are
Â�family support. The health of other members is some- alike and as if everyone understands what is meant when the
times Â�disturbed. In many instances, the ability of the fam- word family is used. In the United States, as in other parts of the
ily to fulfill its maintenance functions for its members, world, many different kinds of families exist. Community/pub-
such as giving
Â� time and attention to young children or lic health nurses need a definition broad enough to encompass
sharing Â�recreational Â�activities, is affected by the illness of the many ways they will be interacting with families. BoxÂ€12-1
a Â�member. The Â�following clinical example demonstrates presents various definitions that have been proposed by family
how Â�illness in one member affects the health of other theorists and experts. The definition of the term family must
members and the entire family. not ignore the atypical or nontraditional family forms that
Single parents
BOXÂ€12-1â•…â•‡ DEFINITIONS OF FAMILY with children (9.4%) Married couples
with children
• A family cooperates economically, may share a common dwelling (20.8%)
place, and may rear children (Strong & DeVault, 1992).
• The family is a haven in a heartless world (Lasch, 1995).
• A family is a unity of interacting personalities (Burgess, 1926).
• The family is the basic unit of society and the social institution that
has the most marked effect on its members (Friedman, 1986).
• The family is an open system that functions in relation to its broader One person
living alone
sociocultural context and that evolves over the life cycle (Walsh, (26.7%)
1993).
• A family is two or more persons who are joined together by bonds
of sharing and emotional closeness and who identify themselves as
being part of a family (Friedman, 1998).
• Definition adopted in this text: a family is an open and Â�developing Other
system of interacting personalities with a structure and Â�process families
enacted in relationships among the individual members, Â�regulated (7.9%) Married couples
without children
by resources and stressors, and existing within the larger community. (28.9%)
Non-families
(6.2%)
FIGUREÂ€12-1â•‡Household composition in the United States
are often encountered in current Â�communities. The Â�definition in 2010. N = 117.5 million households. (Data from U.S. Bureau
should also provide some structure to the way nurses think of the Census. [2010]. America's families and living arrangements:
2010: Tables FG10 and H2. Retrieved September 10, 2011 from
about families to establish a framework for Â�intervention.
http://www.census.gov/population/www/socdemo/hh-fam/cps/
The definition adopted by this text is as follows: a family is an 2010.html.)
open and developing system of interacting personalities with
a structure and process enacted in relationships among the
individual members, regulated by resources and stressors, and is actually a myth that has been popularized through the years
existing within the larger community. (Hareven, 1982). Current family types are varied and chang-
ing. Of all the households in the United States, only 67.1% were
How Are Families Alike and Different? families, defined by the census as two or more persons related
All living systems need some sort of organization and pattern to by birth or marriage and living together under one roof (U.S.
function. Families also have this organization. Many people use Bureau of the Census, 2010). Nonfamily households, includ-
a framework of structure, process, and function to describe the ing single people living alone, nonrelatives living together,
complex nature of families. and cohabiting couples, now comprise 32.9% of the popula-
tion (FigureÂ€12-1). One-third of all households has members
Structure under 18â•›years of age. Among single parent households, 85%
Structure refers to the elements of the family and the organi- are headed by mothers. Two-thirds of children live with both
zation of these elements within the family. Over the life of a Â�parents, 23% live with mother only and 3% live with father only
Â�family, structure does not remain exactly the same, but a Â�certain (Child Trends Data Bank, 2011).
continuity of structure is maintained. Structure is defined in Households have changed since 2000. “Other” family house-
several ways. Some people define structure anthropologically, holds have almost doubled; these include householders with
using family types defined in terms of lineage and power. For adult child(ren), householders with a parent, and grandparent
example, families may be matriarchal or patriarchal. Other householders with grandchild(ren) under 18â•›years of age (U.S.
Â�people look at the arrangement of members within the Â�system Bureau of the Census, 2010). The recent economic recession has
in terms of subsystems, coalitions, and other structures that contributed to more young adult children and adult Â�children
have Â�hierarchies and boundaries; this is explored in more depth living with their parents. Over 40% of births in 2009 were to
in the structural–functional approach discussed later in this unmarried women, although half of these women were in
chapter. Still other persons believe that structure means the cohabitating unions (Child Trends Data Bank, 2011). BoxÂ€12-2
diversity of family forms. presents some different family forms.
Family Forms Process

Some type of family exists in all societies, although there is a A process is a phenomenon that occurs over time. Families, indi-
wide diversity of forms. Variations may even exist among classes viduals, and society go through processes of growth, develop-
within the same society. In the past, in Greece and America, for ment, and change. The term implies change, but within every
example, slaves were prevented by law from forming legal fami- change, some pattern and connectedness with previous and
lies. Even so, the family in some form (although not necessarily future patterns is often found.
the traditional nuclear family) is an ideal that most people try Family process can be defined as predictable and repetitive
to attain. interaction patterns within families. For example, mom always
Family structures have changed across societies and over watches Johnnie's behavior very closely. Johnnie gets upset by
time. Our idea of the traditional American family living in a this and complains to dad. Dad goes to mom and Â�complains
household with extended family members such as grandparents that she is too harsh with Johnnie. Mom backs off for a while but
be open or closed, separate or connected. Families may allow

BOXÂ€12-2â•…â•‡FAMILY FORMS
information from the environment to help them problem-solve
• Nuclear: a father, mother, and child living together but apart from or close themselves off from outside influence. Families may act
both sets of the father's and mother's parents. together in a cohesive manner, withdraw from each other, or
• Extended: members of three generations, including married broth- even split apart. The behavior of the family may be random and
ers and sisters and their families. chaotic or rigid and predictable.
• Three-generational: any combination of first-, second-, and third-
generation members living within a household. Strengths
• Dyad: husband and wife or other couple living alone without When one is discussing families or focusing on health needs,
children. weaknesses or deficits of families frequently jump to the fore-
• Single-parent: divorced, never married, separated, or widowed front. Focusing on family strengths not only helps us bring to
man or woman and at least one child. Most single-parent families light qualities that are sometimes forgotten but also reminds us
are headed by women. of the incredible power and support families continue to offer.
• Step-parent: a household in which one or both spouses have been Family strengths are present in many areas of family function-
divorced or widowed and have remarried into a family with at least ing. All families, especially families at risk, have some strengths
one child. that are working or have worked in the past to maintain some
• Blended or reconstituted: a combination of two families with
level of health for their members.
children from one or both families and sometimes children of the
Otto (1973) is one of the earliest authors to identify Â�family
newly married couple.
• Joint legal custody: both ex-partners retain legal authority as
strengths. The author's framework for assessing family strengths
parents and share child raising. is presented in BoxÂ€12-3. Curran (1983) also identifies family
• Grandparent householder with grandchild(ren): grandÂ� strengths such as teaching respect for others, displaying a sense
child(ren) under 18â•›years of age being cared for by grandparents. of play and humor, teaching children a sense of right and wrong,
• Single adult living alone: a never married, divorced, or widowed having a shared religious core, sharing leisure time, respecting
individual maintaining a separate household, an increasingly com- privacy, and developing shared rituals and traditions. Many
mon occurrence. researchers studying family stress and coping have started to
• Cohabitating: an unmarried couple living together. focus on family strengths—as well as strains and stressors—that
• No-kin: a group of at least two people sharing a relationship and affect families (Bomar, 2004; Feeley & Gottlieb, 2000). Some of
exchanging support who have no legalized or blood tie to each the tools and assessment strategies for these ideas are presented
other. in ChapterÂ€13.
• Compound: one man (or woman) with several spouses.
• Gay: a homosexual couple living together, with or without chil- Function
dren. Children may be adopted, from previous relationships, or from In the past, some who wrote about the family used the term
inÂ€vitro fertilization. functioning to describe the activities the family provided for
• Commune: more than one monogamous couple sharing resources. the well-being of its members. In this text, the term family
Â�
• Group marriage: group of individuals who all are married to each Â�function is used to describe results or the effectiveness of
other and are considered parents of all the children. Â�families. Does the family operate in a way that successfully
Â�provides for the needs of its members? Successful Â�functioning
soon resumes her attention. Such interaction can be observed

in dyads (two-person groups), or in interconnecting triangles
BOXÂ€12-3â•…â•‡ FAMILY STRENGTHS
(three-person groups) within the family.
Families also seem to have a characteristic way of interact- • Ability to provide for physical needs
ing as a unit in relation to the outside world. This process can • Ability to provide for emotional needs
• Ability to provide for spiritual needs
• Respect for parental views and decisions on child rearing
• Ability to communicate openly and in depth
• Consensual decision making
• Provision of security, support, and encouragement
• Ability to relate to each other and to foster growth-producing
relaÂ�tionÂ�ships
• Responsible community relationships
• Ability to grow with and through children
• Ability to help itself and accept help when needed
• Flexibility of family functions and roles
• Mutual respect for individuality
• Ability to see crisis as a means of growth
• Family unity and loyalty and intrafamily cooperation
• Flexibility of family strengths
Adapted from Otto, H. (1973). A framework for assessing family strengths.

haring leisure time and humor through playing games is a
S In A. Reinhardt & M. Quinn (Eds.), Family-centered community nursing
family strength. (pp. 87–93). St. Louis: Mosby.
is a measure of normality or health. Examining how well indi- Family Development

vidual family members care for self and others is a way of
assessing that family's level of health. Unhealthy families are Sharon, a new community/public health nurse, is visiting the
called dysfunctional. Mitchell family. Myra Mitchell has three children aged 18, 14,
Family functioning is best viewed as a continuum. When and 9â•›years. Brenda, the 14-year-old, recently had a baby boy
the words functional and dysfunctional are used, family func- who is now living with the family. Marcia, the 18-year-old, is
tioning can be considered good or bad. There is no such thing in her first year of college but is living at home. Her mother
as a good family or a bad family. All families fall somewhere was helping pay Marcia's tuition by working a Â�second job.
along a continuum from minimal functioning to optimal This work schedule has stopped so she can help with care
functioning in which all members benefit. Many different of the new baby. Marcia finds that studying with the baby
means can be used to assess families, according to different in the house is difficult. Brenda planned to continue high
views of optimal family functioning. Bowen (1978) describes school but is thinking of dropping out. Both girls are Â�failing
families as more or less healthy according to (1) their ability to accomplish their developmental tasks. For Marcia, her
to separate thinking from feeling and (2) the amount of anxi- progress in completing her education, finding a career and
ety that is present in the family. Tapia (1997) defines levels a mate, and establishing her independence is threatened.
of family functioning from chaotic to adult, according to the Brenda is now out of the dating and high school scene with
family's degree of emotional maturity. Olson and McCubbin her peers and cannot even think of her dream to join the Air
(1982) suggest that families should have moderate degrees of Force right now. Myra, who was hoping for some time for
cohesion, coordination, and adaptability for healthy family herself, is now busier than ever. Sharon knows that the family
functioning. is having difficulty completing expected developmental tasks
For optimal family functioning, the structure and Â�process because of these events.
must combine in a way that allows the family to be effective.
Understanding the particular stresses and history that have The family development approach attempts to track change
shaped a specific family's current way of operating helps the over time in a family. Families and individuals are engaged in a
nurse understand that family. Conversely, the typical level of developmental process of growth, aging, and change over the
functioning of a family may determine its developing processes life span. In this approach, a longitudinal view of the Â�family
and structure (e.g., divorce, single parenthood, the arrange- Â�classifies and predicts differences in families as they develop.
ment of subsystems). Structure, process, and function are The assumption is that both individuals in the family and the
interrelated, and all of these aspects must be considered when family as a whole need to accomplish certain tasks at specific
assessing a family. However, no one structure, process, or type times in their life cycles. As the family confronts various stages
of function is proposed here as the right one. Many variations of the life cycle, developmental tasks must be achieved if the
exist within these dimensions that can lead to healthy families. stage is to be negotiated successfully. These tasks carry Â�certain
See ChapterÂ€10 for a further discussion of diversity and cultural role expectations. If the tasks are not achieved at specific times
differences. as a result of stress, crises, lack of resources, or unhealthy
family structure and process, they may never be completely
HISTORICAL FRAMEWORKS achieved. The better equipped a family is to help each Â�member
Â�complete his or her developmental tasks and help the Â�family
The study of family does not fit neatly into any one field, be meet its group tasks, the more successful the development of
it genetics, physiology, anthropology, sociology, or Â�psychology; the Â�family will be. The theory assumes that commonalities
many disciplines have contributed to the understanding of exist for all families.
Â�family functioning. The study of family is interdisciplinary, Duvall (1977) adapted this approach from the theory of
and theories of family have been broadly adapted and used. individual developmental tasks proposed by Havighurst.
However, most frameworks used to study family have been Duvall defined nine ever-changing family developmental tasks
drawn from family sociology or family therapy. that span the family life cycle and outlined eight stages of the
Sociologists have studied families since the nineteenth and family life cycle and specific tasks for each stage (TableÂ€12-1).
early twentieth centuries because of the need to solve emerging Family stages are defined by the age of the oldest child. For
social problems. The 1950s saw the development of conceptual example, a family that has two children aged 7 and 2â•›years
frameworks in family theory. Around that time, interest in the would be considered “a school-aged family” rather than “a
family as a unit of treatment emerged in the field of psychiatry. preschool family.”
Family therapists began focusing on pathological factors within In the cycle of family development, the transition from one
families. Relatively recent trends have included the formulation stage to the next is the critical period. The ease with which a
of family theories attempting to describe the characteristics of family progresses through these critical phases is determined,
healthy families, the development of theories of family coping to some extent, by the completion of earlier tasks. For example,
with stressful situations, and the emergence of frameworks for a family in the launching stage typically has a young adult who
family nursing. is preparing to leave home. The family in this stage must suc-
Family approaches can be separated into several areas that cessfully release the young adult, maintain a supportive home
provide different viewpoints that describe the complexity base, and reestablish the relationships and structure within the
of the family. Families develop, interact, communicate, have Â�family to adjust to the lack of the missing member. The tran-
structures, cope with stress, develop identity, and operate as sition is easier if the family has completed earlier transitions
systems. The following sections describe these approaches in successfully. For example, what if a family is trying to launch
more detail. a young adult but has never worked out a way to share the
TABLEÂ€12-1â•…â•‡ FAMILY DEVELOPMENTAL TASKS

STAGE TASKS
Establishing Marital couple • Establishing a marriage
• Establishing a functional household
• Family planning
• Relating to extended family
• Promoting achievement of developmental tasks for all members
Early childbearing Adding an infant • Managing time and energy
• Stabilizing the family unit
• Developing parenting skills
Preschool Children (3–5â•›years old) • Maintaining a stable marriage
• Making employment decisions
• Nurturing young children
School-age Children (6–12â•›years old) • Promoting school and skill achievement
• Socializing children
• Balancing work and family
Adolescent Teenage children • Balancing adolescent independence with responsibility
• Building an economic and emotional base for the future
• Maintaining open communication
Launching Child leaves home • Disengaging
• Readjusting the marriage and family roles
• Caring for aging parents
Middle age Parents in midlife • Preparing for retirement
• Rediscovering couplehood
• Maintaining intergenerational relationships
• Developing recreational activities
Aging Late adulthood • Adapting to retirement
• Dealing with loss of function
• Managing health issues
• Preparing for death of self and spouse
Adapted from Duvall, E. M. (1977). Family development (5th ed.). Chicago: J. B. Lippincott; and Friedman, M. M. (1992). Family nursing: Theory and
assessment (3rd ed.). Norwalk, CT: Appleton & Lange.
Â�
responsibilities involved in day-to-day life? The member who Â�
current developmental demands, the strategies they are using to
is about to be launched might be unprepared to accept adult meet these demands, and their success at accomplishing these
responsibilities. tasks. Some families need information about the usual course
Duvall's ideas provide a structured and logical way of that can be expected. Other families may benefit from inter-
Â�looking at family life. However, the early framework tended ventions that help them arrange some balance between the
to view all families as nuclear (i.e., mother–father–children). Â�developmental demands and other demands such as illness, job
The Â�organization of the developmental stages is based on the loss, or scarce family resources. In families with a member who
assumption that every family will experience the birth and is ill, the needs of a healthy child will occasionally get lost in
eventual release of children. This portrait of family life does not the shuffle. The goal is to enable the family to accomplish its
represent modern families. Â�function for all its members, not just the ones who are ill or
Others have expanded Duvall's ideas to include varied family Â�otherwise in the forefront.
forms and transitions such as the presence of younger siblings
(McGoldrick etÂ€al., 1993), divorced families (Melnyk & Alpert- Family as a System
Gillis, 1997), adoptive families (Peterson, 1997), single-parent Thinking about the family as a system is so common that many
families, and families in poverty (Hines, 1986). McGoldrick and other approaches actually combine their ways of thinking
colleagues (1993) recognized that families take different forms about families with a systems perspective. The systems perspec-
and are often three generational. In their model, the family life tive views the family as a unit and was first proposed by von
cycle spans more than one generation, and families react to Bertalanffy (1968) as the general systems theory (see ChapterÂ€1).
both the past and the future. For many families, for example, Certain principles are applicable to all systems:
when the youngest child leaves home, increased responsibilities • A system is a unit in which the whole is greater than the sum
for grandparents often arise. The examination by Carter and of its parts.
McGoldrick (1989) of stages and tasks for the divorcing family • Predictable rules govern the operation of these systems.
is outlined in TableÂ€12-2. • Every system has a boundary that is somewhat open or
A community/public health nurse who is aware of deveÂ� closed.
lopmental family theory will attempt to determine the family's • Boundaries allow exchange of information and resources
stage in the life cycle and to assess the family's knowledge of into (external influences) and out of (outcomes) the system.
TABLEÂ€12-2â•…â•‡ STAGES OF DIVORCE AND REMARRIAGE

STAGE DEVELOPMENTAL TASKS
Divorce
Deciding to divorce Acceptance of one's own part in failure of marriage
Planning the breakup Working cooperatively with problems of custody and finances
Dealing with extended family
Separation Mourning the loss of the family
Restructuring marital and parent–child relationships
Realignment of relationships with spouse's family
Divorce Overcoming hurt, anger, guilt, and fantasies of reconciliation
Staying connected with extended families
Postdivorce
Custodial single parent Maintaining flexible arrangements with ex-spouse
Rebuilding own social network
Managing finances
Supporting emotional adaptation of children
Noncustodial parent Finding ways to continue effective parenting
Maintaining financial responsibilities for children
Rebuilding own social network
Planning Remarriage
Entering relationship Recovery of loss of first marriage
Recommitment to formation of a marriage and family
Willingness to deal with complexity and ambiguity
Planning new family Planning for cooperative financial and parenting arrangements with ex-spouses
Allowing time and patience for adjustment of all
Adjusting to multiple new roles, boundaries, space, time, membership, and discipline practices
Dealing with own and children's fears, guilt, and loyalty conflicts
Remarriage Acceptance of a different model of family
Restructuring parental boundaries and adjusting to permeable boundaries of new family
Maintaining relationships of children with all family members
Enhancing new family integration and identity
Sharing memories of history of family and creating new traditions and memories
Adapted from Carter, B., & McGoldrick, M. (1989). The changing family life cycle (2nd ed.). Boston: Allyn and Bacon.
• Communication and feedback mechanisms between parts of Suppose a family with a child with disabilities is not adher-
the system are important in the functioning of the system. ing to daily treatments. Planning an intervention that encour-
• Circular causality helps explain what is happening better ages the mother to spend more time on these treatments may
than linear causality. A change in one part of the system leads help the disabled child, but doing so may take the mother away
to change in the whole system. from tasks that need to be accomplished for her other children.
• Systems operate on the principle of equifinality. The same Viewing families as an interconnected system makes nursing
end point can be reached from a number of starting points care more difficult to plan and perform but is a more accurate
or in different ways. way to think about families.
• Systems appear to have a purpose. This purpose is often Families have boundaries differing in openness to the
the avoidance of entropy or complete randomness and environment. Some boundaries will allow information and
disorganization. resources to pass back and forth freely, and others shut off
• Systems are made up of subsystems and are themselves part this exchange. Families are exposed to stress over time. When
of suprasystems. stress is present in an open system, it can result in adapta-
Family therapists were the first to apply systems theory to tion and growth in the individuals. When stress is present in
families. Approaches such as those of Minuchin and Fishman a more closed family system, it can result in maladaptation;
(1981) and Satir (1972), described later in this chapter, are distorted perceptions, thoughts, and feelings; and less Â�capable
based on the idea of the family as a system in which the whole individuals. Community/public health nurses who interact
is different and greater than the individual members. A Â�family with Â�families need to be aware of the character of a partic-
system perspective recognizes that change in one part of the ular Â�family's boundaries. Helping a family become aware of
Â�system will affect the entire family. Because the system has a its Â�tendencies to use resources from the environment often
Â�tendency to want to stay the same (morphostasis), the family Â�promotes Â�family health.
will usually attempt to resist a change even if the change is help- Family systems tend to want to reach relatively steady states,
ful. Nurses who are planning interventions with families must but change can occur. Change occurs most often when at least
take into account this resistance and the implications for the one member of the system, often the one who is the most flex-
entire system. ible or free of constraints and has some power in the family,
makes a change in his or her way of functioning within the TRIANGLE A:

family. From this perspective, interventions for families are Person
not directed at the member who is ill, injured, or at risk, but at 1
the members who are strongest and most able to change. This
means that the nurse will plan and target interventions with the
members of the system who have some freedom and strength to DISTANCE CLOSENESS
carry out the interventions. A community/public health nurse
who is working with a family that is caring for an aging mother
may choose to spend more time with a daughter-in-law who
has indicated a willingness to help than with the aging mother
or her spouse who is ill and having difficulty himself. Family Person Person
interventions include the entire family, building on its strengths, 2 CONFLICT 3
rather than focusing on its weaknesses.
TRIANGLE B:
Bowen's Family Systems Theory
Person
Murray Bowen is the founder of a school of family therapy that 1
developed the family systems approach in more specific ways
(Bowen, 1978). Although baccalaureate-educated nurses are not
prepared to provide family therapy, several concepts from this
DISTANCE CONFLICT
theory help nurses work more effectively with families.
A key concept is the level of differentiation, or a person's
Â�ability to separate his or her emotions and thoughts. People
exist along a continuum that ranges from being able to Â�separate
Â�decisions and emotional reactions to being totally driven by
Person Person
automatic emotional responses. When an individual is operat- 2 3
ing in a high feeling state, the need to be approved by or close to CLOSENESS
other people is paramount; operating in an autonomous or self- FIGUREÂ€12-2â•‡Triangles are dynamic. (See text for explanation.)
directed way is difficult. A person's level of Â�differentiation will
affect his or her ability to operate Â�successfully in the many spheres
of life, including employment, parenting, money Â�management, Anxiety is another concept that is important in this theory.
and health habits. A person's physical, emotional, and social func- The more anxiety that is present, the more likely it is that people
tioning is related to his or her level of differentiation and to the will react with automatic rather than thoughtful actions. These
amount of anxiety present in the family system. automatic reactions tend to escalate triangles and patterns of
The triangle is another concept that is helpful in under- interactions within the system that have developed over time in
standing family operations (FigureÂ€12-2). Any two-person attempts to manage tension.
system is unstable. Within a short period, tension develops
between the two people and results in the automatic triangling The Levine family has had conflictual family relationships
in of a third person. The three sides of the triangle are (1) a for some time. Carl Levine is a quiet man who works at a
close one in which two people are allied, (2) a conflictual one retail store. His wife, Jackie, is an optometrist. The Â�family
in which two people are in disagreement, and (3) a distant one has always operated with a high level of anxiety in their
in which two people are emotionally separated (Triangle A). daily lives that is noticeable in their everyday relationships.
In periods of calm, the distant position is uncomfortable. The Jackie jumps at anything Carl says that is slightly critical.
distant person (person 2) will usually try to move into a closer She is very quick to start a conflictual conversation. Carl
position (Triangle B). In periods of anxiety, the distant posi- reacts by becoming very quiet. The couple's son, Sam, is
tion is Â�preferred. People try to maneuver into this position to Â�frequently caught up in this conflict and is asked to moderate
escape the tension. Triangles are usually dynamic (i.e., con- the Â�arguments. When the family is experiencing additional
stantly changing), although, in Â�families, they often have pre- stress, Sam's usual Â�reaction is a migraine headache that keeps
dictable and rigid forms. him out of school. The level of differentiation of this family
Community/public health nurses who interact with a family is demonstrated by reactivity under minimal stress. Adding
can use this knowledge of triangles. Remembering that nurses more anxiety is likely to increase family patterns of blame
will automatically become a member of one or several triangles and decrease the family's ability to function effectively.
when interacting with a family, nurses can monitor their behav-
ior and be aware of the pull toward automatic behaviors. For A community/public health nurse applying family systems
instance, a nurse interacting with two brothers trying to make ideas with families realizes that monitoring self-functioning is
plans about moving their mother into a nursing home may find the prerequisite to any intervention. A person who is anxious
himself or herself taking sides with the brother who first con- and not thinking clearly will take this anxiety into the family.
tacted him or her. Being able to operate in somewhat neutral Being in contact with a family without being anxious, being
ways and to maintain contact with all participants is likely to be overresponsible, or taking sides is sometimes difficult. The nurse
more helpful than taking sides with one of the family Â�members. who can remain in contact and continue to relate to the family
Nurses cannot avoid triangles, but they can be aware of the in a way that enables the nurse to see the problem calmly and in
behaviors within them. a broad and thoughtful way is believed to be more helpful to a
family system than is a nurse who is determined to find a way to Family Interaction and Communication
fix the family. If a nurse can enter an anxious system and main- Burgess (1926) described the family as “a unit of interacting per-
tain a somewhat calm presence in the midst of great tension, sonalities.” Family sociologists began using the term Â�symbolic
others in the system may be able to do so as well. Nurses cannot interaction to describe the way family members Â�interact with each
change the functioning of the system, but they can change the other. Interaction is defined as a set of processes taking place among
ways they operate within it. individuals that cannot be separated into Â�isolated parts. Behaviors
of one person are both the cause and the effect of behaviors in
Family Structure and Function another. A representation of self is also learned through values and
In a structural–functional approach, the family is viewed as symbols communicated to the actor by other people.
an organization arranged in a structure with a hierarchy that Symbolic interaction is perhaps most clearly demonstrated
enables it to perform necessary functions. The family is orga- when we think about the process of child development—how
nized into smaller parts, or subsystems. Some concepts relevant a child learns about himself or herself and his or her position
to this framework are values, boundaries, roles, hierarchies, and and status within the environment. This concept is appropriate
interactional style. for all family interactions. For example, in every marriage, many
Structural–functional theory has an outcome orientation: actions become regulated through symbols and shared meanings
What does the family do in relation to society at large? Sociologists that define the situation and each spouse's relationship to the
emphasize three major areas of function: (1) the functions of other. Playing a part (e.g., the competent husband, the comforting
the family for society, (2) the functions of Â�subsystems within wife) may typify many of the interactions in a marriage.
the family for the family, and (3) the Â�functions of the fam- Communications theory, which is based on systems theory,
ily for individual members (Nye & Berardo, 1981). Examples was developed by family therapists. This theory, in which commu-
of Â�functions of family that are frequently mentioned include nication is the primary tool for looking at and working with fami-
socialization of new members into society, reproduction, main- lies, grew out of the work of Watzlawick and colleagues (1967) and
tenance (of the family as an organization), affective functions of Satir (1972). For example, double-bind communiÂ�cation may
(stabilization of adult personalities), and economic functions be seen in schizophrenic families. A double-bind communication
(provision of food, clothing, and shelter for Â�members). To carry sends two conflicting messages. For example, a mother may say to
out these functions, family members assume certain roles or a child, “Come here, I love you,” and yet she may remain rigid and
expected ways of behaving and make contributions. Values or cold when the child approaches. Not only is the child in a double
beliefs about priorities are often learned or shared with similar bind by being unable to respond to both messages, but also the
societal groups. communication usually includes the unspoken message, “Don't
Structural–functional concepts also emerged in family comment on how incongruent this communication is.”
therapy. According to Salvatore Minuchin, a structural Â�family Early observations of communication and interaction among
Â�therapist, symptoms of family members can be resolved through people gave rise to several basic concepts of communications
appropriate family organization (Minuchin & Fishman, 1981). theory:
The concept of boundaries between Â�subsystems is Â�emphasized in 1. Not communicating is impossible because every verbal
his approach. Boundaries represent rules that define Â�participants or nonverbal behavior includes a message. Even silence is
in a subsystem and regulate their behavior. Families with clear communication.
and age-appropriate boundaries are believed to Â�function better 2. Communication has several levels. On one level, the content
than families with rigid or ill-defined boundaries. Subsystems or literal meaning of the message is communicated: “I want
enable the family to perform its functions. Each subsystem has you to go to the store.” On another level, information about
different territories and makes certain demands on its Â�members. intimacy, power, or conflict is transmitted. This level is known
Commonly discussed family subsystemsÂ� include spousal, as metacommunication. “I want you to go to the store” can be
parental, and sibling subsystems. Each of these subsystems has said in many different ways intending to Â�communicate power,
a Â�different place in the hierarchy of family life and has different helplessness, intimacy, conflict, or many other Â�messages about
power in relation to others. the relationship between the communicators.
Interactional style describes the way family members relate 3. Communication implies an exchange of information. Within
to each other. Families sometimes develop repetitive patterns a family, these interactions become patterns that are predict-
of interaction that prescribe their behavior. A family therapist able and repeated. For example, in one family, the only way
observing a family would ask: Do certain patterns reappear that to complain about something may be for the mother to talk
seem to be regulated by the structure and past behaviors within to the son, who will then talk to the father. This communica-
the family? Are these patterns functional in that they help the tion may always occur in a derogatory way so that the father
family achieve its goals? Do they function to keep things the is blamed for what is happening. Because families have a long
same, or do they seek change? history of repeated contacts with each other, these patterns
How is the family organized in general? Is it enmeshed, tend to repeat themselves in somewhat predictable ways.
with boundaries blurred and a strong feeling of overin- 4. In functional families, communication is usually one of the
volvement? Are family members disengaged, with members following:
barely connecting with each other? Are they somewhere in a. A tool to help children learn about the environment
between? Are boundaries so rigid that no growth or adapta- b. A way to communicate rules about how people in the
tion is Â�possible? Structural family therapists often use a tool family should think and act
called a family map to diagram the spatial and relationship c. A tool for conflict resolution
Â�qualities within a family system. This subject is discussed in d. A nurturing method that leads to the development of
more detail in ChapterÂ€13. self-esteem
5. Healthy communication is open, honest, direct, and congru- along developmental lines. For example, a family that is newly
ent with internal feelings. formed will often be centripetal, whereas a middle-aged family
6. Family members assume certain roles relating to family is often centrifugal.
communication. Olson, Sprenkle, and Russell (1982) advanced the Circumplex
Virginia Satir (1972) emphasized the messages about self- Model of families based on the family dimensions of cohesion
esteem communicated within families. Her book Peoplemaking and adaptability. Cohesion is the tendency of the family to inter-
provides interesting exercises and reading for those who want to act as a unit and can vary from open to closed. Adaptability,
learn more about family communication. or flexibility, refers to the family's ability to adopt new ways of
The community/public health nurse using communication operating. Families vary from rigid to extremely flexible; 16
theory principles with families would first assess the family's Â�different types are possible. The model suggests that a balanced
style of communication. Families will have certain rules that level of cohesion and adaptability is most functional, but no one
govern the way they communicate. The family's patterns of family type is believed to be the best (FigureÂ€12-3).
interaction will repeat themselves and can be used as a source of These different models suggest that many variations exist in
information about its communication and members’ relation- the ways families can operate and still be healthy. When work-
ships with each other. These patterns determine how a family ing with families, the community/public health nurse should
will solve conflict, communicate respect or worth, assert power assess for different family styles. Knowing a family's style will
and authority, and develop closeness or distance. The nurse help the nurse plan the best way to proceed in order to fit into
will want to observe what kinds of messages family members the Â�family's usual way of dealing with the world. For example, a
receive about themselves as people and about the problem at family that is operating in a disconnected way may not be able
hand. Ideally, communication will be open (members discuss to present all its members together at a prearranged conference.
events with each other rather than engage in circuitous ways of However, the nurse may be able to see different family members
transmitting the information), honest (members feel free to say at different times and discuss issues with individuals. Families
what they think and feel), direct (members go directly to the that prove to be at either extreme of the continuum may find
Â�person involved rather than communicate through another), themselves in trouble if their conventional way of operating is
and Â� congruent (verbal messages match internal feelings); not working for the current situation. Some families may be
Â�however, the family may not be able to communicate in these receptive to suggestions about alternative ways to do things, but
ways. On some occasions, helping family members alter their others may not. The goal for the nurse is to maximize what can
communication may be appropriate; in other circumstances, be done within the family style.
the nurse may choose to alter interventions to match the Â�family
Â�communication. For example, if a family has a rule that all Family Coping with Stress
communication goes through the father, the nurse may choose Interest in how families cope with stress has been growing,
to communicate with the family in the preferred way. and the emphasis in family theories has changed from concen-
Even if the situation is not conducive to changing Â�family trating on the pathology within families to focusing on family
communication, the community/public health nurse can Â�influence strengths, resources, and adaptability. This focus has resulted in
the family situation by being careful of his or her own commu- attempts to maximize families’ abilities to cope with expected
nication. Taking steps to ensure that communication is open, and unexpected stressors in their lives.
honest, direct, and congruent accurately sends information to As early as 1949, Hill proposed a model that describes fÂ� amily
the family and increases the chance that the family will perceive reaction to stress as a process in which the family experiences
the information accurately. The nurse may sometimes intervene several phases or changes (FigureÂ€12-4). In the ABCX Model
most effectively simply by being a role model of an effective com- (crisis model) of family coping, A (the event) interacts with B
municator. The nurse's meta-position—having the ability to be (resources), which interacts with C (the definition the Â�family
outside the family and observe more accurately what goes on— makes of the event) to produce X (the crisis). The family is
sometimes enables him or her to communicate information thought to experience a roller-coaster course of adjustment,
about family communication patterns that the family Â�cannot a process involving disorganization, recovery, and a subse-
observe. All members in the family deserve commÂ� unication quent level of reorganization. Burr (1973) added the concepts
from the health care system that recognizes their importance and of Â�vulnerability and Â�regenerative power to Hill's framework,
worth as individuals in the family. How the nurse communicates stressing that families vary in their internal resources or abili-
to each member may be as important as what is said. ties to respond to a crisis.
The following clinical example describes a family coping
Distinctive Characteristics of Families with stress.
Other family scholars have attempted to describe families by
identifying their distinctive characteristics. How do families dif- The Bower family has recently been told that the 7-year-old
fer from each other? Do types of families exist? Many of these son, Anthony, has a learning disability. This news is Â�coming
models focus on healthy or normal families in contrast to earlier right at the heels of learning that the mother, Eve, has dia-
theories, which focused on family problems. betes. Eve has been occupied with learning how to take
Beavers and Hampson (1993) studied healthy families and care of her new health problem and is committed to some
developed a model that describes levels of family functioning rigid rules in the family about mealtimes, exercise, bedtime,
that range from healthy to midrange to severely dysfunctional. homework, and chores. In addition, she is recovering from
The authors used two dimensions—family competence and the recent death of her father in an automobile accident. Her
family style—to describe families. Style is centripetal or centrif- Â�husband, Tom, and her daughter, Lisa, will be helping her
ugal; that is, families tend to look for gratification within the learn how to manage Anthony's new requirements, which
family or outside of it, respectively. Family styles tend to vary
Low COHESION High
Disengaged Separated Connected Enmeshed
Chaotic Chaotically Chaotically Chaotically Chaotically

disengaged separated connected enmeshed
High
Flexible
Flexibly Flexibly Flexibly Flexibly
ADAPTABILITY
Structurally Structurally Structurally Structurally

Structured disengaged separated connected enmeshed
Low
Rigid Rigidly Rigidly Rigidly Rigidly

Open Random Closed

FIGUREÂ€12-3â•‡ The Circumplex Model of family systems. (Redrawn from Olson, D. H., & McCubbin, H. I.
[1982]. Circumplex Model of marital and family systems: V. Application to family stress and crisis interven-
tion. In H. I. McCubbin, A. E. Cauble, & J. M. Patterson [Eds.], Family stress, coping, and social support
[p.Â€54]. Springfield, IL: Charles C. Thomas.)
include Â�
frequent medication and behavior management b
strategies. In the past, Eve had managed these types of prob- Existing
lems mostly by herself. She is feeling quite overwhelmed. The resources
community/public health nurse, Dawn, knows that the way
the family appraises the situation, its resources, and their
Â�problem-solving abilities will play a big part in its ability a x
to adjust and eventually adapt to these new demands. The Stressor Crisis
present situation is the first time the family will really be
presented with problems that test its resilience.
c
Perception
of "a"
McCubbin, Cauble, and Patterson (1982) proposed the
Double ABCX Model of family stress and adaptation. This
model adds the concepts of pileup of demands, family system FIGUREÂ€12-4â•‡ Hill's ABCX Model of family coping. (Redrawn from
McCubbin, H. I., & Patterson, J. M. [1982]. Family adaptation to crisis.
resources, and postcrisis behavior. How a family responds to In H. I. McCubbin, A. E. Cauble, & J. M. Patterson [Eds.], Family stress,
crisis will depend, in part, on its response to previous crises. coping, and social support [p. 46]. Springfield, IL: Charles C. Thomas.)
When crises pile up, the family is more at risk for being unable
to maintain sufficient resources and healthy coping behaviors.
The Double ABCX Model is a clear model to use when trying to the meaning the family gives to an event as the most crucial
understand and explain family reactions to stress. Refinements factor determining a family's experience of stress. McCubbin,
have been made to this model as Â�presented in FigureÂ€12-5. McCubbin, and Thompson (1993) defined the Â� concept of
In 1987, the concept of family type was added. Families can family schema, which includes shared family values, goals,
Â�
be regenerative, resilient, and rhythmic. Boss (1987) emphasized Â�expectations, and world views.
b B Bonadaptation
b
Existing Existing and new
resources resources
Adaptation
a a A
x Coping
Stressor Crisis Pile-up
c
c C
Perception x
of "a" Perception X
of X + aA + bB Maladaptation
Precrisis Postcrisis
Time Time
FIGUREÂ€12-5â•‡The Double ABCX Model of family stress and adaptation. (Redrawn from McCubbin,
H. I., & Patterson, J. M. [1982]. Family adaptation to crisis. In H. I. McCubbin, A. E. Cauble, & J. M. Patterson
[Eds.], Family stress, coping, and social support [p. 46]. Springfield, IL: Charles C. Thomas.)
The Resiliency Model of Family Stress, Adjustments, and the adaptation phase, the amount of stressors, strains, and
Adaptation is a refinement of the original Double ABCX Model transitions occurring added to the pileup of events. However,
(McCubbin & McCubbin, 1993). According to this model, newly instituted patterns of functioning, family resources, and
Â�families respond to life events and life transitions in two phases: social support could moderate the impact. The family would
adjustment and adaptation. The adjustment phase involves the assign a meaning to the disability and its impact on the Â�family.
transitory changes families make in response to an event. The The community/public health nurse could work with the
adaptation phase is a longer phase that occurs when a family's Â�family members to help them assign a meaning that includes
attempts to make minor adjustments are not effective and result a view of themselves as Â�succeeding and living with some joy in
in crisis. the face of the demands. This view would interact with their
For example, consider the case of a family that experiences the problem-solving and coping mechanisms to determine a new
birth of a child with a severe disability. When the Â�community/ level of adaptation. Eventually, the family would stabilize in
public health nurse encounters this family, the degree of fam- ways that were different from the way the family was before
ily vulnerability should be appraised. The family vulnerability the birth of the child.
will be related to the current pileup of demands such as finan- Suppose, however, that family resilience was limited. Perhaps
cial obligations, developmental changes being experienced shortly before the birth of the child the father had taken a new
with other siblings, or job pressures. The more events being job, the family had moved to a new community, and the grand-
Â�experienced by the family, the more vulnerable the family will be. mother, who had helped when the older children were young,
However, the community/public health nurse knows that differ- had had a fall and now needed some help herself. The pileup of
ent families will respond to a birth in different ways. The family demands for this family might exhaust their resources and drive
type or amount of resilience—plus resources, problem-solving them into less effective coping behaviors. Or suppose that the
and coping behaviors, and appraisal of the stress—leads to its family appraisal of the birth left its members with feelings of
adjustment to the event. If this family is Â�resilient, has already incompetence and failure. Perhaps the family problem-solving
developed effective problem-solving and coping behaviors, and ability was rigid, and they were unable to trust themselves in
appraises the birth as a challenge that can be dealt with, then Â�trying new coping behaviors. Family members’ lessened capabil-
members will probably manage the period of adjustment fairly ity to pull new patterns of functioning into the situation
Â� would
well. In this clinical case, the community/Â�public health nurse drive them into a less healthy adaptation. Multiple Â�factors enter
found on the initial visits that the Â�family experienced a period into the effectiveness of the family adaptation.
of disorganization at first but was able to make changes that The outcome for this family must be considered in terms of
will help the family care for the child. Family Â�members sought the effect on the individual members and the family as a whole.
resources of time and physical help from extended family and Possibly, resources might be effectively mobilized to provide
friends. The wife adjusted her work schedule so that she would safe care for the child, but the marriage of the parents might end
be home during the day and away in the evening. The Â�husband in divorce. Anyone who works with families should Â�understand
took over child care when he came home from work in the eve- this requirement of simultaneous balancing of individuals’
ning. Family meals and Â�routines were simplified. needs and family needs.
This family was faced with caring for a son who would
require respiratory care, physical therapy, and fairly frequent HOW CAN THESE APPROACHES BE INTEGRATED?
monitoring for many years. After the initial adjustment, the
family would continue to make changes in its way of operating Understanding the family is not a simple task. The models and
to deal with the longer-term demands. As the family entered theories presented here provide a wide array of ideas about
BOXÂ€12-4â•…â•‡CHARACTERISTICS OF FUNCTIONAL FAMILIES

• Developmental stages and tasks: A family goes through predict- • Open or closed system: As the system closes, all variables and
able stages, according to the age and development of its members. If Â�patterns become fixed and less adaptable. Energy is used in dys-
tasks are not achieved at the stage-appropriate time, they may never functional ways. Open systems can adapt and change as feedback is
be achieved. Maturational crises are predictable. Some crises are received from within and outside the system. This aspect is related to
unpredictable and interfere with achievement of tasks. permeability of boundaries.
• Roles: Define certain patterns of expected behavior; are often male • Communication: Healthier when it is clear, honest, direct, congru-
or female linked; need to be appropriate for age and sex; also need to ent, and specific and when the family is able to use it as a mechanism
be flexible, not rigid, and able to support family functioning. to resolve conflict.
• Boundaries: Exist around the system to handle exchange between the • Values: Related to cultural, socioeconomic groups; provide some stabil-
family and the environment; also exist between subsystems to differ- ity, rules, and guidelines; need to be able to change with changing times.
entiate members belonging to each subsystem; need to be permeable • Encouragement of autonomy and acceptance of difference:
to allow information and resources in and out; boundaries between A balance needs to exist between autonomy of members and the
subsystems should have clear generational lines and support a strong need to be a cohesive group.
parental coalition; should be neither too rigid nor too diffuse. • Level of anxiety: When the family is calm, people in the family can
• Subsystems: Each member of the family belongs to several simulta- think and solve problems better. The family tends to do better than in
neously: spouse, parent-child, sibling, and grandparent. Subsystems times of stress. Anxiety can be transitional or long term. Long-term
should include all (and only) age-appropriate members. anxiety tends to wear down the ability of the family to function well.
• Patterns of interaction: Repeat themselves; are healthier when one • Resources and social support: Available to most families from
member is not blamed, left out, or put down in the interaction; should within and outside the family, but the family must be able to use them.
be somewhere in between enmeshed and disengaged. Communication Extended family is often used. Socioeconomic status and geographical
theorists describe how people communicate (e.g., placatory, blaming, location tend to influence these. All families have some strengths.
superresponsible). Bowen (1978) talks about four ways of handling • Meaning, perception, and paradigm: The way a family perceives
fusion: distance, conflict, projection, and dysfunction. a situation, the meaning it attaches to the events, and its typical way
• Power: Results from clear role definition and appropriate rules; of relating to the outside environment influence the ways families
should be somewhat shared, appropriate to age, and within the react.
parental subsystem until the children are independent. • Adaptability: Flexibility, adaptability, and resilience are necessary
• External stressors: Usually present at some point. If they vary, for a family to be able to cope with changing demands. A Â�family
are not very intense, and are spread out over time, the family has a needs to maintain a certain degree of flexibility and yet a certain
chance to adapt. Illness brings its own set of demands to the family. degree of cohesiveness and predictability.
Developed by Marcia Cooley, PhD, RN. Copyright Elsevier.
how families work. Some characteristics of families that are FAMILY PERSPECTIVES IN NURSING
Â�functional, however, seem to be universal and are brought up
over and over in these theories. A summary of these character- Concepts and principles from family theories must be used
istics is presented in BoxÂ€12-4. within a framework that considers the role of the nurse and the
Best practices for community/public health nursing can be relationship between the nurse and the client. Some early nurs-
derived from the various family models and theories discussed ing theorists have included the idea of family in their theories.
in this chapter (BoxÂ€12-5). This evidence affirms the work that One of the major concepts of King (1981) was that the family is
community/public health nurses have engaged in with families a social system. Other theorists did not include family in their
for over a century. early work but added the component later (Newman, 1979;
Orem, 1971; Rogers, 1970). All theorists discussed the family
as a unit that can be the focus of care (Newman, 1983; Orem,
1980; Rogers, 1983). However, none of these nursing theories
BOXÂ€12-5â•…â•‡BEST NURSING PRACTICES described the family or interventions for the family in enough
INFORMED BY FAMILY MODELS detail to direct family nurse interactions.
AND THEORY
What Is Family Nursing?
• Determine the family's stage in the life cycle and address current Family nursing is a relatively new approach to nursing science.
developmental demands. Although those in nursing can learn from other disciplines
• Build on family strengths, rather than focusing on weaknesses. such as sociology and family therapy, nursing theory must
• Be aware of triangles in families, and avoid taking sides. direct nursing practice. Nursing theorists began to formulate
• Maintain a calm presence. frameworks specifically for family nursing in the 1980s. Family
• Communicate openly, honestly, directly, and with emotional nursing has now evolved to include multiple approaches to
Â�congruence; model effective communication.
family care.
• Alter interventions to match family communication patterns, if
Some nurses began to suggest more strongly that the focus of
needed.
family nursing should be on health. Gillis and colleagues (1989)
• Maximize what can be done within the family style.
• Assist family to assign meaning to life circumstances and use began with an interest in family health and illness. Bomar (2004)
resources. emphasized family health promotion. Denham (2003) Â�provided
a framework for studying and improving fÂ� amily health. Denham
defined family health as the “ways families communicate, coop-

erate, and provide care for each other and maintain and sustain
health routines.” Denham further identified common family
health routines, including dietary habits, sleep and rest, activ- Family as a unit
ity patterns, care of dependent members, avoidance behaviors,
medical consultation, and health recovery activities.
Three approaches are strong examples of integrated fam-
ily nursing theory. Hanson (2005) and colleagues developed
the Family Assessment and Intervention Model using the Family
System Stressor-Strengths Inventory to measure family stress
and guide interventions built on family strengths. The Friedman
Interpersonal
Family Assessment Model (Friedman, Bowden, & Jones, 2003)
considers families within the larger community. It draws on
Environment
developmental, structural–functional, stress and coping, and Individual
environmental approaches. The Calgary Family Assessment and
FIGUREÂ€12-6â•‡ Levels of intervention in family nursing.
Intervention Model is a systems model that uses communication
and change theory to address family affect, behaviors, and func-
tion (Wright & Leahey, 2009). policies, and practices at a local, state, national, or even inter-
Interest has also increased in shifting the focus of family national level. The community or even the larger system of
nursing practice from a deficit-based to strength-based and society is also an appropriate level of intervention. Thus, the
empowerment perspectives. The concept of individual and four levels of intervention for the community health nurse are
family strengths is central to the McGill Model of Nursing the individual, the interpersonal, the family system, and the
(Allen, 1999). Feeley and Gottlieb (2000) identified differ- environmental levels (FigureÂ€12-6), all of which are Â�discussed
ent types of strengths that reside in individuals and families. more in ChapterÂ€13.
Skerrett (2010) suggested ways to apply concepts from positive
psychology to family nursing practice. Jones etÂ€al (2011) devel- What Is the Appropriate Area of Concern for Intervention?
oped the Care-giver Empowerment Model (CEM) to serve as a Which aspects of the family's experience need intervention? Is
guide in developing and testing theory-based interventions to directing practice to physical dimensions of health and illness
promote positive outcomes when families care for their mem- enough, or are other areas of family functioning appropriate
bers with illnesses. Bomar (2004) suggested that the role of to address in the role of the family health nurse? As discussed
nursing is to identify and call forth strengths and to mobilize in ChapterÂ€11, health promotion and primary, secondary, and
and regulate resources. Â�tertiary prevention are all appropriate with families. Bomar
and McNeely (1996, p. 5) integrate these ideas and then
Who Is the Client? describe a global view of family health nursing as the “assess-
In the frameworks described earlier, family is viewed in two ment and enhancement of family health status, family health
ways in nursing: (1) family as client and (2) family as context for assets, and family potentials.”
the individual (Whall, 1993; Wright & Leahey, 2009). Viewing
the family as the unit of care means that the entire family is Definition of Family Nursing
the recipient of the nursing intervention. This viewpoint recog- Some people believe that a nurse who practices with families
nizes the standard put forth in the American Nurses Association as clients should be a specialist with advanced preparation in
(ANA) public health nursing standards of practice (ANA, family nursing; others suggest that all nurses practice family-
2007), which identifies clients as individuals, families, com- centered care (Hanson, 2005). Different nurses bring different
munities, and populations. In contrast, viewing the Â�family as amounts of knowledge and experience to the family situation.
Â�context recognizes the impact the family has on an individual. All nurses practice family nursing at the individual level, but
This viewpoint underscores the need to understand the family only a nurse who guides family communication can practice
environment in which the individual exists. interpersonal family nursing. Community/public health nurses
At what level do family health nurses intervene? If the family practice at the interpersonal level when they assist Â�parents in
is the client, do nurses intervene with individuals, some mem- communicating with their preschool children or assist Â�family
bers, the family as a unit, or even larger systems? Friedemann's members in sharing their thoughts with a member who is
framework (1995) outlines system-based family nursing prac- Â�terminally ill. Nurses who provide family therapy or family
ticed on three levels. The individual level is directed at the systems nursing need to have advanced education (Friedman
family as a composite of individuals. The interpersonal level is etÂ€al., 2003). However, all baccalaureate-level nursing graduates
directed at dyads and other small groups of people within the can conduct basic family assessments and interventions such as
family. The family system level is directed at the total system as those discussed in ChapterÂ€13.
it interacts with the environment. This text adds a fourth level: The definition of family nursing proposed in this text is
the environmental level. Sometimes, the environment itself as follows: Family nursing is the practice of nursing directed
may need to be addressed. Novice community/public health toward maximizing the health and well-being of all individu-
nurses can reduce environmental hazards, link families with als within a family system. Two views of family are incorporated
community resources, and develop resources that are exter- into this definition: (1) family as the unit of care and (2) family
nal to families. Community/public health nurses are often as context. Family nursing views the family as a system existing
involved at a level at which they are addressing legislation, within a larger system. As noted earlier, levels of intervention
are the individual, the interpersonal, the family system, and the 3. Nurse–client interaction is a crucial part of family nursing
environmental levels. The goals of family nursing include opti- intervention.
mal functioning for the individual and for the family as a unit. 4. Family nursing interventions need to be modified to match
For community/public health nurses, improving the health of different family needs, family strengths, family styles, and
families is one way to improve the health of communities (ANA, levels of family functioning.
2007; Minnesota Department of Health, 2001; Quad Council of To begin this transition to using a family perspective, the-
Public Health Nursing, 2011). orists have suggested that the nurse guide his or her family
practice by considering some questions about the nature of the
How Is Family Nursing Practiced? contact:
Family nursing practice, like any nursing practice, begins • What have I learned during my assessment of family struc-
with the nursing process. By using this process, the nurse who ture, process, and function that best explains the phenomena
practices with a family perspective is potentially able to inter- happening in this family?
vene effectively at the individual, interpersonal, family unit, • What does the family want from me? What are they expect-
or Â�environmental level. After assessing the individuals, dyads, ing me to do?
family unit, and suprasystem, the nurse is ready to begin iden- • What does the larger system expect or require of me? What
tifying areas of concern or needs. Smith (1985) suggested that is a community/public health nurse's responsibility in this
nurses who work within the community will discover that situation?
Â�family needs fall into one or several of five categories: (1) needs • What level of expertise and skill am I bringing to the situa-
of families dealing with growth and development, (2) needs of tion? What do I have the skills to do? What are my relation-
families coping with illness or loss, (3) needs of families dealing ship skills?
with external stressors, (4) needs of families with inadequate • What have I learned from evidence-based science and theory
resources or support, and (5) needs of families with distur- that seems to apply to this situation?
bances in organization. In addition to needs, family strengths • What might I know or be able to offer to help the individuals
that will help the family move toward optimal functioning and the family achieve a more optimal level of health? How
and health are identified. The family style, or process, must be do I present this as a choice to the system?
Â�considered as the nurse works with the family. This consider- • At what level of the system will I intervene (individual, inter-
ation helps the nurse choose appropriate ways of interacting. personal, family system, or environment)?
Finally, family function—an evaluation of the effectiveness of The decisions and actions of a nurse with regard to families
the family—must be assessed to determine if the goals are real- are performed within the nursing process. How family nursing
istic. This Family Needs Model for family nursing is based on is actualized within each step of the process—assessment, plan-
four assumptions: ning, implementation, and evaluation—is discussed in more
1. Improvement in the functioning of an individual will elicit detail in the next chapter. Working toward family health is a goal
improvement in the functioning of the whole family. that will support people today and strengthen our society for
2. Because of the systemic nature of family, interventions can the future. Family nursing is an essential basis of community/
be directed at any of several levels with a resultant change in public health nursing practice. Healthier families contribute to
family operation. healthier communities.
KEY IDEAS
1. Using a family perspective is necessary for the community/ 6. Community/public health nurses can intervene with fami-
public health nurse. lies at any of several levels: individual, interpersonal, family
2. The nature of the American family is changing, which has led Â�system, and environmental.
to the emergence of many different family forms. 7. Family nurses need to identify family needs, family strengths,
3. No one type of healthy family exists. Families organize them- family styles, and family level of functioning.
selves in different ways that work for them. 8. Helping individuals maintain or restore their functioning
4. Historic frameworks from social sciences and family therapy will ultimately help strengthen the family.
provide information about the nature of families. 9. Nurse–client interaction is a crucial part of family nursing
5. Recent efforts in the development of nursing frameworks and is adjusted for differing family situations.
identify the family as the context in which an individual lives
or as the unit of care.
1. Write a description of an ideal family. Take a moment to Â�
example, how are boundaries between subsystems related to
reflect on where these ideas originated. In what ways is your communication patterns?
family similar to and different from your ideal? 3. Observe a family in a public place such as a restaurant or
2. Compare the characteristics of a functional family with shopping center. What does the members’ interaction tell
those of a clinical family with which you are providing care you about the family? Do you get a sense of the emotional
(see BoxÂ€12-4). In what ways does the latter family exhibit tone and what it would be like to live in this family?
the ideal, and in what ways is it weak? Can you see at which 4. Mentally review the families living in your neighborhood.
point some of the concepts begin to relate to each other? For How many of these families are a traditional family? What
other family forms do you recognize? From your knowledge family, using it to explain the drama, or presenting it as the
of any of these families, do you think family form determines answer to the heroic dilemma in the plot?
family health? 6. Think about intervening at the individual, interpersonal,
5. Watch a television show depicting family life. What form family, or environmental level. At what levels have your past
does this family represent? In your opinion, is it a healthy interventions been? At what levels do you feel comfortable
or not-so-healthy family? From where is the drama or com- intervening now? What additional experience or skills would
edy in the show originating? Is the show making fun of the you eventually like to have to intervene at all these levels?
7. Write a plan for improving your family's health.

Annie E. Casey Foundation: http://www.aecf.org/ Journal of Family Nursing: http://jfn.sagepub.com/
Caring for Every Child's Mental Health: http://www.samhsa.gov/ National Mental Health Association: http://www.nmha.org/
children/ National Council on Family Relationships: http://www.ncfr.org/
Center for Mental Health Services: http://www.samhsa.gov/about/ Stepfamily Association of America: http://www.saafamilies.org/
cmhs.aspx Strengthening America's Families: http://www.strengthening-
Grandparents Raising Grandchildren: http://www.usa.gov/ families.org/
Topics/Grandparents.shtml U.S. Department of Health and Human Services: http://www.
International Family Nursing Association: http://international- hhs.gov/
familynursing.org/
WEBSITE
STUDY AIDS
Visit the Evolve website for this book to find the following study and assessment materials:
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Circumplex model of marital and family systems. Wright, L., & Leahey, M. (2009). Nurses and families: transition (16th ed.). Upper Saddle River, NJ:
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Olson, D. H., & McCubbin, H. I. (1982). Circumplex (5th ed.). Philadelphia: F. A. Davis. Steinglass, P. (2006). The future of family systems
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stress and crisis intervention. In H. I. McCubbin, Systems and Health, 24(4), 396-411.
A. E. Cauble, & J. M. Patterson (Eds.), Family SUGGESTED READINGS Sussman, M., Steinmetz, S., & Peterson, G. (1999).
stress, coping, and social support (pp. 48-68). Handbook of marriage and the family (2nd ed.).
Springfield, IL: Charles C. Thomas. Bell, J. (2009). Family systems nursing: Re-examined. New York: Springer-Verlag.
Orem, D. (1971). Nursing: Concepts of practice. Journal of Family Nursing, 15(2), 123-129. Walsh, F. (2011). Normal family processes (4th ed.).
New York: McGraw-Hill. Betz, C. L. (1996). A systems approach to adolescent New York: Guilford Press.
Orem, D. (1980). Nursing: Concepts of practice (2nd transitions: An opportunity for nurses. Journal of Wright, L. M., & Leahey, M. (2009). Nurses and
ed.). New York: McGraw-Hill. Pediatric Nursing: Nursing Care of Children and families: A guide to family assessment and
Otto, H. (1973). A framework for assessing family Families, 11(5), 271-272. intervention (5th ed.). Philadelphia: F. A. Davis.
strengths. In A. Reinhardt & M. Quinn (Eds.), Black, K., & Lobo, M. (2008). A conceptual review Zinn, M., Eitzen, D., & Wells, B. (2011). Diversity
Family-centered community nursing (pp. 87-93). of family resilience factors. Journal of Family in families (9th ed.). Upper Saddle River, NJ:
St. Louis: Mosby. Nursing, 14(1), 33-55. Pearson.
CHAPTER
13
Family Case Management
Claudia M. Smith*
FOCUS QUESTIONS
What is family case management? How do family style, family strengths, and family functioning
What is the purpose of family assessment? influence care planning?
What methods and tools are used for assessing individuals? How do family–nurse interventions vary with different family
Subsystems? The family unit? The family within the needs?
environment? What are the possible outcomes of the evaluation phase of the
How does the nurse analyze family data? nursing process?
What are family nursing diagnoses? How does the nurse coordinate termination with a family in a
How are priorities determined in family nursing? way that will benefit the nurse and the family?
What principles will help the nurse and family develop an
effective plan of care?
CHAPTER OUTLINE
Family Case Management Implementing the Plan
Family Assessment Helping the Family Cope with Illness or Loss
Assessing Individual Needs Teaching the Family Experiencing Developmental
Assessing Family Subsystems Changes
Assessing the Family as a Unit Connecting the Family to Needed Resources and
Assessing the Family within the Environment Support
Analyzing Family Data Coaching the Family to Change Its Internal Dynamics
Determining Family Needs Helping the Family Remain Healthy within the
Determining Family Style Environment
Determining Family Strengths Evaluation
Determining Family Functioning Methods
Determining Targets of Care Factors Influencing Evaluation
Determining the Nurse's Contribution What to Evaluate
Determining Priorities of Identified Needs Outcome of Evaluation
Developing a Plan Terminating the Nurse–Family Relationship
Principles of Family Care Planning Evaluation of Family Case Management Programs
KEY TERMS
Eco-map Family strengths Social support
Family case management Family style Summative evaluation
Family functioning Formative evaluation Targets of care
Family map Genogram
Family needs Priorities
*This chapter incorporates material written for the first three editions by Marcia L. Cooley.
340
CHAPTER 13â•… Family Case Management 341
The betterment of human communities is the goal of commu- • Determining family functioning allows the nurse to set
nity/public health nursing. To achieve this, community/public Â�realistic goals with the family.
health nursing interventions may be directed to the Â�community As with all nursing practice, the practice of family health
and its populations, community systems, and individuals/Â� nursing builds on the foundation of the nursing process.
families within populations at risk (Minnesota Department of Community/public health nurses assess, diagnose, plan,
Health, 2001). Improving the health of families can improve the Â�implement, and evaluate their nursing care for and with families.
health of the community (American Nurses Association [ANA], For nurses who work with families, extra challenges are
2007; Quad Council, 2011). As part of their scope of practice, posed in the complexity and skill that are sometimes required to
baccalaureate-prepared community/public health nurses are deal with these larger and more intensely connected groups of
expected to be able to implement programs of care targeted Â�people. The nurse's ability to establish a relationship that respects
toward families. the family's rights and strengths becomes more Â�important than
Family health nursing is the practice of nursing directed any other task. Trust, open communication, and acceptance of
toward maximizing the health and well-being of all Â�individuals diverse family values are essential. Although the community/
within a family system. Two views of a family are Â�incorporated: public health nurse has responsibilities to the Â�community and
(1) family as the unit of care and (2) family as context for wishes to affect the health of each family member and the Â�family
Â�individuals and family subsystems. When working with Â�families, as a whole, she or he must always remember that the family is
the community/public health nurse's goal is to promote Â�optimal ultimately responsible for its actions. The nurse's role is Â�limited
health for each member of the family and for the family as a to that of a facilitator, educator, or advocate, except in the most
unit. Bringing a family perspective to the arena in which the extreme cases of personal safety or abuse. Success depends
nurse will meet with the family will change the way the nurse Â�primarily not on what the nurse does but on her or his talent at
practices. The nurse begins to consider more complex needs and empowering the family to act for itself.
more complex interactions as care is offered. The Family Needs
Model of family health nursing introduced in ChapterÂ€12 will FAMILY CASE MANAGEMENT
be used as the guide in this text (FigureÂ€13-1). Using the Family
Needs Model, the community/public health nurse assesses and Case management of families seeks to “optimize the self-care
analyzes family needs, family style, family strengths, and family capabilities” of families regarding their health and well-being
functioning. (Minnesota Department of Health, 2001, p. 93). A Â�public
• Identifying family needs allows the nurse to determine the health nursing perspective for family case management
areas in which the family needs help. includes Â�outreach to find families in need, focus on preven-
• Assessing family style allows the nurse to adjust interper- tion, and Â�reliance on health teaching, counseling, and referral
sonal interactions to match the family's preferred style of and Â�follow-up with families (Minnesota Department of Health,
communicating and relating. 2001). Nurses Â�consult with family members in problem solving,
• Describing family strengths enables the nurse to suggest ways as well as coordinate services and resources on behalf of Â�families.
to build on the family competencies. Public health nursing case management is “Â� client-centered
Environment
y as a unit
Famil
Family Family
Needs Style
Family members
Family Family
Strengths Functioning
FIGUREÂ€13-1â•‡The Family Needs Model of family health Â�nursing,

created by Marcia Cooley and Claudia Smith. (See text for A nurse taking a health history during a family home visit.
Â�explanation.) (Copyright [1995]. Used with permission.) (Copyright CLG Photographics.)
342 CHAPTER 13â•… Family Case Management
and Â�relationship-based” (Minnesota Department of Health, Â�

family assessment should include information gathered about
2001, p. 100). Additionally, advocacy and collaboration within and from all of these levels. Data that are essential to collect
the community or community systems may emerge from the include the following:
relationship(s) with families. Family case management in Â�public • Household composition
health nursing is neither disease management nor benefits • Health status and behaviors of all members
management for managed care or an insurance company. The • Interaction among the family members
above aspects of case management in community/public health • The relationship of the family with its community
nursing are considered best practices (Minnesota Department
of Health, 2001) and are integrated with the nursing process Assessing Individual Needs
(ANA, 2007). Typically, one member of the family is identified as the client
who is to be the recipient of nursing care. This client may have
FAMILY ASSESSMENT an identified health problem (e.g., a recent discharge from a hos-
pital after a stroke, a communicable disease), a chronic Â�illness
As with all assessment, the nurse uses as many possible sources that needs continued monitoring (e.g., diabetes), or a Â�potential
of data as is practical to help complete a comprehensive Â�picture problem (e.g., a new mother who needs Â�education about car-
of the family and each member. Of course, before Â�discussing a ing for her infant). Adequate identification and Â�collection of
family or reviewing the family’ s records with a Â�member of the Â�information about the client’ s response to these actual or poten-
health care team from another agency, the family’ s Â�permission tial health problems is the first priority in family assessment.
must be obtained. Sources of data can include, but should not However, many families will have more than one mem-
be Â�limited to, charts and written health records, Â�biological ber with actual or potential health problems. Because family
data such as blood pressures or specimens, telephone calls members are interconnected, the health of all members is a
and Â� conversations with other health care team members, concern to the nurse. Depending on the mission and guide-
Â�information from social service agencies involved with the lines of the agency and the nurse’ s role, all family members
family, and environmental and community Â�
Â� information. are potential targets of individual assessment. For example,
However, the most accurate and complete information can be suppose the identified client is a 55-year-old man who has
obtained only by observing and interviewing the family itself. developed a foot ulcer. He may eventually need assistance
Interviewing families can be more difficult than interview- with moving and transferring. What if the only other Â�member
ing an individual client and, for a nurse who is not familiar of the family, his wife, has chronic obstructive Â�pulmonary
with this situation, a little frightening. After all, the family has Â�disease (COPD) and is unable to help? Family health is inter-
been together for a long time and has a history together that connected because members share their environment and
gives strength and a collective power to even the most dysfunc- depend on each other.
tional family. Interviewing families can also be a rich source of Individual assessment will vary with the age, gender, and
Â�information and a path to establishing relationships that are particular health status of each person. Included in the assess-
fulfilling and meaningful for both the nurse and the family ment may be comprehensive health or physical assessment,
members. assessment of developmental level, mental status assessment,
Families may first be seen in the hospital, clinic, community focused information about specific health problems such as
setting, or in their own homes. Meeting families in their own incontinence or decubiti, or assessment of coping and adap-
environments is preferable because the nurse can observe first- tation. Some specific individual assessments are outlined in
hand the physical and environmental conditions, as well as the BoxÂ€13-1.
way family members interact with each other on their own turfs. All family members can benefit from health promotion and dis-
Preparing for a home visit is discussed in ChapterÂ€11. Ideally, the ease or injury prevention. Community/public health nurses need
nurse will keep these principles in mind when planning the first to assess the history of immunizations and screening tests for
meeting with the family. each family member. By comparing this information with rec-
The nurse should try to include as many family members as ommended schedules for immunizations (see ChapterÂ€8) and
is possible in the interview. Each family will have a communica- screening tests (see ChapterÂ€19), nurses can identify the immu-
tor (someone who tends to speak for the other members of the nizations and screening tests that each family member needs.
family) and usually a leader (someone who takes charge of fam-
ily operations). Often, but not always, the communicator and Assessing Family Subsystems
the leader are the same person. Although you can work through Families interact in small interpersonal groups. Understanding
this strength, be aware that, to be accurate, perceptions of the the interactions and functioning of these dyads and triangles
problem or concern and other data must be gathered from all is important to understanding the functioning of the fam-
persons. Being able to see the family together often gives the ily and ascertaining available support. Subsystems such as
observer information about family interaction that is useful. the parent–child subsystem, the marital pair, and the sibling
The goal of family assessment is to gather information that subsystem should always be assessed. Other, less obvious,
allows the nurse and family to identify family needs together Â�subsystems might be grandparent–grandchild, foster Â�parent–
and to plan care that will allow the family to work toward child, or parents–young married couple. Tools that can be
more optimal health for individual family members and for used include maps of social interaction, tools that assess the
the Â�family as a whole. Families can then be assessed on several health of developmental bonds such as mother–child inter-
levels: assessing individuals within the family, assessing interaction, and tools that target problems in dyads, such as elder
actions among subsystems, assessing the family as a unit, and abuse screening tools. Examples of these assessments are
assessing the family within the environment. A comprehensive Â�presented in BoxÂ€13-1.
BOXÂ€13-1â•…â•‡ EXAMPLES OF ASSESSMENTS

Individual Assessments Family Assessments
Physical assessment of the newborn Calgary Family Assessment Model (CFAM) (Wright & Leahey, 2009)
Adult physical examination Family Inventory of Life Events and Changes (FILE) (McCubbin &
Diet history Thompson, 1987b)
Discharge Planning Risk Screen (Blaylock & Cason, 1992) Family Nutritional Assessment Tool (James & Flores, 2004)
Mental status examination (Jernigan, 1986) Family Social Support (Roth, 1996)
Incontinence assessment (Kane etÂ€al., 1993) Family Systems Stressor-Strength Inventory (FS3I) (Berkey & Hanson, 1991)
Mortality Risk Appraisal (Pender, 1987) Family Nursing Scale (Astedt-Kurki etÂ€al., 2002)
Spiritual assessment (Zerwekh, 1989) Family Coping Oriented Personal Scales (F-COPES) (McCubbin &
Levels of Cognitive Functioning Assessment Scale Thompson, 1987a)
(Flannery & Korchek, 1993)
Denver Eye Screening Test (Wong & Whaley, 1995) Environmental Assessments
Assessment of Immediate Living Environment (Skelley, 1990)
Interpersonal Assessments Building Accessibility Checklist (Mumma, 1987)
Brief Screening Inventory for Postpartum Adaptation (Affonso, 1987) Eco-map (Hartman, 1978)
Elder Abuse Assessment Tool (Fulmer, 1984) Home Observation for Measurement Environment (HOME)
Neonatal Perception Inventory (Broussard & Hartner, 1995) (Caldwell, 1976)
Social Assessment of the Elderly (Kane etÂ€al., 1993) Occupation/Environment Health History (Wiley, 1996)
Assessing the Family as a Unit nurses remember the family members, patterns, and significant
Although assessing families in smaller segments is helpful, these events that are important in the family’s care. The picture of
assessments do not capture the nature of the family as a whole. the family that is presented in the genogram helps the observer
Families have unique identities that cannot be understood when think about the family systemically and over time. Occasionally,
thinking about only the segments. Parameters that are often when a larger picture is presented, connections between events
assessed include family processes, roles, communication, division and relationships become clearer and are viewed in a more
of labor, decision making, boundaries, styles of problem solving, objective way.
coping abilities, and health-promotion Â�practices. Some specific Genograms serve several other functions. The process
tools are outlined in BoxÂ€13-1, and some of the more widely used of collecting and recording information for constructing a
family assessments are discussed in the Â�following sections. genogram serves as a way for the interviewer and family to
connect in a personal but emotionally safe way. The geno-
Family Maps gram also provides the interviewer with information about
A family map is used to diagram spatial and relationship qual- how the members of the family think about family problems
ities of a family system. The tool originated with structural– and interact with other members. Recording Â�information
functional family therapists (Minuchin & Fishman, 1981).
These researchers began observing the structure and interac-
tion of families in therapeutic situations and mapping Â�families
to understand their hierarchies, roles, and power. After an inter- FAMILY MAP
view in which the family is observed in an interactive Â�situation,
a map is drawn that details the subsystems, the boundaries Mr. R Mrs. R
between subsystems, and interactive patterns, such as coalitions,
conflict, and avoidance.
A healthy family will demonstrate age-appropriate subsys- Patricia
tems. Power will reside with parents, and children will have the
Ellen Tom
nurturant guidance they need to grow. Spousal subsystems will
have a clear identity. Boundaries between subsystems will be clear KEY
and permeable. Diffuse boundaries allow too much confusion Clear boundary Affiliation
because members move back and forth without clear definition Diffuse boundary Overinvolvement
of roles. Rigid boundaries serve to shut off necessary interaction
Rigid boundary Conflict
and discourage flexibility and adaptiveness. Interactive patterns
tend to repeat themselves and provide information about who F Father
Coalition
will communicate and in what way the communication may M Mother
D Daughter
occur. Symbols for the maps are shown in FigureÂ€13-2.
S Son
C Child
Genograms
A genogram is a format for drawing a family tree that records FIGUREÂ€13-2â•‡Family map using family example from the
information about family members and their relationships for at Nursing Practice in Process at the end of the chapter. (Adapted
least three generations (Cain, 1981; McGoldrick, Shellenberger, from Minuchin, S. [1974]. Families and family therapy. Cambridge, MA:
& Petry, 2008). Genograms help community/public health Harvard University Press.)
on a genogram can serve to detoxify issues or reduce anx- educational level. Critical family events and transitions such as
iety about the family problem. During the process, family moves, marriages, divorces, losses, and successes are recorded.
Â�members are required to think, Â�organize, and present facts. Family members’ physical, emotional, or social problems or ill-
The nurse helps the family normalize and reframe problems nesses are identified. A genogram facilitates discussion of the
so that they are viewed in a larger context. This type of inter- role of heredity and recommendations for genetic screening
action can help family members step back and think about (De Sevo, 2010), as well as prevention of illnesses common in
an issue in a calm way. the family. A chronology, or time line, of family events is often
Typically, the genogram is constructed in the first or an early useful to help people see relationships between events and
session and revised as new information becomes available. behavior changes.
Genogram construction may be divided into three parts: Observing and describing family relationships is the stage
1. Mapping the family structure that is the most crucial and often the most helpful to the family
2. Recording family information but is often ignored. Relationship patterns can be quite complex
3. Delineating family relationships and are inferred from observations and from family members’
To map the family structure, a diagram of family members comments and analyses. The nurse should identify patterns of
in each generation is drawn using horizontal and vertical lines. closeness, conflict, and distance. When relationships are too
Symbols used to represent pregnancies, miscarriages, marriages, close, this intensity is also noted. Some Â�symbols that are used to
and deaths are presented in FigureÂ€13-3. Male family members represent relationships are Â�presented in FigureÂ€13-3. Triangles
are placed on the left of the horizontal line; female members are present in every family
Â� (see ChapterÂ€12). Attempting to map
on the right. Birth order is represented by placing the oldest the primary or most Â�influential triangles in the family is a part
Â�sibling on the far left and progressing toward the right. In the of describing the family relationships.
case of multiple marriages, the earliest is placed on the left and The genogram is an assessment tool that can be useful
the most recent on the right. throughout the contact with the family. At some point, the
Family information that is usually helpful includes ages, genogram may also be used as a therapeutic tool whereby infor-
dates of birth and death, geographical location, occupation, and mation is interpreted and used to help individuals define the
GENOGRAM
Farmer Farmer,
Minister CVD died breast cancer
Md. Pa.
Retired
pipefitter, Homemaker
diabetes, 80 74
Baltimore
ASCVD D
Baltimore
Teacher D
Baltimore
Homemaker
Pat Ellen Tom Baltimore
1982
Secretary
4 5 Baltimore 6 4
KEY OF STANDARD SYMBOLS
A
Male Adopted child Separation
Female Pregnancy Twins (this case boys)
Marriage relationship Miscarriage or abortion Intensity of relationships:

overclose
Parent-child Death Conflictual

relationship
D
Relationship Divorce Distant
FIGUREÂ€13-3â•‡ Genogram using family example from the Nursing Practice in Process at the end of
the chapter. (Adapted from Cain, A. [1981]. Assessment of family structure. In J. Miller & E. Janosik [Eds.],
Family-focused care [p. 117]. New York: McGraw-Hill.)
way they would like to operate within the group. Although the Community resources and facilities that are available to the
nurse may yield to thinking that she or he knows what the Â�family family should also be noted. However, some families can live
should do, interpretations that come from family Â�members within a fairly resource-rich environment and be unable to main-
themselves are usually more accurate and useful for change. tain the connections that are needed to tap these resources. An
eco-map (Hartman, 1978) is a tool that can help the nurse and
Family Cultural Assessment the family discover patterns of energy flow into and out of the
At this point, competence in family cultural assessment is also family. The family’ s relationships with Â�significant Â�community
required. When working with diversity in families, the nurse resources, activities, and agencies are diagrammed. Are these con-
needs to develop an awareness of her or his own Â�existence, nections strong, tenuous, or stressful? The Â�diagram illustrates the
thoughts, and environment without letting it have undue influ- amount of energy that a family uses to maintain
Â� its system and
ence on others. The nurse should be able to demonstrate knowl- what support is available. After the nurse helps the family pre-
edge and understanding of the family’ s culture and also respect pare the diagram, the eco-map helps family members visualize
for cultural differences. If language is a barrier, interpreters can be how relationships with external systems are affecting their state of
used, but time must be allowed for translation, and using children well-being. An eco-map is presented in FigureÂ€13-4.
as interpreters should be avoided. Cultural norms about personal Other aspects of the environment, such as chemical expo-
space, touch, and eye contact vary; thus, the nurse needs to be sure, air quality, and danger in neighborhoods with a high level
aware of nonverbal behavior and adjust it, as necessary. BoxÂ€13-2 of criminal activity, also affect families. Krieger and Â�colleagues
presents Purnell and Paulanka's model (2008) of cultural compe- (2005) described low-income families that are at risk for asthma
tence with hints for areas of family life to assess. See TableÂ€10-4 for related to the high incidence of indoor asthma triggers in their
a more detailed guide to family Â�cultural assessment. environment. Lead exposure for young children in older b Â� uildings
is another example of risk. Musculoskeletal injuries, accidents,
Assessing the Family within the Environment exposures to radiation and carcinogens, and sound damage to
The family is a group of interacting people who also live within hearing are examples of danger in the workplace. An example of
an external physical and interpersonal environment. Data about a tool to assess a family’ s occupational and environmental history
the family’ s physical environment, such as the presence of acci- is the Occupational and Environmental Health History (Wiley,
dent hazards, window screens, plumbing, and cooking facilities, 1996) in BoxÂ€13-3. Also see BoxÂ€9-2 for another tool.
help the nurse (1) plan care that matches or supplements fam-
ily resources and (2) identify potential health problems. Some
physical conditions that should be assessed are presented in
BoxÂ€13-1. Home Observation for Measurement Environment Pharmacy
(HOME), an observation tool developed to assess the potential
of the environment for development of children from birth to
6â•›years of age, is an example of a tool that can be used to collect
data about the physical environment (Caldwell, 1976) (see also
ChapterÂ€9). Family
Physician or
household
BOXÂ€13-2â•…â•‡FAMILY CULTURAL ASSESSMENT
Mr. R Mrs. R
1. Who is the head of the household? Who has the final say? For
example, some families are patriarchal; some are matriarchal.
2. Does the family operate with specific assigned roles, or are the
roles less defined? Who is responsible for maintaining health? For
example, some families have clear separations for what men and Patricia Ellen Tom
women should do.
3. Do family members exhibit essential or taboo behaviors? For
example, some families have prescriptive behaviors such as
Â�
Â�purging their children with laxatives; others have restrictive behav-
iors such as not allowing unchaperoned dating. KEY
4. What are the family's goals for members? Strong connection
5. What is the cultural significance of children, older members, and
Tenuous connection
extended family?
Stressful connection
6. What is the family's acceptance of different lifestyles?
7. How does the family respond to living with a partner without FIGUREÂ€13-4â•‡An eco-map using family example from the
Â�marriage? Homosexuality? Divorce? Nursing Practice in Process at the end of the chapter. Directions:
8. What are the family's health-related behaviors? Fill in connections where they exist. Indicate their nature by
9. What do they do to promote and maintain health? To prevent descriptive words or different lines. Draw arrows along lines
Â�illness? What home remedies are used? to signify flow of energy and resources. Identify significant
Â�people. Fill in empty circles, as needed. (Adapted from Hartman,
Adapted from Purnell, L. D., & Paulanka, B. (2008). Transcultural health S. [1978]. Diagrammatic assessment of family relationships. Social
care: A culturally competent approach (3rd ed.). Philadelphia: F. A. Davis; Casework, 59, 470. Reprinted with permission from Families in Society
and Spector, R. E. (2008). Cultural diversity in health and illness (7th ed.). [http://www.familiesinsociety.org], published by the Alliance for Children
Upper Saddle River, NJ: Pearson. and Families.)
BOXÂ€13-3â•…â•‡ OCCUPATIONAL AND ENVIRONMENTAL HEALTH HISTORY

Identifying Data
Name: _______________________________________________
Address: ______________________________________________
Telephone number: ________________________________________
Social security number: _____________________________________
Gender: _______________________________________________
Age: ______________ Date of birth: _________________________
___________________________________________________________________________________________________________
Chief Complaint and Stressors Perceived by the Client: _______________________________________________________

________________________________________________________________________________________________________________________
Key Questions
1. Describe the health problem or injury you are currently experiencing. ______________________________________________________
________________________________________________________________________________________________________
2. Are any other members of your family experiencing this problem? Any co-worker? Any acquaintance? _______________________________
3. Do you smoke? ____________ Use chewing tobacco? ____________ Consume alcohol? ____________ Use any other drugs? ____________
_____________________________________________________________________________________________________
(Packs of cigarettes per day, quantity, frequency, number of years in which cigarettes used) ______________________
4. Do you smoke while on the job? __________At home? _____________Do your co-workers smoke on the job? ____________Do family
Â�members smoke while you are in the room? ________________
5. Have you missed work within the last 6â•›weeks? ____________When did these symptoms begin? ____________Have you stayed in bed since
this condition started? ____________Are you distressed by your disability now? _____________
6. Have you ever worked at a job or other activity that has caused you to have this problem before? ______________If so, describe the pattern of
illness or Â�difficulty. _________________________________________________________________________________________
7. Have you ever found yourself short of breath, light headed, dizzy, with a cough, or wheezing at work? ______________ After work? ____________
At the beginning of the workweek? ______________At the end of the workweek? _______________ During the weekend? ______________
8. Have you ever changed jobs, homes, or hobbies because of a health problem? ________________________________________________
9. Have you ever experienced muscle or moving difficulties (back pain, fractures, sore muscles, decreased ability to move around, joint pain) related
to work, home, or play?
10. Name the chemicals and compounds with which you work and the frequency of your contact with each substance. _____________________
________________________________________________________________________________________________________
11. Name the chemicals and compounds with which your spouse or other family member works. _____________________________________
________________________________________________________________________________________________________
12. Does your skin ever come in contact with any chemicals or substances at work or play? __________________________________________
________________________________________________________________________________________________________
13. Describe your neighborhood. Map out the location of industrial areas, waste disposal sites, water sources, and waste disposal processes.
________________________________________________________________________________________________________
14. Have any community environmental problems evolved recently? __________________________________________________________
15. Have there been any toxic spills, sewage breakage, smog changes, or Occupational Safety and Health Administration investigations pertinent to
your condition? ____________________________________________________________________________________________
16. What types of pesticides, cleaning solutions, glues, solvents, metals, or poisons are used in your home? _____________________________
________________________________________________________________________________________________________
17. What type of heating and cooling system is used in the home? ____________________________________________________________
________________________________________________________________________________________________________
18. What is its impact on the illness pattern? __________________________________________________________________________
Adapted from Wiley, D. (1996). Family environmental health. In P. Bomar (Ed.), Nurses and family health promotion: Concepts, assessment, and
interventions (2nd ed.; p. 351). Philadelphia: Saunders.
ANALYZING FAMILY DATA way. What does this information mean, and in what way can it
be used to help the nurse and family plan their work together?
The different types of assessments discussed in the preceding The information must be integrated and analyzed before deci-
section provide not only a comprehensive assessment but also sions about the plan of care can be made. Once the information
a massive amount of data. Family assessments can be complex is summarized and targets of care are identified, the process of
and confusing if these data are not sorted and analyzed in some intervention is clearer for the nurse and the family. Neglecting to
accomplish this task carefully can lead to feelings of being over-

BOXÂ€13-4â•…â•‡INDIVIDUAL AND
whelmed or to nonfocused, constantly changing interventions.
INTERPERSONAL NURSING
The following steps can be used to help organize these data:
• Determining family needs or areas of concern DIAGNOSES
• Determining family style • Breast-Feeding Pattern: Ineffective
• Determining family strengths • Caregiver Role Strain
• Determining family functioning • Coping: Ineffective
• Determining targets of care • Health Maintenance: Ineffective
• Determining nursing’s contribution • Home Maintenance Management: Impaired
• Determining priorities of identified health needs • Parenting: Impaired
• Role Performance: Ineffective
Determining Family Needs • Self-Care Deficit
When looking at family needs, the nurse is asking the follow- • Self-Health Management: Ineffective
ing questions: • Sexual Dysfunction
“What?” • Social Interaction: Impaired
“In what areas does the family need help?” • Social Isolation
“What concerns do the nurse and family want to explore?” • Verbal Communication: Impaired
These needs are identified on multiple levels: needs of indi- • Violence, Risk for: Self-Directed or Directed at Others
vidual members, needs of family subgroups, needs of the fam- From North American Nursing Diagnosis Association (NANDA)
ily as a whole, and needs related to the family interacting with International. (2009). Nursing diagnoses: Definitions and classification,
the environment. Nursing diagnoses can be developed that 2009-2011. Ames, IA: Wiley-Blackwell.
represent each of these areas. The North American Nursing
Diagnosis Association (NANDA International) has been identi- developmental challenges often benefit from health-Â�promotion
fying and listing diagnostic nomenclature since the early 1970s. and illness-prevention education or supportive Â�contact as fam-
These diagnoses are formulated to help nurses choose and focus ily members master behaviors appropriate for their new stage
nursing interventions by concentrating on client responses of life.
to health promotion and actual or potential health problems Families coping with illness or loss not only need emotional
rather than on the disease process. Each diagnosis consists of support but also need concrete help such as direct care, educa-
two parts: (1)Â€the unhealthy response and (2) an indication of tion, and connection to services. Families dealing with external
the factors contributing to the response. Problems may be those stressors such as natural disasters, unemployment, or societal
that exist currently (actual) or may possibly exist in the future violence benefit from emotional and physical support. During
(potential), or the problems may relate to health promotion. this time of crisis, the family may be strained and not as func-
Nursing diagnoses for individual family members are iden- tional. However, a crisis period may also be a time for the family
tified just as they are when an individual is the sole target of to grow and discover strength under stress.
care. Diagnoses that represent responses to health problems are Inadequate resources or support can be temporary or long
organized according to patterns or clusters of behaviors such as term. For example, a family with several events happening at
sleep and rest, elimination, and activity and exercise (Newfield once (e.g., children in college, an illness, an aging parent) may
etÂ€al., 2007). find its usually sufficient resources inadequate. Other fami-
Interpersonal nursing diagnoses may include needs that lies deal with the chronic problem of poverty, lack of access to
represent the interaction of more than one person, for exam- resources, and inadequate energy to maintain self-esteem and
ple, “Breast-Feeding: Ineffective,” or diagnoses that affect more meet other persons’ emotional needs (see ChapterÂ€14).
than one person, for example, “Social Interaction: Impaired.” Families with disturbances in internal dynamics create stress
Examples of individual and interpersonal nursing diagnoses are from within. The unhealthy way in which they operate tends to
presented in BoxÂ€13-4. provoke rather than mediate their stress. Of course, families can
Family nursing diagnoses have also been identified by have combinations of these problems, or some of the problems
NANDA International (2009). The nomenclature used includes may potentiate others. However, this framework covers most of
the following: the needs families will present in the community/public health
• Family Processes: Dysfunctional setting.
• Family Processes: Interrupted Environmental problems for families are described in the
• Family Processes: Readiness for Enhanced Omaha System problem classification scheme (Martin, 2005).
• Family Coping: Compromised or Disabled Problems with material resources and physical surroundings
• Family Coping: Readiness for Enhanced include income, sanitation, residence, and neighborhood
Â� and
The major defining characteristics that correspond to these workplace safety, including environmental hazards (TableÂ€13-1).
diagnoses include most of the concepts discussed within the Family problems related to the social environment may
family chapters in this book and are presented in BoxÂ€13-5. occur in the areas of communication with community
However, some authors find that the NANDA International resources and social contact (TableÂ€13-2). Each problem may
family nursing diagnoses are not sufficiently specific. The Family have actual or potential impairments or opportunities for
Needs Model (Smith, 1985) suggests that five major areas exist in health promotion.
community health nursing in which families and nursing inter- Different family needs require different intervention strate-
sect (BoxÂ€13-6). This delineation may help the nurse identify gies from the nurse. Specific interventions for each of the five
more specific family needs. Families meeting Â�normal growth and categories of family needs are discussed later in this chapter.
BOXÂ€13-5â•…â•‡ MAJOR DEFINING CHARACTERISTICS OF FAMILY DIAGNOSES

Family Processes: Dysfunctional Family Coping: Compromised
Psychosocial, spiritual, and physiological functions of the family unit Usually supportive primary person (family member or close friend)
are chronically disorganized, which leads to conflict, denial of problems, Â�provides insufficient, ineffective, or compromised support, comfort,
resistance to change, ineffective problem solving, and a series of self- assistance, or encouragement that may be needed by the client to
perpetuating crises. Â�manage or master adaptive tasks related to his or her health challenge.
In families with this diagnosis, the family system or family members A. Subjective
have the following characteristics:* (1) Client expresses [or confirms] a complaint or concern about
1. Alcohol abuse Â�significant person's response to health problem.
2. Blaming (2) Significant person expresses inadequate knowledge base
3. Contradictory or controlling communication or understanding, which interferes with effective supportive
4. Disturbances in academic performance in children behaviors.
5. Failure to accomplish developmental tasks (3) Significant person describes preoccupation with personal Â�reaction
6. Inability to accept help (e.g., fear, anticipatory grief, guilt, anxiety) to client's need.
7. Inability to accept or express a wide range of feelings B. Objective
8. Inability to meet emotional needs of its members (1) Significant person attempts assistive or supportive behaviors
9. Inability to meet security needs of its members with unsatisfactory results.
10. Inability to meet spiritual needs of its members (2) Significant person displays protective behavior disproportionate
11. Inappropriate expression of anger to the client's abilities or need for autonomy.
12. Ineffective problem solving (3) Significant person enters into limited personal communication
13. Intimacy dysfunction with the client or withdraws from client.
14. Isolation
15. Lack of dealing with conflict Family Coping: Disabled
16. Orientation toward tension relief rather than achievement of goals Behavior of a significant person (family member or other primary
17. Stress-related physical illnesses Â�person) that disables his or her capacities and the client's capacities to
18. Substance abuse other than alcohol Â�effectively address tasks essential to either person's adaptation to the
19. Verbal abuse of children, parent, and/or spouse health challenge:
20. Family does not demonstrate respect for autonomy or individuality 1. Abandonment or desertion
of its members 2. Aggression or hostility
3. Agitation, intolerance, or depression
Family Processes: Interrupted 4. Carrying on usual routines without regard for client's needs
Change in family relationships and/or functioning often related to develop- 5. Client's development of dependence
ment transitions, family role shifts, interaction with community, changes 6. Distortion of reality regarding the client's health problem
in family finances or social status, power shift of family members, shift in 7. Family behaviors that are detrimental to well-being
health status of family member, or situational transitions or crises. 8. Impaired individualization
In families with this diagnosis, the family system or family members 9. Impaired restructuring of meaningful life for self; prolonged over-
have the following characteristics: concern for client
1. Changes in assigned tasks 10. Neglectful care of the client in regard to basic human needs or
2. Changes in availability for affective responsiveness or emotional support Â�illness treatment
3. Changes in communication patterns 11. Neglectful relationships with other family members
4. Changes in effectiveness in completing assigned tasks 12. Psychosomaticism
5. Changes in expressions of conflict with or isolation from community 13. Taking on illness signs of client
resources
6. Changes in expressions of conflict within family Family Coping: Readiness for Enhanced
7. Changes in intimacy Effective management of adaptive tasks by family member involved in
8. Changes in mutual support the client's health challenge who now exhibits desire and readiness for
9. Changes in participation in problem solving or decision making enhanced health and growth in regard to self and in relation to the client:
10. Changes in participation in power alliances 1. Chooses experiences that optimize wellness
11. Changes in rituals 2. Family member attempts to describe growth impact of crisis
12. Changes in satisfaction with family 3. Family member moves in direction of health promotion
13. Changes in somatic complaints 4. Individual expresses interest in making contact with others who have
14. Changes in stress-reduction behaviors experienced a similar situation
*See pages 211–213 of source for additional defining characteristics.
From North American Nursing Diagnosis Association (NANDA) International. (2009). Nursing diagnoses: Definitions and classifications, 2009-2011.
Ames, IA: Wiley-Blackwell.
Determining Family Style

Most families have characteristic processes they use to meet “How?”
challenges and deal with others. Identifying this style will help “How should I adjust my interpersonal interactions to match
the nurse choose appropriate actions and ways of working the family style?”
with the families. Determining the family style helps the nurse “How will the way the family typically acts affect planning and
answer the following questions: implementation of care with this family?”
BOXÂ€13-6â•…â•‡ DETERMINING FAMILY NEEDS

1. The family dealing with normal growth and development 3. The family dealing with external stressors
• Transitions such as births, divorces, and a child going to college are • Stress from the environment is usually unexpected and is, there-
stressful for all families. fore, more difficult to manage.
• As family members grow older, the family must adjust and learn • An event may be positive or negative but is still stressful because
new roles and ways of operating as a group. the family is required to rearrange itself or to adjust emotionally.
• Normal age-related behaviors may be unexpected or unfamiliar to • The environment may be hazardous.
the family. 4. The family with inadequate resources and support
• All families must adjust health-promotion and illness-prevention • The family may lack equipment, money, tools, space, or other materials.
behaviors for their life stages. • The family may lack emotional or social support.
2. The family coping with illness or loss • The family may have never had resources, may have depleted
• Illness may be acute or chronic but is almost always accompanied them, or may not know how to connect with available supports.
by stressors such as financial demands or inability to perform family 5. The family with disturbances in internal dynamics
roles. • Internal dynamics lead to relationships that are problematic and
• The family often needs to accomplish health care tasks such as ineffective.
Â�special diets, exercises, or tracheostomy care. • Power and authority are not appropriately placed.
• Myth: All people should be encouraged to talk about their feelings. • Organization may be chaotic and unpredictable or too rigid and inflexible.
In fact, individuals cope in different ways—humor, action, denial, • Family members are not responsible for themselves: they either
intellectualizing, seeking support of others. push things onto others or assume extra responsibility that should
• Myth: Family coping requires simple, open communication. In fact, belong to another.
families cope in different ways—pulling together, depending on • Unhealthy patterns such as blaming, conflict, scapegoating, with-
one member, distancing, seeking help from the community. drawal, or sacrifice of one member are used.
Categories adapted from Smith, C. (1985). Goals for community health nursing (unpublished manuscript).
TABLEÂ€13-1â•…â•‡NURSING DIAGNOSES FOR TABLEÂ€13-2â•…â•‡NURSING DIAGNOSES

ENVIRONMENTAL PROBLEMS RELATED TO THE USE OF
SOCIAL RESOURCES
PROBLEM SIGNS AND SYMPTOMS
Income Low/no income, uninsured medical expenses, PROBLEM SIGNS AND SYMPTOMS
difficulty with money management, able Communication with Unfamiliarity with options/procedures for
to buy only necessities, difficulty buying community resources obtaining services, difficulty understanding
necessities, other roles/regulations of service providers,
Sanitation Soiled living area, inadequate food storage/ unable to communicate concerns to
disposal, insects/rodents, foul odor, service provider, dissatisfaction with
inadequate laundry facilities, allergens, services, cultural or language barrier,
infectious/contaminating agents, mold, inadequate/unavailable services,
excessive pets, other transportation barrier, other
Residence Structurally unsound, inadequate heating/ Social contact Limited social contact, uses health care
cooling, steep stairs, inadequate/obstructed provider for social contact, minimal
exits/entries, cluttered living space, unsafe outside stimulation/leisure time
storage of dangerous objects/substances, activities, other
unsafe mats/throw rugs, inadequate safety
Adapted from Martin, K. (2005). The Omaha System: A key to practice,
devices, presence of lead-based paint, documentation and information management (2nd ed.). St. Louis: Saunders.
unsafe gas/electric appliances, inadequate/
crowded living space, homeless, other
Neighborhood and High crime rate, high pollution level, with organization, are resistive, or are Â�distant. Identifying this
workplace safety uncontrolled animals, physical hazards, style will help the nurse choose appropriate actions and ways
unsafe play areas, other of working with the family. Information gained from tools that
assess the family’ s coping ability, Â�patterns of interaction, and use
Adapted from Martin, K. (2005). The Omaha System: A key to practice,
of support from others can be integrated to complete this analy-
documentation and information management (2nd ed.). St. Louis: Saunders.
sis. TableÂ€13-3 presents a format for thinking about Â�family style.
Different family styles require different interactions from the
“How will I even get in the door or get the family to accept my nurse. The competent family health nurse will be able to adjust
presence?” her or his own personal way of relating to others to match the
“In what ways does the family usually act to process information, family style. If a family is distant in the face of emotional
Â� and
solve problems, and open or close itself to the enviroÂ�nment?” private events, moving in too quickly would make them retreat
Family style usually has two components: (1) internal Â�family even more. Each nurse should examine Â�personal ways of behav-
interactions and (2) relationship to the outside world. These ing and practice a flexible repertoire of interactions to be used
patterns remain fairly consistent over time. The styles describe when the family situation requires it. The Â�principles for inter-
family patterns of meeting challenges and dealing with others. acting with different family styles are presented in TableÂ€13-4.
Some families are organized within Â�themselves and are receptive In this example, the nurse modifies her communication
to interactions with a helper. Other families have more trouble Â�pattern to match the family’ s style.
Determining Family Strengths

Vonda, a community/public health nurse, was having dif-
Clients and families in the community are often categorized
ficulty connecting with the Baker family, which included
according to their weaknesses. In spite of problems, families have
a mother-in-law who was recovering from a major stroke.
many helpful and healthy behaviors that carry them through.
Whenever Vonda called to make an appointment, Mr. Baker
Family strengths are positive behaviors or qualities that help
would answer the phone and indicate that she should talk to
maintain family health. Family strengths are really the key to
his wife. Vonda left a message, but Mrs. Baker would never
a successful intervention. After all, the family will be doing the
call back. Vonda talked to her supervisor, who knew the
work, not the nurse. A list of some possible family strengths is
family, and she suggested that the Baker family would ben-
presented in BoxÂ€12-3 (Otto, 1973). Feeley and Gottlieb (2000)
efit from the contact but were using a distant style. Vonda
suggested three aspects to the use of family strengths in nursing:
decided to send the family a list of common problems of
(1) identifying strengths, (2) developing strengths, and (3) call-
stroke victims with a suggestion that she had some equip-
ing forth strengths.
ment that might help. Vonda was feeling anxious at this point
Identifying the family’s good points and competencies is the
because she knew the family had five authorized home visits
secret to helping a family be effective in their ability to change
that were about to expire, and she had no accurate assess-
and grow. Simply asking the questions to identify strengths often
ment of the grandmother’ s status. Mrs. Baker called back the
starts the change process. This action helps the nurse develop a
next day and asked for some help with the catheter. Vonda
caring relationship with the family and emphasizes the power
offered to come over that day, but Mrs. Baker wanted to wait
the family will have in making decisions and carrying out the
until the following week. Vonda carefully explained the date
implementation. When determining family strengths, the nurse
that the authorization would end. Mrs. Baker decided to
is asking the following questions:
make an appointment for the next day, and Vonda visited.
“Who, and where?”
At that time, she made arrangements for four more visits,
“Who in the family is most able to respond to this crisis?”
once a week at the same time each week. She was not pushy
“Where does the family show talents or areas of pride?”
or anxious. At the end of the visits, Mrs. Baker indicated how
Developing strengths includes discussion in concrete
grateful she was for the help.
terms that both validates the presence of a strength and also
TABLEÂ€13-3â•…â•‡ DETERMINING FAMILY STYLE

FAMILY STYLE DEFINING CHARACTERISTICS
Receptive • Is open to suggestions
• Is eager to work with the system
• Will accept part of the responsibility for the problem and solution
Distancing • Understands the problem but has difficulty making connections with resources
• Is embarrassed or tries to deny the problem's existence
• Has difficulty dealing with the emotions surrounding the contact
Resistive • Denies or disagrees with institutional interpretation of the problem or the solutions
• Feels powerless in the face of the larger system
• May play along without really cooperating or following through on suggestions
Disorganized • Is flexible and experiences frequent and quick changes
• May be extremely adaptive or so disorganized or pressured that this problem is only one of many
• May have difficulty cooperating with planning or solutions because family life is unpredictable and unstructured
Rigid • Has a fixed way of dealing with things that cannot easily be changed to accommodate new demands or behaviors
• May see itself as incapable of carrying out new routines, even if the family accepts the solutions
Lopsided • Power or responsibility lies mostly with one adult member
• Member may be too burdened to accomplish all that needs to be done
• The “doer” may have to struggle with another adult to accomplish the changes
Ordered • Hierarchy, roles, and lines of communication are clearly spelled out
• The way the family usually works together results in success and accomplishments
Tight • Family members depend on each other for physical assistance and emotional support
• Talking to one member usually means the rest of the family will receive the information quickly
• The family prefers to look to its own rather than to persons outside the family unit
Teeter-totter • Family members trade the roles of caregiver and care receiver; often occurs when a strong family member becomes
sick or disabled
• Or more than one family member may trade the role of caregiver; often happens when different family members
provide care at different times for the receiver
• Family members need to adjust to new roles as others around them adjust also
Dependent • The family as a unit prefers to look to others to provide direction and supply their needs; often happens when no
member is available to take a leadership role
• The family may have learned this behavior from previous generations
• Dependency may be accompanied by anger when external systems cannot supply what is needed
Developed by Marcia Cooley, PhD, RN.
TABLEÂ€13-4â•…â•‡ PRINCIPLES FOR ADJUSTING INTERACTIONS TO FAMILY STYLE

FAMILY STYLE PRINCIPLES FOR INTERACTION
Receptive • Be clear about boundaries and keep to professional role.
• Be realistic about time and skill.
• Take the opportunity to use family strengths to focus on growth for the family.
• Education and linkage with resources will be helpful here.
Distancing • Move carefully. Watch timing and do not pursue too much.
• Be aware of your own anxiety. Be aware of increased emotionality, and try to be calm and patient.
• Expect to have repeated contacts.
Resistive • Make stronger attempts to connect.
• Follow the family interpretation of the situation and focus on their priority.
• Be concrete; provide information, but do not argue.
• Watch your own frustration.
Disorganized • Be creative and loose about connecting.
• Have very simple plans.
• Go after only a few changes.
• Do not try to structure the family or the family operations.
• Use flexibility.
Rigid • Assess the family's expectations, and make every attempt to meet them if reasonable; work hard to match the
plan of care to the family's routine.
• Role-model or gently suggest new ways.
• Support their original way; stroke it.
Lopsided • Work through strength; work to get the “doer” to pull back; coach others to do more.
• Get additional resources.
• Stress that taking care of self is helpful and in the long run benefits others in the family.
Ordered • If it is not broken, do not try to fix it; find out the family's way of operation and follow it.
• Help them determine what they need or want and offer resources.
Tight • Find the family communicator; give concrete assistance first; feed information and resources to that family
member.
• Do not try to take a family member's place, especially the communicator's.
Teeter-totter • Be aware that the active member and the expenditure of energy change; work through the member in action at
the present time.
• Keep a connection to all members though, especially the previous active member.
• Help members see the cycle of overdoing, getting tired, underdoing. Reframe blame, disappointment, guilt, and
so forth as reactions to changes in energy patterns.
Dependent • Decide on your own limits and goals at the beginning of the contact; keep this in mind through the
relationship.
• Be aware of a family tendency to wait or expect you to do for them; clearly communicate what you can or will
do with warmth, not anger.
• Translate requests into simple plans of action that family members can perform for themselves.
• Step in immediately when the safety of any member is in danger.
Copyright Marcia L. Cooley. (1994). Used with permission.
links the strength specifically to its effects. This action may Ed, a community/public health nurse, was working with a
change the family perspective on the behavior and present a family he did not like very much. The Peters family includes
forum for change. Discussing strengths also helps the family Susan, age 51, her daughter Carol and her son Mark. Mark
see the value of using more of their strengths for the desired was addicted to drugs and asked his mother for money and
effects. The nurse can also help the family transfer the use transportation frequently. He was not able to keep a job.
of a strength from one context to another and to develop Carol was working at a department store but was having a
new skills. hard time managing her diabetes and her weight. Ed had
Nurses need to be creative, though, in assessing family been called in to help with dressing changes and intrave-
strengths. Frequently, many family strengths are not evident. nous therapy for an ulcer on Carol's leg. Susan was depressed
When the nurse is viewing a family this way, reframing can be about both situations and her finances. No matter what Ed
a tool to help identify some strengths. For example, a family suggested, the family seemed unable to follow through with
that is messy and chaotic can be reframed as permissive and any suggestions for improvements in their health.
creative. Calling forth new strengths may involve focusing on Ed tried a different tactic and began focusing on what the
a minor one that can become more evident or teaching new family did well. Together, he and Susan began talking about
ones. The following clinical example provides a description of Carol's laissez-faire style and Susan's ability to organize.
this concept.
to Â�progress more quickly and with less dependence on the nurse

By identifying these strengths, Ed demonstrated that Susan
than will a Â�family with less ability.
was able to set up a plan for meals and wound care that Carol
Many schema to measure functioning can be used. For
might more easily complete given that she was able to Â�follow
example, the McMaster Family Assessment Tool examines the
directions well. Ed knew that Susan needed to be more firm
level of family functioning across a range of behaviors such as
with Mark about finances and began focusing on those times
communication, problem solving, and emotional support to
she was able to set limits. Finding strengths related to Mark
members (Epstein etÂ€al., 1978). This text suggests that begin-
was more of a challenge, but Ed realized that Mark's interest
ning nurses use Tapia's criteria (1972). Families are classified
in social activities extended to Carol. Ed reframed his own
according to their level of maturity and potential to function
behavior by emphasizing Mark's concern for other people.
Â�independently (TableÂ€13-5). Even though family functioning
The family began asking Mark to extend this concern to
can be measured in other ways, Tapia (1972) provided sugges-
Carol and his mom. By focusing on strengths rather than on
tions to guide nurses’ decisions about setting goals.
deficits, the family made more progress toward health.
Determining Targets of Care
Targets of care are different levels of the system, including indi-
Determining Family Functioning viduals, dyads, the whole family unit, or the community, that
The final component of the Family Needs Model is the area may be recipients of nurse and family actions. Determining
of family functioning. Remember that, in this context, Â�family Â�targets of care involves asking the following questions:
functioning means family effectiveness in achieving and “Who will be involved in the care?”
Â�maintaining physical, emotional, interpersonal, and occupa- “Who is the most likely person in the family to be able to change
tional health. Looking at family functioning helps the nurse her or his own behavior?”
answer the following questions: “Who is likely to communicate with or assert power over other
“To what extent can goals be accomplished?” members?”
“What is the potential for change?” “What members are so burdened by problems that they need
“How much energy is available for growth and change?” support rather than new challenges?”
To determine the level of family functioning, the nurse The family assessment may reveal many actual needs or
may want to integrate information about family resources and potential problems. Too many needs and problems may be
Â�coping. Families with stable internal patterns, plenty of Â�support, Â�present to manage at once, and some people may not wish to be
and the widest ranges of coping behaviors are more able to involved in the care. Because families act as systems, an action
manage multiple stresses and strains. A family with Â�limited applied to one member will influence the other members. The
health may appear functional in times of calm but fall apart nurse may need to make predictions about how certain actions
with relatively little stress. Conversely, a healthy family may be may affect individual members and the family as a whole. For
able to Â�function well in the presence of crushing adversity. A instance, if a child who is afraid of school is successfully
family with greater functional and adaptive ability will be able Â�encouraged to return to school, another child in the family
TABLEÂ€13-5â•…â•‡ CRITERIA FOR SELECTION OF FAMILY FUNCTIONING

CHARACTERISTICS NURSING GOAL
Level I: The Chaotic Family
1. Disorganization in all areas of family life To establish a trusting relationship; to help family
a. Barely meets needs for security and physical survival obtain basic necessities and safety
b. Unable to secure adequate wages or housing
c. Unable to budget money
d. Unable to maintain adequate nutrition, clothing, heat, and cleanliness
e. No future orientation
2. Inability to provide for healthy emotional and social functioning of its members
(apparent alienation from community)
a. Distrusts outsiders
b. Unable to use community services and resources
c. Becomes hostile and resistant to offers of help
3. Poor role identification
a. Immature parents unable to assume responsible adult roles (child neglect or abuse
often seen)
b. Parents unable to act as mature role models for children
4. Family fails to provide support and growth for its individual members
a. Exhibits depression and feelings of failure
b. Insecurity of family members prevents change
5. Family sees the nurse as a good parent and will test her or him for consistency and try
to be dependent
TABLEÂ€13-5â•…â•‡CRITERIA FOR SELECTION OF FAMILY FUNCTIONING—CONT'D

CHARACTERISTICS NURSING GOAL
Level II: The Intermediate Family
1. Lesser degree of disorganization of family life than Level I family To increase the ability of family members to
a. Slightly more able to meet the needs for security and physical survival understand themselves in their interaction
b. Economic level may fall within a wide range as a group and to grow to the point at which
c. More hope for better way of life they can work on solutions to some of their
2. Family unable to support and promote growth of members problems
a. Members appear unable to change
b. Defensive and fearful
c. Lacks resources to gain a sense of accomplishment
d. Does not seek help actively
e. Requires much assistance to acknowledge problems realistically
3. Role identification
a. Parents are immature; socially deviant behavior may occur
b. Distortion and confusion of roles exists, but parents are more willing to work
together for benefit of whole family
c. Children not neglected to the extent that they must be removed from the home
4. Family will see the nurse as a sibling; that is, they will vacillate between
dependence and independence and compete for attention and control
Level III: The Adolescent Family

1. Essentially normal but has more than the usual amount of conflicts and problems To help family members improve the ability to
a. More capable of physical survival and providing security for its members (abilities manage their roles and tasks as they proceed
may vary greatly) from one problem to another
b. Economic level may fall within a wide range
c. Future oriented, even though present may be painful
2. Increased ability to provide healthy emotional and social functioning of its members
a. Greater trust in people
b. Have knowledge and ability to use some community resources
c. Less openly hostile to outsiders
d. Increased ability to face some of its problems and look for solutions
3. Role identification
a. Usually one parent appears more mature than the other
b. Children have less overall difficulty adjusting to changes in family, school,
environment
c. Difficulty in providing sexual differentiation and training of children
d. Because one parent may appear quite immature, adult role model for one or
more of the children may be lacking (physical care usually adequate, but emotional
conflicts usually present)
4. Family members experience achievements and successes outside the family to
replace missing satisfaction within family life
5. The nurse will be seen by the family as an adult helper with expertise in the
solution of problems
Level IV: The Adult Family

1. Normal organization in most areas of family life To provide preventive health teaching to
a. Capably provides for physical security and survival enable the family to maintain and promote
b. Steady, adequate wage earner its health and to increase the members’ self-
c. Enjoys present and plans for future understanding and effectiveness in group
2. Capably provides for emotional and social functioning functioning
a. Has ability to adapt and change in crisis situations
b. Is able to handle most problems as they arise; however, may show anxiety
over these problems
c. Often refers to outside services for help
d. Individual and group needs and goals are usually brought into harmony
3. Family confident in roles
4. Main problems center on stages of growth and developmental tasks
5. Family sees the nurse as an expert teacher and partner and is able to use this
partnership
Adapted from Tapia, J. (1972). The nursing process in family health. Nursing Outlook, 20(4), 267-270.
may begin to act out. Of course, the most useful care plan will and Â�disappointment. Inexperienced nurses sometimes believe
develop from the wishes of the family members who will be that they must change the internal dynamics of the Â�family Â�system
responsible for implementing it. Targeting some individuals as if their nursing care is to be successful. However, a change to the
recipients of care without their cooperation will be less helpful family system can come only from within the family. Other goals
than if the idea to participate comes from within. Every assess- (e.g., strengthening support systems, Â�engaging in health-pro-
ment should include identifying the most functional and most motion behaviors, learning to cope with an Â�illness, Â�promoting a
willing members. These people will usually be the ones to follow healthful environment) are helpful and more appropriate when
through with the intervention plan. working with families.
Determining the Nurse's Contribution

DEVELOPING A PLAN
Determining the nurse's contribution asks the following ques-
tion: “What can the nurse do for and with this family?” Planning family nursing care occurs after the family system is
The nurse needs to define a focus not only for the family but assessed and data are analyzed in a systematic way. Priorities
also for self. The needs of the family may be beyond the scope are determined with the family. Remember that nursing inter-
of the nurse's competence or energy, and time and resources ventions are primarily directed toward the five areas of needs
become a factor in making decisions about what a nurse can that are identified through most family–nurse interactions: (1)
do. The agency and reimbursement mechanisms also dictate growth and development, (2) coping with losses and Â�illness,
the nurse's role. A successful community/public health nurse (3) adapting to the demands of or modifying the environ-
will be aware of her or his strengths and preferences and try to ment, (4) strengthening inadequate resources and support, and
use them whenever possible. Being able to say no or to give up (5) Â�dealing with disturbances in internal dynamics. The Â�target
responsibilities is helpful in the long run when potential Â�nursing of the interventions may be an individual, a subsystem, the
actions are not realistic. The description of nursing roles by Â�family unit, or the interaction with the environment. The level
Friedemann (1989) is helpful here. The nurse, depending on of Â�family functioning will affect the type and extent to which
the analysis of the family and the nurse's experience, chooses to goals can be achieved. For example, families with lower levels
focus on Â�individuals, interpersonal interactions, the family as a of functioning benefit from goals that are short term, realis-
whole, or the family's interface with its community. tic, concrete, and compatible with their definitions of what is
needed. Additionally, family style will determine the way the
Determining Priorities of Identified Needs nurse applies interventions.
When determining priorities of needs, the nurse asks the
Â�following questions: Principles of Family Care Planning
“What is most crucial?” Mutuality
“What is the most essential or necessary?” The biggest mistake a nurse can make is to forget that the
“What is possible given current constraints?” care plan is supposed to benefit the family. If the family has
“What is most likely to empower the family to act in healthy Â�identified the problem and some solutions toward which they
ways on behalf of itself in the future?” are willing to work, their energy and attention will be directed
Some people will use a framework such as that developed by toward a goal that both the nurse and the family support. Dunst
Maslow (1972) to help them determine priorities. Priorities are and Â�colleagues (1989, p. 13) remind us that “a need is an indi-
areas of concern or tasks to be accomplished that require imme- vidual's judgment of the discrepancy between actual states or
diate action of additional energy from the family and the nurse. conditions and what is considered normative, desired, or valued
In most instances, anything that is life threatening or is a threat from a help seeker's and not a help giver's perspective.” Unless an
to physical safety will be the top priority. Beyond this, certain indicated need exists on the part of the help seeker, a need may
decisions need to be made to help ensure that the care of the not exist, regardless of what the professional believes to be the
family will be effective. Dunst and colleagues (1989) suggested case. Mutuality in family–nurse interactions must occur during
that the key to working with families is recognizing their need identification of the family's needs, definition of goals, choices
for empowerment. Helping the family discover or regain its for nurse and family actions, and evaluation of effectiveness.
sense of power and hope is the basis for the members to be able
to continue to build adaptive behaviors and strengths. When Personalization
working with families, the need that assumes top priority Even though many families experience similar issues and have
(after life-threatening emergencies) is the need that the Â�family common health problems, each family care plan must be unique
itself identifies as most important. This concept may some- for that family. The family structure, style of operation, Â�values,
times conflict with the nurse's ordering of priorities. Dunst and strengths, perception of the problem, resources, preferred goals,
colleagues (1989) urged the nurse to choose the family's identi- and level of functioning will all influence the way nursing care
fied need first, achieve some success and trust when a realistic should be planned. Two families may have the same health
and achievable goal is accomplished, and then continue with problem and yet require a different nursing intervention.
priorities that the nurse suggests.
Once the family and the nurse have identified the family Realistic Goals
needs and strengths and established priorities, plans for action When a nurse first connects with a family, the tendency is to do
can be made. Interventions with the family system are the everything at once. An outsider looking in on a family can often
most exciting and challenging part of the nurse's role in Â�family see many things that hinder the growth and happiness of some
Â�nursing. However, the nurse who enters this role Â�without an of the members. Problems that are identified as potential prob-
Â�appropriate understanding of some principles risks Â�frustration lems by the nurse, however, do not mean that these problems
concern the family or that the family wants to change. Time and “Who?”
resources are also limited, and goals must be adjusted to the lim- “Where?”
itations determined by the nurse's employer or by funding. To “To what extent can goals be achieved?”
some extent, family functional level will also determine the level Most nurses are well prepared to address family needs by bor-
of goals that can be achieved. According to Tapia (1972), a fam- rowing previous skills and knowledge from prior practice
ily that is operating on an adult level will be able to achieve goals settings. For example, the nurse might teach a family how
that involve health prevention and minimization of potential to feed an infant, to clean a tracheostomy, or to role model
problems. In contrast, a realistic goal for a chaotic family would communication with an adolescent. Each one of the need
Â�
be connecting the family to a resource that will perform some Â�categories requires knowledge and competencies. While the
of the family maintenance functions and then coaching them to needs are being addressed, the nurse is also managing self to fit
use the resource appropriately. the family style. Summaries of principles used in these actions
are Â�presented in TableÂ€13-4 and TableÂ€13-7.
Values and Health Care Beliefs
Behavior begins with thoughts and feelings about the pres- Helping the Family Cope with Illness or Loss
ent situation. The family's beliefs and values will direct their Nurses often view their role as one that supports a family's cop-
responses to any situation. A care plan that takes the family's ing. Most nurses think this role means that the nurse is expected
values into account will have a greater chance of success than a to provide emotional support for a family that is experienc-
plan that works against family values (see ChapterÂ€10). ing stress. This task is often accomplished in conversations in
which the nurse is available and empathetic to family concerns.
Coordination with the Health Care Team However, many families actually need other, different types of
Neither the nurse nor the family operates in isolation from other interventions to support their coping.
professionals and institutions within the community. The plan Coping is a set of behaviors that emerge whenever a person or
must be coordinated with all parties involved for it to be suc- family is confronted by a stressor that requires some mobilization
cessful, avoid duplication, and maximize the use of resources. of energy. The stressor can be a positive or negative event, but
Nothing is more frustrating to a family than to be pulled or some adaptation or change in behavior is often demanded from
advised in two different directions by two agencies that are sup- a member or the family as a whole. Effective coping will result in
posed to be helping them. an outcome that is positive not only for one family member but
also for the whole family. Coping requires both instrumental and
Defining Self affective actions. Instrumental actions are coping behaviors that
For the nurse who works within the community, the demands accomplish a task such as changing a dressing, locating a source
and needs that she or he sees will be great and sometimes over- of oxygen supply, or making a clinic appointment. Affective
whelming. In a community in which many people are oper- actions are coping behaviors that help modify negative emotions
ating with scarce resources, many people must do as much as that might arise during the stressful situation. Examples of affec-
they can. The nurse who wants to work in a community setting tive coping include talking to others, putting the illness out of
for any extended period will soon realize that choices must be one's awareness, or using humor to diffuse tension.
made about how time and resources are spent. Being aware of Families and individuals within families already have a
her or his own beliefs and purpose within the setting will help Â�repertoire of coping behaviors that they use when stress arises.
the nurse to make these choices in ways that continue to be sat- These coping behaviors are sometimes effective, and sometimes
isfying and do not overextend the capabilities of any one person. they are not. TableÂ€13-8 lists possible family coping strategies.
The nurse will sometimes encounter a situation that is at odds When a stressful situation first arises, the nurse can be most
with her or his personal beliefs. Being clear about a person's helpful in assisting a family to think about its meaning. How a
operating principles helps her or him respond in a thoughtful family perceives the events may greatly affect how it is able to
and ethical way rather than an automatic, emotional way. deal with them. The same situation may be perceived by one
A traditional care plan format is presented in TableÂ€13-6 and family as a crisis from which no recovery is available and by
completed in The Nursing Process in Practice feature later in another family as an opportunity to forge new bonds. After the
this chapter. crisis is identified and an accurate perception of what is hap-
pening is shared, some family members may benefit from dis-
IMPLEMENTING THE PLAN cussing their emotional reactions to the crisis, and some may
be uncomfortable with this strategy. In this early stage of the
When the nurse is implementing the plan, she or he asks the fol- crisis, the nurse can help the family identify its typical coping
lowing questions: behaviors and support or encourage their use. A family in crisis
“What?” should not try to change unless what it is doing is dysfunctional
“How?” or not working.
TABLEÂ€13-6â•…â•‡ COMPONENTS OF A CARE PLAN

GOALS AND NURSE–FAMILY
NURSING DIAGNOSIS OBJECTIVES ACTIONS RATIONALE EVALUATION
Individual, interpersonal, family, Long- and Interventions to be Evidence-based: derived from Criteria are observable;
and environmental diagnoses short-term performed research or theory; personalized outcomes are measurable
TABLEÂ€13-7â•…â•‡ PRINCIPLES GUIDING INTERVENTIONS WITH FAMILY NEEDS

FAMILY NEED PRINCIPLES GUIDING INTERVENTIONS
Growth and development • Provide anticipatory guidance/education regarding tasks of normal life transitions; give feedback to affirm.
• Plan for difficulties of unusual transitions or of multiple transitions occurring at the same time.
• Advocate for policies that support family development and self-determination.
• Provide guidance for health promotion.
Coping with illness or loss • Provide information and instrumental and emotional support.
• Teach individual and caregiver details of medical regimen and nursing care.
• Be the case manager to coordinate care.
• Collaborate with multiple disciplines, including physicians.
• Monitor individual health status and adjust interventions as necessary.
• Help family define coping styles and their effectiveness; suggest new behaviors, if needed.
Strengthening resources and • Facilitate mobilization of resources internal to the family.
support • Facilitate mobilization of friends and other informal support.
• Strengthen support systems by referring family to external resources.
• Help family identify barriers to their use of resources, including family style.
• Collaborate with others in the community to create community support groups or services.
Changing family dynamics • Manage participation in family triangles to decrease triangling behavior; stay in contact with all family
members without taking sides.
• Do not pursue a distancer; offer services and stay in touch.
• Assist family members to make decisions consistent with their values and based on thinking rather than
automatic emotional reactions.
• Explore alternatives and choices that encourage responsibility of individual members.
Remaining healthy within the • Remove hazards from family or vice versa. Teach family about environmental factors that may interfere with
environment health or well-being.
• Teach family to modify the environment to meet needs.
• Report unhealthy environmental factors to appropriate agencies.
• Advocate for healthful environmental policies.
Copyright Claudia M. Smith. (1995). Used with permission.
No single right or wrong way to cope exists. For example, the need for and teach this information until the family has
denying a problem or distancing oneself from it may, in some mastered the process.
cases, be protective and necessary until the situation changes. Additionally, many common family reactions and changes
In some instances, the coping that the family chooses does not exist to illness. Most illnesses bring changes in family roles and
work, or it does not work in a healthy way for the entire fam- responsibilities, occupational and financial changes, alterations
ily. At this point, the nurse can help the family identify alterna- in social opportunities, feelings of loss and grief, and a need to
tive coping behaviors. Developing a list of alternatives can be adjust expectations of future functioning. Health behaviors and
accomplished jointly with the nurse, who may have more ideas routines need to change to accommodate the illness and to pre-
or information than the family. vent future problems. Changes in daily living such as sleep and
The nurse then helps the family select alternative coping behav- rest, exercise and activity, diet, recreation, and sexual activity are
iors that seem workable to the family members. As the Â�family tries commonly required. The community/public health nurse can
these new ways of coping, the nurse is available to offer feedback, help the family by providing information and support about
reinforce new behaviors, and act as a sounding board as the Â�family these normal and common changes.
makes decisions about the next course of action. Illnesses also have different phases. The earliest phase of diag-
When families are dealing with illness, the community/pub- nosis often involves preparation and cooperation with Â�diagnostic
lic health nurse can gather nursing knowledge from other health testing, dealing with anxiety and uncertainty, and mobilizing
care settings to help the family manage the illness. The nurse support while awaiting the diagnosis. After the Â�illness is iden-
needs to help the family deal with three areas of knowledge tified, the client and family then enter a Â�working phase Â�during
and adjustment to illness: (1) knowledge of the specific illness, which people are learning illness-management techniques and
(2) adjustment to the changes common with all illness, and (3) making adjustments in daily living to Â�manage the care. A period
adjustment to different stages of illness (Cooley, 1989). of rehabilitation may precede the return to functioning for some
Each illness requires that the family have information and illnesses. Chronic illnesses often have periods of remission and
skills necessary to manage the demands of that particular ill- exacerbation that need to be Â�predicted, Â�identified, and Â�managed.
ness. For example, a client with COPD may need to monitor Finally, when a client enters the Â�terminal stage of Â�illness, both
the weather, prevent exposure to infections, learn how to set the client and the family are helped with coping with the end
up oxygen equipment, and learn to use inhalers appropriately. of life.
However, a client with chronic pain may need to learn to use Families are the primary social environment for children with
an infusion device, practice daily exercises, and monitor stress. chronic illnesses. These children have higher social–emotional
Each illness has specific information and skills to be learned for coping skills and become more adaptive adults if their fathers
proper management. The nurse's responsibility is to anticipate participate in their care (Hovey, 2005). Furthermore, when the
TABLEÂ€13-8â•…â•‡FAMILY COPING STRATEGIES: FAMILY CRISIS ORIENTED PERSONAL

SCALES (F-COPES)
WHEN WE FACE PROBLEMS OR
DIFFICULTIES IN OUR FAMILY, STRONGLY MODERATELY NEITHER AGREE MODERATELY STRONGLY
WE RESPOND BY: DISAGREE DISAGREE NOR DISAGREE AGREE AGREE
1. Sharing our difficulties with relatives 1 2 3 4 5
2. Seeking encouragement and support from 1 2 3 4 5
friends
3. Knowing that we have the power to solve 1 2 3 4 5
major problems
4. Seeking information and advice from persons 1 2 3 4 5
in other families who have faced the same or
similar problems
5. Seeking advice from relatives (grandparents, 1 2 3 4 5
etc.)
6. Seeking assistance from community agencies 1 2 3 4 5
and programs designed to help families in our
situation
7. Knowing that we have the strength within our 1 2 3 4 5
own family to solve our problems
8. Receiving gifts and favors from neighbors 1 2 3 4 5
(e.g., food, taking in mail)
9. Seeking information and advice from the 1 2 3 4 5
family physician
10. Asking neighbors for favors and assistance 1 2 3 4 5
11. Facing the problems head-on and trying to get 1 2 3 4 5
a solution right away
12. Watching television 1 2 3 4 5
13. Showing that we are strong 1 2 3 4 5
14. Attending religious services 1 2 3 4 5
15. Accepting stressful events as a fact of life 1 2 3 4 5
16. Sharing concerns with close friends 1 2 3 4 5
17. Knowing that luck plays a big part in how well 1 2 3 4 5
we are able to solve family problems
18. Exercising with friends to stay fit and reduce 1 2 3 4 5
tension
19. Accepting that difficulties occur unexpectedly 1 2 3 4 5
20. Doing things with relatives (get-togethers, 1 2 3 4 5
dinners, etc.)
21. Seeking professional counseling and help for 1 2 3 4 5
family difficulties
22. Believing that we can handle our own 1 2 3 4 5
problems
23. Participating in religious activities 1 2 3 4 5
24. Defining the family problem in a more 1 2 3 4 5
positive way so that we do not become too
discouraged
25. Asking relatives how they feel about the 1 2 3 4 5
problems we face
26. Feeling that no matter what we do to prepare, 1 2 3 4 5
we will have difficulty handling problems
27. Seeking advice from a minister or other 1 2 3 4 5
religious leader
28. Believing that the problem will go away if we 1 2 3 4 5
wait long enough
29. Sharing problems with neighbors 1 2 3 4 5
30. Having faith in God 1 2 3 4 5
From McCubbin, H. I., & Thompson, A. I. (1987). Family assessment inventories. Madison: University of Wisconsin–Madison.
father supports the mother in her role as primary caregiver, 1993). For effective teaching of families with developmental
the mother deals with stress better. Family emotional close- needs, the nurse must assess each member's current knowledge
ness is associated with less depression in teenagers with diabetes of the developmental issue and then gain agreement from fam-
(Cole & Chesla, 2006). Conversely, when children must care for ily members that this is something they would like to learn more
a Â�parent with a chronic disease such as multiple Â�sclerosis, it is about. Teaching–learning interactions should be planned for
important to consider child adjustment (Pakenham & Bursnall, maximal effectiveness, considering timing, the learner's ability,
2006). Adolescents are often at greater risk of psychological and the method of presentation. After each session, the nurse
Â�distress than are young children (Pedersen & Revenson, 2005). validates the family's understanding of the content. Finally, the
When illness of a family member is severe and the family has nurse helps the family formulate solutions that will satisfy the
low cohesion, the risk of conflict is higher. current or potential developmental demands.
Families that are dealing with illness and loss may encoun-
ter experiences in which nothing that they do will make the
situation better. When tragedy strikes—a loved one dies, or
a Â�family must confront an irreversible loss—no actions will
make the Â�situation right again. In these situations, both the
nurse and the family often resolve the situation by searching for
some Â�meaning within what has happened. The book by Dass
and Gorman (1986) How can I help? provides valuable insight.
When the nurse cannot help in more concrete ways, he or she
can be valuable to a family in this situation by finding meaning
in what she or he does. Having a compassionate and thought-
ful Â�contact within the health care system is useful for almost any
family dealing with a crisis.
Teaching the Family Experiencing Developmental
Changes
Every family has to deal with the experiences of members
who grow older and confront day-to-day life in new ways.
Many Â�families add or lose members as the family reproduces,
the Â�children grow to adulthood, and the family ages. The
Â�developmental stage of a family will indicate typical tasks that
need to be completed (see ChapterÂ€12). Even the most func-
tional Â�families are novices during the experience of growing into
a new stage. Other families confronted by situational as well as
maturational tasks may be overwhelmed by dealing with many
new things simultaneously. Families at lower functional levels
may be poorly prepared to deal with any additional demands
and may view new behaviors of developing members with anger
or misunderstanding (see ChapterÂ€14).
The nurse's role when dealing with families that are nurse reviewing medication dosage and frequency with a
A
Â�client and her daughter.
Â�confronting developmental demands is primarily educational.
Providing information about normal growth and development
and the adaptations that parents, children, and extended Â�family Through this entire process, the nurse is concerned with nor-
members require can prevent potential problems and help malizing the situation for the family. In other words, the more
Â�families manage current ones. The information that is provided the family members can perceive a situation as something that
may be new to the family, or it may be a reinforcement of what the all families face, the more objective they may be about it. Even
family already knows but has not recognized as important. For though a situation is normal, families may feel pressured or
example, nurses can teach families to evaluate age-appropriate uncomfortable. Not all families will or should adapt to the sit-
toys that will not frustrate or overstimulate the child. This action uation in the same way. Helping the family use its knowledge
enables all parents, regardless of income or education, to proof its strengths and values to choose operating principles that
mote their child's growth and skill development. Smith (1989) are compatible must be done on an individual basis for each
found that a group of mothers in the postpartum period had family. TableÂ€13-9 presents some family research related to par-
major concerns related to self-care and care of their new babies enting and to parenting programs; nurses either conducted the
that had not been addressed during their hospital stay with their research or were involved in implementing the programs.
new baby. All the mothers viewed teaching sessions in the home Some families will have special needs for education. For
after discharge as very valuable. Young fathers especially should example, adoptive families have had a different developmen-
be included to explore the meaning of being a “good” father and tal experience than a biological family. Asking the right ques-
ways they can support their families (Lemay etÂ€al., 2010). tions at the right time can have a great impact on the well-being
Families will differ in their ability to absorb information that of a family that may be facing situations that were not antic-
the nurse presents, especially if the timing competes with other ipated (Peterson, 1997). Other families may have normative
demands that seem more pressing (Hausman & Hammen, development, but they may be limited in their knowledge of
TABLEÂ€13-9â•…â•‡ SELECTED FAMILY RESEARCH RELATED TO PARENTING AND SOCIAL SUPPORT

RESEARCHER TARGET POPULATION INTERVENTION TYPE OF STUDY OUTCOMES
Fergusson etÂ€al. 443 families in an Early Community health nurses Evaluation of Early Start • Positive parenting and child-
(2006) Start Program in New conducted home visits to Program related outcomes related to child
Zealand promote well-being. Randomized, controlled health, education, and parenting
Social learning model: trial of home visitation • Absence of family level
Assessment Partnership on parent and family changes related to stress
Collaborative outcomes; assessed at 6, exposure, economics, and family
problem-solving 12, 24, and 36â•›months functioning
Support
Haggman-Laitila & Families with Children Small goal-oriented groups Qualitative evaluation of • Information
Pietila (2007) Project: 123 parents and of 14 members meeting parental perceptions of • Motivation to seek information
58 children in Finland 7 times over 10â•›months; small group benefits. • Rest and “company”
led by multiple • Stronger social support networks
Videotaped interviews after
professional disciplines, group meetings • Stronger awareness of own
including public health personal resources
nurse • Reliance on own coping,
confidence, future orientation
Black & Ford- Convenience sample of 41 Not applicable Assessment of resilience, • Mothers’ employment,
Gilboe (2004) single, white, adolescent family health promotion, professional support, and
mothers in Ontario, and own health-promoting resilience predicted mothers’
Canada lifestyle. health-promotion behaviors
Verbal responses to
questionnaires
From Black, C., & Ford-Gilboe, M. (2004). Adolescent mothers: Resilience, family health work and health promoting practices. Journal of Advanced
Nursing, 48(4), 351–360; Fergusson, D., Grant, H., Horwood, J., etÂ€al. (2006). Randomized trial of the Early Start Program of Home Visitation: Parent
and family outcomes. Pediatrics, 117, 781-786; Haggman-Laitila, A., & Pietila, A. (2007). Perceived benefits on family health of small groups for
families with children. Public Health Nursing, 24(3), 205-216
normal developmental sequences. For example, Wayland and Â�

limited social support. Community/public health nurses assist
Rawlins (1997) studied a group of unmarried teenage moth- families to mobilize resources and strengthen social support.
ers and found that their perceptions of parenting were based on
their own limited experiences. These mothers lacked informa- Mobilizing Resources
tion about breast-feeding, common childhood illnesses, basic Resources are supplies or support that enable the family to meet
growth and development, safety, and discipline; they also had and handle its situations. Some families do not have Â�necessary
problems dealing with crying infants and conflicts with family resources; other families have difficulty accessing them.
members. These adolescents often depended on grandmothers Resources are both internal and external—that is, within both
to care for the children. the family and the community. Resources can be tangible (e.g.,
Depending on the age of family members and the stage of money, clothing, transportation, shelter) or intangible (e.g.,
family development, each family can benefit from knowledge strong values, emotional support, religious beliefs, a sense of
of health-promotion and illness-prevention activities. Health- family solidarity). Resources for health promotion, illness pre-
promotion strategies across the life span are discussed in vention, and early detection of health problems are especially
ChapterÂ€18, and screening tests appropriate for various ages are important (see ChaptersÂ€18 and 19). One of the most obvious
discussed in ChapterÂ€19. All families experience developmental responsibilities of the community/public health nurse is helping
changes and need to learn to adapt their health-promotion and families identify and access resources. Families may not know
health-screening behaviors appropriately for their life stages. An their way around the community or the health care Â�system as
important focus of community/public health nursing practice well as does an effective community/public health nurse. The
is educating families for health promotion. ability to act as a provider of information, referral agent, liaison,
or coordinator of resources is essential for community/public
Connecting the Family to Needed Resources health nurse case managers.
andÂ€Support The nurse who desires to help families access resources will
Resources, including social support, contribute to family
Â� well- thoroughly assess tangible and intangible resources that have
being. Families that access resources and experience social the potential for being useful in the situation. Many families
support are better able both to prevent and to cope with life have a need for multiple resources; identifying the one or two
stressors. For example, one qualitative research study Â�conducted that are most helpful to the need will target the nurse's and
by nurses explored how families managed mental illness Â�family's energies.
(Walton-Moss etÂ€al., 2005). Families who were stable or doing In some instances, resources that are not typically seen as
well reported adequate support. Families that reported Â�living helpful may be used creatively in certain situations. For exam-
with uncertainty and frustration had limited finances and ple, the family may think that no one is available to care for a
member who is ill but may not be considering a family mem- Cooper, 2006). The community/public health nurse needs to
ber who is able to, but typically does not, perform this role. assess the barriers to social support and work with the Â�family to
Encouraging the family to open itself up to new ways of using remove these barriers. For example, if a caregiver spends most
internal resources is useful. of her or his time caring for a bed-bound spouse, rarely leaves
Families that are relatively closed—that is, families with the home, and is experiencing loneliness, the caregiver may
boundaries that are not very permeable—often attempt to regain social support through telephone calls and by Â�having
deal with problems themselves. These families may have strong others visit her or his home.
beliefs that they should manage their problems themselves. When internal family relationships are unhealthy and stress-
Helping them accept aid from extended family members, the ful, family members may have difficulty establishing and main-
community, or professionals may involve exploring their beliefs taining a social network outside the family because they have
and offering help while acknowledging their preferred tight not learned to trust others or have not been taught necessary
style. Other families may have had experiences with resources interpersonal skills. Community/public health nurses can work
that have turned out to be ineffectual or inadequate. Making with the family members most ready for change and assist them
sure that resources are reliable and that the family has realistic to seek positive relationships outside their family. For example,
expectations of what the resource can provide are ways to pre- children of alcoholics might be referred to self-help groups such
vent repeats of earlier negative experiences. as Adult Children of Alcoholics.
Strengthening Social Support Coaching the Family to Change Its Internal Dynamics
Social support is the perceived positive value of the interper- The process of change within a family will occur naturally as
sonal relationships or contacts of the family. Social support the family grows and adapts to new and ever-changing environ-
is a resource that affects health and well-being by (1) directly mental circumstances. Most families do not need help to change
Â�providing a sense of belonging, approval, and social Â�contact, their way of operating in general; instead, they need help to
(2) Â�helping prevent life stresses by providing information about adapt and cope with new developmental, situational, and envi-
how to avoid hazards and prevent stressors, and (3) buffering ronmental challenges. The nurse assists the family to change not
the effect of life stresses by helping to reduce threats or increase because something is wrong with the family, but rather because
coping, or both (Uphold, 1991). Therefore, social Â� support the family style and organization are not effectively meeting the
is relevant to health promotion and all three levels of illness current demands.
prevention. Sometimes, however, families do not effectively meet the
Deficits in social support may be episodic or chronic. For needs of their members even in times that are relatively calm.
most families, the primary sources of social support are fam- These families with disturbances in internal dynamics are
ily members, extended family, close friends, and neighbors. Â�candidates for change in the family system.
When these relationships are disrupted through death, divorce, The community/public health nurse who is informed about
or relocation, family members may experience deficits in social the dynamics of families and has some training in family coach-
support. Deficiencies in social support also may occur when ing is in the perfect position to serve as a catalyst for change. Most
health or other problems exceed the family's usual capacity for baccalaureate-prepared nurses do not receive this education;
problem solving (Bullock, 2004). Community/public health family coaching is taught most frequently at the graduate level,
nurses can assist family members to strengthen social support. especially among psychiatric/mental health/behavioral nurses.
The nurse assists the family to identify what help they need and The following principles of change must be kept in mind
possible sources of that support. The first priority is to mobilize when working with a family toward change:
social support from inside the family or from informal support 1. Many families are resistant to change. Even when the change
networks such as friends, neighbors, and religious Â�communities. would probably be beneficial to the family, families may
These relationships are more likely to be long lasting and to be Â�prefer to remain as they are. Remaining in what is known is
the most culturally appropriate. When specialized assistance easier than exerting energy to move into the unknown.
is needed or families are in crisis, the nurse refers Â�families to 2. Sequencing or timing will affect the outcome. Families have
the appropriate professional sources such as home health difficulty changing during times of crisis or stress. However,
Â�agencies, grief counseling, vocational rehabilitation services, or this period is often the best time to change because the Â�family
legal Â�services. The goal is for families to access meaningful and sees the need for it then. Change is most likely to happen
Â�supportive relationships. after perceptions of the situation begin to change. Working
Community/public health nurses can collaborate with others on the family's cognition or thinking about the problem is
to create community support groups and services where none the first step in an intervention. Helping the family modify
exists. Drury-Zemke (1997) describes her experience in start- affect and behavior comes next.
ing an amputee support group in her city of 300,000 people. 3. Past patterns must be interrupted. Families tend to operate
Support groups such as these provide opportunities for persons in patterns of interaction that repeat themselves. Triggers
to network with others who understand each other's problems set up behaviors to which all family members respond auto-
and experiences. matically. Breaking these patterns and starting healthier
Some families experience chronic deficiencies in social Â�behavioral sequences is difficult, but it can be done.
support. For example, one study in the United Kingdom
Â� 4. A change in one part of the system will affect the whole system.
explored the perceptions of family caregivers of persons with No person can change another, but any person can change
developmental disabilities and challenging behavior. Almost half herself or himself. What we do and the way we react have an
of the caregivers reported that they did not receive professional impact on others. When any one person in a system changes,
support or that the input was not helpful (Papachristoforou & the system will automatically change.
5. The more important a family member is to the family's func- Helping the Family Remain Healthy within the
tioning, the more impact a change in that family member will Environment
have. Not all family members will change equally or have The world in which families live is resource rich, and our Â�society
equal capacity to change. Identifying the family member performs many functions that used to be the responsibility
who is most likely to be able to change is a good Â�strategy of the family. Families and family members are healthier and
for the nurse who desires to help the family modify its have access to many more living aids than did families in the
functioning. past. However, today's world is also a potential threat to health
6. Family strengths are as important as family problems. The in many ways. Pollutants in the air, water, soil, food, homes,
perception of the family problem is often unhealthier than schools, and occupational settings are threats to family health.
is the problem. When one family member is blamed or The social environment also exposes us to unsafe Â�situations
held responsible for others, the shared nature of the Â�family of crime, violence, drug abuse, and deteriorating interper-
problem cannot be recognized. For example, at times, sonal behavior. Many families make plans for their lives only to
Harry is lazy and irresponsible. Is it also possible that have them affected by situations beyond their control, such as
Harry adds humor and genuineness to a restricted family Â�buyouts and mergers of employers, changes in health and retire-
environment? Can the problem be reframed and seen as an ment benefits, and a changing economy.
asset? The community/public health nurse who is interested in
7. A family's capacity to change is related to its level of func- Â�family health will consider family–environment interactions
Â�
tioning. The family has probably operated at a certain level (see ChapterÂ€9). Actual health problems may be related to
of health for some time before the nurse appears on the or aggravated by environmental issues, and potential health
scene. Having realistic ideas about what can be accom- problems related to environmental issues may be diverted.
Â�
plished for each family is necessary. The nurse who can For example, Krieger etÂ€al. (2005) described how community/Â�
help the family think about issues in ways that lead to a public health nurses provide case management and train health
small improvement in or maintenance of functioning will care workers to provide outreach to help families reduce home
mean that the family is in better shape than having no exposure to multiple indoor asthma triggers. Surveillance,
Â�
intervention at all. detection, and correction of environmental threats become a
Techniques that advanced practice nurses use to help Â�families way to help Â�families maintain their health. Lead poisoning is
change include contracting, tracking family process, increasing another Â�preventable condition of childhood with devastating
cognitive awareness, reframing, aligning or Â�maintaining neutral effects on a young child. For lead contamination and other envi-
connections to family members, exploring affect, restructuring, ronmental issues, educating families and communities is crucial
suggesting direct interventions, and offering paradoxical inter- to help the public become aware of potential health threats and
ventions (Minuchin & Fishman, 1981). Contracting, tracking strategies for dealing with them. Nurses also have the opportu-
family process, reframing, and maintaining neutral connections
Â� nity to intervene by providing data that influence health care
with family members are appropriate for Â�baccalaureate-Â�educated decisions and by participating in legislative and executive pro-
nurses. cesses that formulate health policy.
Formulating a contract with the family at the beginning of
the interaction, having a definite goal, and limiting the num- EVALUATION
ber of sessions help keep the interaction focused. At different
times during the sessions, the professional carefully chooses a Even though evaluation is the final step of the nursing process,
position in relation to family members, such as aligning with a it is also a step that starts at the beginning of the contact and
weak member or maintaining neutral but meaningful connec- occurs continually as the contact progresses. The word evaluate
tions to all. means “to determine the worth of something.” Many methods
Reframing is a way to label a negative as a positive. can be used to evaluate nursing care, but the key to evaluation is
Something that is perceived as negative can be explored and to determine the correct criteria that demonstrate the value of
renamed in a positive way. This action breaks up the family's the nursing contact. Criteria for evaluating client outcomes are
typical way of thinking about the problem and helps family derived from the objectives developed with the Â�family. Because
members begin to think of alternatives. Cognitive perceptions the outcomes of nursing interventions occurring Â�during one
and knowledge about family dynamics can be broadened. visit may not be apparent until later, both long-term and
When this expansion happens, objectivity about the family Â�short-term evaluative criteria should be developed.
problem is increased, and family members are able to act in
less reactive ways. Methods
During early sessions, the family process or patterns of Two methods of evaluation are formative and summative eval-
interaction are tracked by the professional and brought into uation. Formative evaluation occurs during the course of
the awareness of the family. Seeing the repetitive nature of the nurse–family interactions. This form of evaluation can be used
behavior sequences and recognizing the behavioral triggers are to guide decisions about modification of goals, Â�objectives,
the first step to being able to modify behavior. Affect or feel- nursing actions, and priorities as the nursing Â�
Â� encounters
ings that accompany behavioral sequences can be named and unfold. Data are Â�collected once or multiple times during the
examined. Many times, if the behavioral sequence is changed, home-visiting Â�process, clinic visits, telephone conversations,
the emotion that accompanies it will also change. and Â�health-education classes and events. Examples of forma-
Helping a family change its internal dynamics is not a goal tive evaluation methods include keeping daily records of blood
that every nurse should attempt. However, with practice and Â�glucose levels, holding monthly health care team meetings to
training, many nurses become effective family coaches. discuss family progress, or asking the family for feedback at
the end of each nurse–family

Â� encounter. Formative evalua- or the actions performed to accomplish the goal may be
tion helps the nurse and family modify nursing care in a more necessary.
Â�effective way.
Summative evaluation occurs at the end of the family–nurse Examining the Effect on the Family Member Who Is Ill
relationship and is used to summarize the value of the interac- Many family nursing encounters are initiated because someone
tion to the family. A description of the extent of goal accom- in the family has been identified as having an illness. The person
plishment and remaining family needs helps the family make who is the focus of care, especially one who has been identified
choices about termination or referral. The family can review by an agency or reimbursement mechanism, is the primary per-
with the nurse the actions that it used to achieve its goals and son to be evaluated. What effect did nursing actions have on the
can leave the relationship with a sense of accomplishment. family member who is ill? Is her or his health status improved?
Summative evaluation can also help inform the nurse about her Has her or his position and role within the family changed in
or his effectiveness and provide feedback about specific nursing any way? To what extent is this person satisfied with the Â�nursing
actions and suggestions for working with other families in the contact?
future. Examples of summative evaluation include an oral quiz
about a client's knowledge of her or his medication, a discharge Examining the Effect on Individuals
planning meeting with the health care team, or a conversation In many cases, other individuals within the family have health
with a family about the series of visits. needs of their own. Other members will be involved in offering
care to the person who is ill, coping with necessary changes, or
Factors Influencing Evaluation promoting health. Family nursing interventions often upset the
Many factors influence evaluation; an example is the availability balance within a family. What is the impact on each member of
of data. If data are easy to obtain and have been carefully col- the family? To what extent have individual health needs been met?
lected, the evaluation is likely to be accurate and complete. An To what extent is each person satisfied with the nursing contact?
electronic health record and system is helpful (Martin, 2005).
The resources available to the nurse and health care team also Examining the Effect on Subsystems
influence the outcomes being judged during evaluation. In a A subsystem of the family may have been the target of care
community health situation that is resource rich, the expecta- or may be particularly affected by the activities of the family.
tion is that many of the family's needs will be met. In a situa- For example, the nurse may have been working with a single
tion with fewer resources, outcomes are likely to be judged more mother with regard to her parenting of a toddler. The sibling
leniently. Family expectations also influence evaluation. If the subsystem—two older children in the family—may feel left out
family begins the encounter(s) with a realistic expectation of or may have benefited by the mother's new skills. As families
what can be accomplished and under what circumstances the learn new behaviors, other groups of people within the family
nurse would leave, then the family is more likely to be satisfied
Â� may be affected. Have the changes been beneficial and satisfy-
with what has happened. Families that expect something that ing for all the members of the system? Do interventions need to
the professionals are unlikely to deliver will naturally leave the be planned for another portion of the family to balance recent
interaction feeling disappointed. Additionally, the nature of activity?
the family–nurse–health care team interaction often influences
the way people view the encounter. Relationships that have Examining the Effect on the Family Unit
been pleasant and mutually satisfying are more likely to lead A family is more than a collection of individuals; it is a unit
to perceptions that the nursing care has been effective than are that stands on its own. How has the family as a whole bene-
relationships in which some or all of the parties have been dis- fited or responded to the nursing interventions? Is the Â�family
satisfied or uncomfortable. able to function more effectively? Does the family operate
Finally, the nurse's attitudes will influence her or his judgment more smoothly as a unit? What is the affective response to the
of success. Many new nurses enter community/public health interactions? Is the family more able to master situations and
situations with unrealistic expectations of their own powers. solve problems for itself? Is the family more engaged in health-Â�
Although nurses cannot fix families, they can help families main- promotion activities?
tain or improve their level of wellness within realistic limits.
Examining the Interaction with the Environment
What to Evaluate The family does not exist in isolation; it lives within an envi-
Examination of Goals ronmental context. How has the family–environment inter-
At the beginning of the planning process, the nurse and family action changed? Is this change beneficial to the family? Is the
state the criteria for goal achievement. If these criteria are clearly family better able to avoid or reduce environmental hazards? Is
stated and data are available, then it is a simple matter to deter- the change beneficial to the community? Is there reason to plan
mine goal achievement. Goals should be written in the form of more or different actions directed toward the family's interac-
outcomes so that the true impact of the nursing intervention tion with their context?
can be determined. For example, knowing that a family member
read a pamphlet about parent–child communication is not the Examining the Nursing Performance
same as seeing the parent interact with the child. The nurse also will benefit from evaluating herself or himself.
Remember that both short-term and long-term objectives Was the nurse prepared for each nursing visit? What knowledge
exist. During the evaluation process, examining Â�short-term did the nurse bring to the visit? What new knowledge would
objectives may make evident that the long-term goal is not have been helpful? How skillful was the nurse while Â�performing
going to be achieved. Revision of either the long-term goal her or his tasks? Does the nurse need to acquire other skills?
How did the nurse's own values and attitudes influence the or his Â�personal feelings about separation. Many people have
interactions? Did the nurse use feedback to modify perfor- a preferred form of separation: they may distance themselves;
mance? How much effort was put into communicating and attempt to Â�prolong the contact; become angry, sad, or act out;
coordinating care with other members of the health care team? or deny that the relationship has been important. The type of
To what extent is the nurse satisfied with the family interac- reaction depends to some extent on the way separations have
tions? (See ChapterÂ€11.) These insights can be used to maintain happened in the past.
the quality of the current family care and for the nurse's future In the community health setting, the nurse frequently expe-
family contacts. riences termination. Clients may experience terminations all
too often when community/public health nurses are transferred
Outcome of Evaluation or families move to another jurisdiction without much notice.
People sometimes think of evaluation as the end of the nurs- Careful planning, providing advance notice, and talking about
ing process. In many situations, however, evaluation is just the the emotions and issues that arise are helpful for everyone
beginning. If evaluation is used properly at several predeter- involved. The nurse will often bring up the issue of termination
mined times during the nurse–family relationship, it should before the client is ready. Allowing clients to express reactions
help the nurse refine the nursing care plan and improve its and helping families perceive themselves as being able to master
quality. Three outcomes are possible: modification, continua- upcoming situations independently will help the family make
tion, and resolution. the transition to independence and termination.
During the final encounters, the nurse begins to prepare
Modification the family by reminding them that the time together is limited.
Modification, or change, may be necessary in any part of the A date or goal should be set that is understood as the mark-
nursing care plan, including identifying needs, establishing pri- ing point for termination. Goal accomplishment, satisfaction
orities, selecting short-term or long-term goals, or choosing with the process, and plans for continuing health maintenance
nursing or family actions. The nurse and family may change should be discussed. If referrals or transfers are needed, they are
their ideas about timing or which family member will perform arranged at this time. Criteria should be established for the fam-
certain tasks. Modification is a necessary step in a nursing care ily to know when to seek health care again; for example, reap-
plan if it is to be a plan that the family really needs. pearance of the signs and symptoms of a chronic mental illness
would be a signal for the family to contact the clinic. Hopefully,
Continuation the nurse will find a way to frame the outcomes of the visits in
The evaluation may show that the plans that have been made a way that indicates success for the family even if the original
are working or are likely to work. Continuing the plan is evi- goals were not met. In almost every contact, the nurse and fam-
dence of successful planning but does not imply that termina- ily have learned something, or they grew in some way that can
tion is imminent. be presented as a success.
Resolution
EVALUATION OF FAMILY CASE MANAGEMENT
Hopefully, some or all of the original needs will be resolved or
no longer require nurse and family actions. A need is resolved PROGRAMS
when outcome criteria have been achieved or when the fam- Evidence-based articles have been published that evaluate
ily no longer perceives intervention as a need. Resolution of programs of nursing case management with families. Since
some needs may allow the family to proceed to needs perceived 2000, four major perspectives have been published: qualita-
as having less priority or to decide that terminating the nurse– tive studies about nurse–client relationships (BattleSmith,
family relationship is appropriate. 2009; McNaughton, 2000); literature reviews of outcome stud-
ies (Liebel etÂ€al., 2009; Markle-Reid etÂ€al., 2006; McNaughton,
TERMINATING THE NURSE–FAMILY RELATIONSHIP 2004); controlled trials (Eckenrode etÂ€al, 2000; Koniak-Griffin
etÂ€al., 2003; Olds etÂ€al., 2007; Schumann, Nyamathi, & Stein,
Ending a meaningful relationship is always an emotional 2007); and studies using electronic health records and systems
experience for the family and for the nurse. In any relation- to describe family problems and nursing interventions (Monsen
ship that has been defined as potentially therapeutic for the etÂ€al., 2011). Programs targeting families with children, older
family, attention should be paid to the termination process. adults, and persons with chronic illnesses are the most Â�prevalent
During termination, everyone involved must deal with her among the studies.
KEY IDEAS
1. Family nursing takes place within the framework of the family. The success of family health care depends on setting
Â�nursing process. realistic goals related to the level of family functioning.
2. Family needs, style, strengths, and functioning are assessed 4. Several diagrams help assess families. A family map diagrams
with the Family Needs Model of family nursing. Families are the structure and organization of the family and its subsys-
assessed on several levels: individual, subsystem, family unit, tems. A genogram identifies family facts and process, includ-
and family–environment interaction. ing illnesses and multigenerational patterns of relationships.
3. The goal of family assessment is mutual identification of An eco-map describes the energy exchanges between the
needs and care planning that includes both the nurse and the family and the environment.
5. Analysis of family data helps the nurse determine family family style. Family strengths are as important as family
needs, family style, family strengths, and family functioning. problems.
Analysis of family data includes determination of the targets 8. Families are resistant to change, but a time of crisis is often
of care, nursing contribution, and the priorities of family the best opportunity for change. As the importance of the
needs. family member increases, the impact of a change in that
6. NANDA International has specified several nursing diag- member on the family increases. Helping a family change its
noses related to families, focusing on family processes internal dynamics is not a goal for every community/public
and family coping. The Omaha System identifies fam- health nurse or every family.
ily problems related to the use of social resources and the 9. Evaluation should include examination of goals and the
environment. effect of intervention on a family member who is ill, other
7. Different nursing intervention strategies are used for each individuals, family subsystems, the entire family, and the
family need: developmental and health-promotion needs, environment. Evaluation should also include evaluation of
coping with illness or loss, inadequate resources and sup- the quality of nursing performance. The outcome of evalu-
port, disturbances in internal dynamics, and coping with ation may be modification of the plan, continuation of the
the environment. Nursing interactions are adjusted to the plan, or resolution of the problem.

Formulating a Family Care Plan
Mr. R., an 80-year-old retired pipe fitter, lives with his wife; he has had Mr. R.'s behavior and does not want anyone from outside the family to
diabetes for 15â•›years. Although his diabetes has been moderately con- see what is happening.
trolled with diet and daily insulin, some complications have occurred. On her initial home visit to this family, the community health nurse
He experiences arteriosclerotic cardiovascular disease and peripheral notes that Mr. R. appears somewhat drowsy and unkempt. Mrs. R.
neuropathy, and he recently spent 2â•›months in the hospital due to circu- looks anxious and tired, her skin color is slightly ashen, and she has
latory problems in his left leg. The progressive deterioration of circula- circles under her eyes. When the nurse asks them what they hope
tion resulted in an amputation below the knee. Although fitting him with to get out of the nursing visits, Mrs. R. says, “Actually, you don't
a prosthesis would be possible, he has refused this and is wheelchair need to keep Â�visiting. In a few weeks we'll be back to normal and
bound. Mr. R. currently depends on someone else to help with transfers. doing fine.”
He is cranky, irritable, and demanding to almost everyone. He recently Based on a thorough assessment of the family, the community health
has stopped following his diabetes regimen because he claims, “It just nurse may begin to develop a mutually acceptable plan of care with
doesn't matter anymore.” the family.
Mr. R.'s wife, Doris, is a 74-year-old woman who has been a home-
maker most of her life. She has always been the “watchdog” for Mr. R.'s Assessment
health. Mostly through her changes in food preparation and her lifestyle In the initial interview, the community health nurse completes a
adjustments, Mr. R.'s diabetes has been managed. She schedules his Â�genogram and an eco-map with the family (see FiguresÂ€13-3 and 13-4).
physician appointments, buys his medical supplies, and administers his After the second family interview, the nurse also completes a Â�family
insulin. He is now refusing to accept her help, and she is anxious and map that describes the members’ interactions with each other (see
angry about his behavior. They frequently have arguments, after which FigureÂ€13-2). A family guide to help structure a family assessment is
Mrs. R. retreats to her room. presented in BoxÂ€13-7.
Mr. and Mrs. R. have three children and four grandchildren who live in Completing the genogram helps break the ice to get the family to
the same city. The eldest daughter, Patricia, calls or stops by about once talk about their situation. The genogram provides a safe and thought-Â�
a week. The other children, Tom and Ellen, are busy with their families provoking way for Mrs. R. to supply appropriate information about the
and see their parents mostly on holidays; they have very little commu- situation. During this process, the nurse obtains information about other
nication with Patricia or their parents. When the children do come to family members, their general levels of functioning, and the Â�possibility
visit, Doris tries to put on a happy expression and pretend that everything of acting as resources. She identifies family members’ patterns of
is going well to avoid worrying them. She is also embarrassed about Â�closeness and distance.
BOXÂ€13-7â•…â•‡ FAMILY ASSESSMENT GUIDE

I. Identifying Data
Name: ___________________________________________________________________________________________________
Address: __________________________________________________________________________________________________
Phone number(s):_____________________________________________________________________________________________
Household members (relationship, gender, age, occupation, education):____________________________________________________
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
BOXÂ€13-7â•…â•‡FAMILY ASSESSMENT GUIDE—CONT'D

Financial data (sources of income, financial assistance, medical care; expenditures):___________________________________________
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Ethnicity: __________________________________________________________________________________________________
Religion: __________________________________________________________________________________________________
Identified client(s):______________________________________________________________________________________________
Source of referral and reason: ___________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
II. Genogram
Include household members, extended family, and significant others
Age or date of birth, occupation, geographical location, illnesses, health problems, major events
Triangles and characteristics of relationships
III. Individual Health Needs (for each household family member)

Identified health problems or concerns: ________________________________________________________________________________
_____________________________________________________________________________________________________________
Medical diagnoses:_____________________________________________________________________________________________
_____________________________________________________________________________________________________________
Recent surgery or hospitalizations: _________________________________________________________________________________
_____________________________________________________________________________________________________________
Medications and immunizations: _________________________________________________________________________________
_____________________________________________________________________________________________________________
Physical assessment data: ______________________________________________________________________________________
______________________________________________________________________________________________________________
Emotional and cognitive functioning: _______________________________________________________________________________
_______________________________________________________________________________________________________________
Coping: _____________________________________________________________________________________________________
Sources of medical and dental care: ____________________________________________________________________________
Health screening practices: ____________________________________________________________________________________
IV. Interpersonal Needs

Identified subsystems and dyads:________________________________________________________________________________
Prenatal care needed: _________________________________________________________________________________________
Parent–child interactions:_______________________________________________________________________________________
Spousal relationships:_________________________________________________________________________________________
Sibling relationships:_________________________________________________________________________________________
Concerns about older members:___________________________________________________________________________________
Caring for other dependent members:________________________________________________________________________________
Significant others:_________________________________________________________________________________________
_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________
V. Family Needs
A. Developmental
Children and ages:____________________________________________________________________________________________
______________________________________________________________________________________________________________
Continued

Responsibilities for other members: _____________________________________________________________________________
_____________________________________________________________________________________________________________
Recent additions or loss of members:_____________________________________________________________________________
____________________________________________________________________________________________________________
Other major normative transitions occurring now:____________________________________________________________________
____________________________________________________________________________________________________________
Transitions that are out of sequence or delayed:_____________________________________________________________________
____________________________________________________________________________________________________________
Tasks that need to be accomplished:_______________________________________________________________________________
_____________________________________________________________________________________________________________
Daily health-promotion practices for nutrition, sleep, leisure, child care, hygiene, socialization, transmission of norms and vÂ� alues: ____________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Family planning used:_______________________________________________________________________________________
_____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
B. Loss or Illness
Nonnormative events or illnesses:______________________________________________________________________________
_________________________________________________________________________________________________________
Reactions and perceptions of ability to cope:________________________________________________________________________
__________________________________________________________________________________________________________
Coping behaviors used by individuals and family unit:_________________________________________________________________
_________________________________________________________________________________________________________
Meaning to the family:_________________________________________________________________________________________
Adjustments family has made:________________________________________________________________________________
Roles and tasks being assumed by members:_________________________________________________________________________
__________________________________________________________________________________________________________
Any one individual bearing most of responsibility:_____________________________________________________________________
Family idea of alternative coping behaviors available:____________________________________________________________________
___________________________________________________________________________________________________________
Level of anxiety now and usually:_________________________________________________________________________________
___________________________________________________________________________________________________________
C. Resources and Support
General level of resources and economic exchange with community:_________________________________________________________
External sources of instrumental support (money, home aides, transportation, medicines, etc.):____________________________________
Internal sources of instrumental support (available from family members):___________________________________________________
External sources of affective support (emotional and social support, help with problem solving):_____________________________________
___________________________________________________________________________________________________________
Internal sources of affective support (who in family is most helpful to whom?): _________________________________________________
___________________________________________________________________________________________________________
Family more open or closed to outside?______________________________________________________________________________
Family willing to use external sources of support?_______________________________________________________________________
D. Environment
Type of dwelling:________________________________________________________________________________________________
Number of rooms, bathrooms, stairs; refrigeration, cooking:_______________________________________________________________
___________________________________________________________________________________________________________
Water and sewage:______________________________________________________________________________________________
Sleeping arrangements:_____________________________________________________________________________________________
Types of jobs held by members:_______________________________________________________________________________________

Exposure to hazardous conditions at job:___________________________________________________________________________
Level of safety in the neighborhood:____________________________________________________________________________________
Level of safety in household:________________________________________________________________________________________
Attitudes toward involvement in community:___________________________________________________________________________
Compliance with rules and laws of society:____________________________________________________________________
How are values similar to and different from those of the immediate social environment?_____________________________________
__________________________________________________________________________________________________________
E. Internal Dynamics
Roles of family members clearly defined?______________________________________________________________________
Where do authority and decision making rest?_____________________________________________________________________
Subsystems and members:__________________________________________________________________________________
Hierarchies, coalitions, and boundaries:________________________________________________________________________
Typical patterns of interaction:_______________________________________________________________________________
Communication, including verbal and nonverbal:__________________________________________________________________
Expression of affection, anger, anxiety, support, etc.:________________________________________________________________
__________________________________________________________________________________________________________
Problem-solving style:________________________________________________________________________________________
Degree of cohesiveness and loyalty to family members:_________________________________________________________________
__________________________________________________________________________________________________________
Conflict management:________________________________________________________________________________________
__________________________________________________________________________________________________________
VI. Analysis
Identification of family style:__________________________________________________________________________________
Identification of family strengths:_____________________________________________________________________________
Identification of family functioning:____________________________________________________________________________
What are needs identified by family? __________________________________________________________________________
__________________________________________________________________________________________________________
______________________________________________________________________________________________________
What are needs identified by community/public health nurse?_______________________________________________________
_______________________________________________________________________________________________________
The eco-map presents a picture to both the nurse and Mr. and Mrs. R. Family Style
of a family that is not well connected to outside resources. Little energy This family is a distancing family that prefers to keep its Â�problem-Â�solving
is coming in or going out of the immediate family system, with the excep- activities to itself. However, this isolation limits family Â�members’ Â�ability to
tion of intervention by the health care system, which the family wants to support each other. The community health nurse must adjust her nursing
discontinue. When the community health nurse later completes a family interactions to accommodate this family's style of operating. The nurse
map, she becomes aware of Mrs. R.'s tendency to act as a parent and should respect the family's need for distance, approach them cautiously,
Mr. R.'s tendency to act as a child. This blurring of boundaries has set up and observe for cues that indicate that they are becoming anxious.
a behavior pattern in which Mr. R. gives away responsibility for his own
health. At the same time, however, the rigidity of these boundaries keeps Family Strengths
the children out of these interactions. After assessing the family, the nurse This family has some ability to organize activities that need to be
tries to guide her practice with some questions. She asks herself about accomplished to maintain Mr. R.'s health. Family members are con-
the family's needs, strengths, functioning, and style. She examines the cerned about each other and may be able to adjust schedules or rou-
family's priorities and the resources they are using or are potentially able tines. Mrs. R. is committed to Mr. R.'s health care and will try to do what
to use. She looks at her own skills and abilities and attempts to define is required. The family has a long history together and in the past has
her responsibility to the family system. These questions help her begin developed a sense of identity and common purpose.
to analyze the family data. This analysis leads to several determinations.
Family Functioning
Family Health Needs Even though the family is currently stressed, long-term functioning is
The family needs help coping with this illness and connecting with resources fairly healthy. No one member has consistently been a problem or has
and sources of support. Some minor disturbances in internal dynamics are failed to fulfill her or his role. The adult children are not acting in their
influencing the way the family is dealing with the problem. The nurse age-appropriate roles of support to parents. This status seems to reflect
assigns the family the nursing diagnosis of “Family Coping: Compromised.” the family style but can possibly be modified.
Continued
Targets of Care past—self-reliance, appropriate action, distancing, and some denial

The community health nurse believes several levels of this family—the of the problem—are not working in this situation. The first goal for
individuals with health problems (both Mr. and Mrs. R.), the Â�couple, and nursing implementation addresses individual health needs. The second
the family as a unit—are potential targets for care. When she reviews goal involves helping Mr. and Mrs. R. think about the crisis and iden-
who the most likely person in the family is to be able to change Â�behavior, tify their present coping strategies. Because the nurse knows that the
she looks for someone who seems willing to change. She decides this family style is distant, she will proceed slowly with this step, adjusting
person is Mrs. R. and potentially the children. to suit the family's pace. She will initially keep the discussion focused
on thoughts and facts rather than feelings. Mr. R. perceives the situ-
Nurse's Contribution ation as hopeless. It is important to help the family reframe this per-
The community health nurse reviews her own caseload and her avail- ception so that the current crisis is seen as being able to be modified.
able time and attempts to make an accurate assessment of her skills. Subsequent plans with regard to family coping would include identify-
She is fairly comfortable in dealing with families and decides she will ing alternative coping behaviors and practicing them. Because signifi-
intervene on three levels: individual, subsystem, and family unit. Her cant strengths are present and the family level of functioning is fairly
contribution will be to offer information, counseling, and connection high, the community health nurse would expect the family to use infor-
with other resources. She can visit one time per week and will try to mation to appropriately problem-solve in this crisis. The family may
schedule these visits when some of the children can be present. also use the situation as a way of growing into new behaviors that
foster family health.
Priorities Connecting the family with resources must be done in a way that
The family has several needs. Which one is the most crucial? Any allows this family to make the choice about outside care. Providing
Â�life-threatening situation must be top priority, but nothing will be accom- information about the extent to which other modern families use these
plished without the family's agreement that this is their concern. After resources may help them accept this intrusion into their world. Internal
discussing these ideas with the family, the nurse and the family decide resources that are available to the family include the adult children, who
to first address individual health concerns. Mr. R.'s hyperglycemia is may be able to offer instrumental or emotional support simply by being
noted, and he admits it is making him feel bad. Mrs. R.'s cardiac status made aware of the extent of the need.
is to be assessed next week at an appointment with the family physician. The internal dynamics of the family, in which the couple's roles are
Although Mr. R. seems agreeable to resuming his insulin injections, he has unbalanced, given that the wife has assumed more and more responsibil-
no desire to change his diet or learn how to walk with a prosthesis. The ity for the husband, are likely to be long-term patterns. Expecting a Â�family
community health nurse puts aside these problems for the time being and at this stage of life to change a formerly effective pattern of relating
Â�
addresses Mrs. R. She wonders if Mrs. R. would be interested in exploring to each other is unrealistic and ill advised. Instead, helping Mrs. R.
her current care for herself. Mrs. R. tentatively agrees. Using additional focus on herself more so that she can care for her own needs and help-
resources to help Mr. R. transfer in and out of his wheelchair is something ing Mr. R. increase his awareness about his responsibility for his health
that can be accomplished, but the family is still reluctant about this course and to his wife are more appropriate interventions.
of action. This problem, too, is put off to a later time.
Evaluation
Planning The community health nurse reviews the care plan periodically with the
The community health nurse and the family together develop both long- family and at the end of the contact. This evaluation includes examina-
term and short-term goals. tion of goals. As the family crisis subsides, goals are quickly accom-
Mr. R.: plished and revised weekly.
• Will monitor and record blood glucose levels every morning The family also examines the effect of the interaction on the member
• Will accept administration of insulin by Mrs. R who is ill (Mr. R.). His hyperglycemia is modified the first week, and his
• Will begin range-of-motion and strengthening exercises to promote blood glucose levels drop to a normal range within several weeks of
mobility for eventual transfer of self to chair contact. He accepts his insulin and even expresses interest in admin-
• Will communicate to Mrs. R. his ability to take care of any of his own istering it himself. His stance with regard to eating whatever he wants
needs as each opportunity arises also changes, and he begins to follow his diet recommendations more
• Will demonstrate improved blood glucose levels within 1â•›month closely. He continues to resist attempts to be fitted for a prosthesis
Mrs. R.: but eventually learns to assist with his transfers. When the community
• Will have her cardiac status evaluated within 2â•›weeks health nurse leaves this family, a goal still to be accomplished is Mr. R.'s
• Will self-monitor her health and record her health status for 1â•›week learning to use a walker.
• Will decide on one goal to take care of herself within 2â•›weeks Examination of the intervention's effect on individuals includes looking
• Will practice this behavior for 1â•›month at Mrs. R.'s health status and that of the adult children. Mrs. R.'s cardio-
• Will allow Mr. R. to care for himself when he desires vascular status has deteriorated. She begins some cardiotonic medica-
Mr. and Mrs. R. together: tion and is urged to moderate her activity and stress level. All three of
• Will experience decreased frequency of arguments within 1â•›month the adult children begin sharing in the care of their father. Although the
• Will spend some relaxed time together every evening children are busier than before, the impact on them is manageable.
The family: Examination of the effects on the subsystem includes effects on the
• Will discuss new ways of coping with this situation as a group interactions of the marital couple. Mr. and Mrs. R. both begin to assume
• Will try out two behaviors that use different family members within more appropriate responsibility for themselves. The arguments and
2â•›weeks anger lessen, although their long-term way of relating to each other
• Will accept one resource to help within 1â•›month does not change a great deal.
The effect on the whole family is also examined. Incorporating addi-
Implementation tional resources lead to a decreased perception of the crisis and an
The community health nurse is aware that the disturbances in the fam- increased calm in the family. As the members begin to renew con-
ily's coping ability are fairly recent. The behaviors they have used in the nections with each other, they discover new sources of emotional
support. Following Mr. R's death due to a pulmonary embolus several As she is working with this family, the community health nurse con-
months later, the children are able to support their mother during the tinually seeks feedback to evaluate her own performance. She carefully
time of loss. monitors the family's reactions to her interventions and her reactions to
In examining the family's interaction with the environment, it becomes the family. She is frustrated at the need to proceed slowly with the fam-
apparent that the family members have become more aware of the com- ily but is satisfied with her choice when she sees that the strategy has
munity resources available to them. The family members are still very worked. Her contact with the family leads her to enroll in a course about
private but begin to use available resources appropriately. Their home client nonadherence. She learns to be patient during this experience
environment is relatively safe. and takes these behaviors with her in her future contacts with families.
1. Choose one of the family assessment tools and apply it to a 9. Think about a patient you have known in an inpatient
family you know. In what ways does the tool help you iden- capacity. Can you apply some of the family concepts to her
tify information to collect? Would you have considered this or his situation? How might knowing more about the fam-
information important without the guidance of the tool? ily have helped you with her or his care?
In what ways does the tool restrict your thinking about the 10. Think about the family you have in your community/pub-
Â�family? What important information was not included? lic health clinical practicum. What categories of needs does
2. Trace the origins of one of the assessment tools back to the this family have? Do the family needs fit into more than one
original theoretical concepts from which it evolved. Is the category? Which category of needs do you believe you are
theory appropriate for thinking about this family? Would most prepared to deal with as a nurse? In which category
different concepts seem to fit better? are you the least informed? What do you need to learn to
3. Draw a structural–functional map of an ideal family. Then prepare yourself to deal with these types of needs?
draw a structural–functional map of a family you know 11. Assess your clinical family's environment. How does the
from television programs such as “The Simpsons,” “The environment affect your thinking about your care planning?
Bernie Mac Show,” “George Lopez,” or “Everybody Loves 12. How many different dyads (two-person groups [e.g., mother–
Raymond.” In what ways does the television family match infant]) can you conceive that might occur in a family? Where
your ideal? do health priorities and problems fit into these dyads?
4. Complete a genogram of your own family for at least three 13. In a student group, role-play an initial encounter with a fam-
generations. What was it like to ask family members ques- ily. Introduce yourself, engage the family, make some initial
tions about your family? Did you find out information that assessment, and set up a contract for your repeated visits.
was not known to you before you began? How did fam- 14. In a student group, role-play a visit in which you and the
ily members respond to thinking about past generations? family are planning mutual goals. Have an observer set up
Can you figure out the relationships, as well as the facts, the situation so that the goals of the family and the goals of
of the family? Where would you go to find the missing the nurse are slightly different. Can you negotiate and come
information? to an agreement?
5. What categories of needs exist within your family of ori- 15. Think of three examples of summative evaluation and three
gin? What data support your analysis? What developmental examples of formative evaluation in your clinical area.
and health-promotion issues are relevant in your family? What formative and summative evaluation methods would
In what ways does your family experience needs related to be appropriate for your clinical family?
illness or loss, inadequate resources and support, family 16. Identify the family style of one family that you know. Try
dynamics, and environmental threats? different interpersonal approaches with this family. Which
6. What style would you assign to your family of origin? What ones seem to work best? Does the family give you any clues
data support your analysis? What suggestions would you about how they would like you to interact with them?
give to a community health nurse about how to interact 17. Watch a movie that demonstrates family interaction (e.g.,
with your family? Soul Surfer, My Family, One True Thing, Smoke Signals,
7. What are the strengths within your family of origin? How Arranged, The Debaters, Into the Wild, The Tree of Life, or
are these strengths valuable to your family, especially in The Descendants). Try to apply family assessment tools
stressful times? to the family in the film. Can you make a care plan that
8. What functional level would you assign to your family of addresses that family's needs, style, strengths, and level of
origin? What data support your analysis? functioning?

Information about each organization listed here is found on its Grandparents Raising Grandchildren: http://www.childwelfare.
website. gov/preventing/supporting/resources/grandparents.cfm
Association for Conflict Resolution: http://www.acrnet.org/ National Mentoring Partnership: http://www.mentoring.org/
Council for Exceptional Children: http://www.cec.sped.org/am/ Nurse-Family Partnership: http://www.nursefamilypartnership.org/
template.cfm?section=Home Parent Help USA: http://www.parenthelpusa.org/
Educational Resources Information Center (ERIC): http://www. Seattle-King County Healthy Homes Project: http://www.kingcounty.
eric.ed.gov/ gov/healthservices/health/chronic/asthma/past/HH2.aspx
WEBSITE
STUDY AIDS
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CHAPTER
14
Multiproblem Families
Claudia M. Smith*
FOCUS QUESTIONS
What characterizes a family in which members are unable to What guidelines can the nurse use in searching for strategies
meet basic needs or maintain optimal levels of health? that are effective with multiproblem families?
What constitutes a resilient family and a resilient individual? How does a nurse transcend labeling, blame, and cutoff when a
How do they deal with problems and challenges? multiproblem family is encountered?
What feelings are experienced by nurses who work with To what extent does clear definition of the nursing role play a
multiproblem families? part in moderating a nurse's frustration?
How do nurse and family values interact in these nurse–client What are appropriate and achievable goals for multiproblem
relationships? families?
How does the nurse work toward mutual goal setting with
multiproblem families?
CHAPTER OUTLINE
Families Experiencing Crisis Resilience
Families with Chronic Problems Responsibilities of the Community/Public
Multiproblem Families Health Nurse
Vulnerable Families Assessment
Families with Negative Choices Planning
Families in Poverty Issues in Intervention
Families with Disturbances in Internal Dynamics Realistic Goals and Outcomes
KEY TERMS
Appraisal Family resilience Stressor
Coherence Hardiness Vulnerable families
Crisis Multiproblem family
Family of promise Resources
Working with families is challenging, but the true challenge for often have little capacity to organize health promotion behaviors
a community/public health nurse is working with families that as they try to deal with immediate and serious problems.
have problems in several areas simultaneously. These families can Many health care professionals base their appraisal of family
be called multiproblem families to indicate that they face several behavior on the basis of what they are comfortable with, which
concurrent difficulties. The problems may be serious, for exam- defines what they consider normal. Biased definitions of appro-
ple, abuse, neglect, substance abuse, illegal activities, homeless- priate family functioning or the importance of self-Â�sufficiency
ness, chronic mental illness, and major deficits in Â�ability to care for can create barriers to working with multiproblem families.
members (Berne etÂ€al., 1990; Black etÂ€al., 2001; Jaffee etÂ€al., 2007). Terms such as vulnerable families and families at risk help us
Families that experience this level of stress or Â�disorganization recognize that certain families have an increased probability of
*This chapter incorporates material written for the previous editions by Marcia L. Cooley.
372
CHAPTER 14â•… Multiproblem Families 373
experiencing acute or chronic problems. The term family of The family manages stress, often adjusting behaviors as time goes
promise would be better to describe these families to decrease on to adapt to new demands and changing Â�environments (Boss,
our tendency to blame these families and to convey an attitude 2002). Adaptation is not an outcome but an ongoing process. This
of hopefulness (Swadener & Lubeck, 1995). Any family, no mat- process occurs within the context of the community in which the
ter how distressed, may be viewed as a family of promise because family lives, which will greatly affect a family's decisions and also
all families have the potential to stabilize and grow from difficult suggests pathways for intervention (Patterson, 1988).
experiences. Most vulnerable families can be divided into two Sometimes, however, the coping measures themselves
general types: (1) families that are experiencing crisis and (2) become stressors. For example, taking time off work to attend
families with chronic problems. a health appointment may endanger a job. In many lower-
income families, dependence on an older daughter for help with
FAMILIES EXPERIENCING CRISIS the household becomes burdensome, endangering the young
female's growth and development (Crouter etÂ€al., 2001).
The families of today's world are exposed to multiple intense Families that have experienced a pileup of demands—
events such as natural disasters and acts of terrorism such as that is, long-term accumulation of and exposure to multiple
the events of September 11, 2001. More of our families face Â�stressors—will sometimes exhaust their ability to be resilient.
Â�catastrophic fears, loss, and disruptive transitions (Walsh, 2006). These families are more vulnerable to stress when it is presented
Even the healthiest family, when it encounters multiple stressors again. Such families may then find themselves in crisis.
and stress of long duration, can be pushed beyond its resources In the family described in the following clinical example, preg-
to crisis. Most families can be supported through the crisis and nancy, illness, and unemployment pile up as demands that reduce
can regain some measure of their previous level of health. In the adaptability of the family. When a couple's son is born prema-
crisis, some families even develop emergent behaviors to help turely with developmental delays, the family is overwhelmed.
them face the future. But families pushed to the limit are more
vulnerable to future problems. What leads a family to crisis? Martha and John Galt married and had two children by the
Family crisis is a continuous disruption, disorganization, or time Martha was 19â•›years old. John worked as a plumber's
incapacitation of the family social system (Burr, 1973). Families apprentice, while Martha went to school to get her GED and
in crisis may have serious disturbances in family organization took care of the kids. Things were actually going pretty well.
and require basic changes in family patterns of functioning Both of the couple's families were supportive, and the two
to restore stability. Crises come in many forms. The Resiliency bought a small house near Martha's mother's house. Then
Model of Family Stress, Adjustments, and Adaptation (McCubbin Martha got pregnant again and also found out that she was
& McCubbin, 1993) reminds us that the stressor along with diabetic. At about that time, John lost his job and was unable
the family's resources and appraisal of the stressful event inter- to find another. Their son was born prematurely and spent
act to drive the family to a state of crisis or to adaptation (see several weeks in the neonatal intensive care unit, which
FigureÂ€12-5 in ChapterÂ€12). The family's response is influenced, resulted in a large bill. After the baby came home, his develop-
in part, by the characteristics of the stressor, including the pre- mental problems became clear. The family was now in crisis.
dictability, extent, onset, intensity, perceived solvability, and
content of the stressor (Price & Price, 2010). Each dimension Helping families cope with crisis is within the scope of the
differs in its ability to affect the family. For example, an intense, community/public health nurse's role. Interventions useful to
unpredictable event such as a sudden death is more stressful this process are presented in BoxÂ€14-1.
than is the expected loss of an older family member.
The family's perception of the event may be the most impor- FAMILIES WITH CHRONIC PROBLEMS
tant mediating factor (Boss, 2002). When presented with a
stressor, the family makes an appraisal of the situation. An Ever since nurses began visiting in the community, they have
appraisal is the perception of or assignment of meaning to a encountered families that have had chronic problems and many
stressful event. The family schema or shared family view of the barriers to achieving optimal health. Some of the families have
world shapes this appraisal. If family members judge themselves experienced generations of poverty, as well as problems in
as inadequate to meet the demands, the tension increases. many areas of functioning such as physical, psychological, and
Another factor is the family's resources, including inher- social. Many of these families have disturbances in their internal
ent family strengths and specific coping abilities. Resources can dynamics. The personal and family resources available to them,
include personal assets such as innate intelligence or sense of their range of coping behaviors, and their willingness and abil-
humor, family system resources such as communication and ity to use external sources of support combine to keep them in
problem-solving ability, and social support. a perpetual state of stress.
During the initial process of situational appraisal, including Some families experience multiple situational stressors
evaluation of the stressor, assessment of the family's capabilities simultaneously (multiproblem families). Some families are vul-
and strengths, and consideration of alternative courses of action nerable, some are presented with only negative choices, some
and coping strategies, the family ultimately comes together as a struggle with poverty, and some have disturbances in internal
unit to manage the stress. The process of coping begins. The suc- dynamics. Many families with chronic problems have combina-
cessful family has several coping strategies that include internal tions of these situations at the same time. Experienced commu-
and external mechanisms. Such a family knows how to use the cop- nity/public health nurses recognize this situation and become
ing mechanism that is most appropriate to the problem presented. aware of their own frustrations in dealing with families that
374 CHAPTER 14â•… Multiproblem Families
BOXÂ€14-1â•…â•‡HELPING FAMILIES COPE WITH Developmental needs exist for the school-aged child, Keith,
CRISIS: BEST PRACTICES his cousins, and the adult family members. Illness needs are
related to Keith's muscular dystrophy, and family resources for
1. Start by recognizing sources of family resilience and strength. Keith's physical care are inadequate. Underlying all the other
2. Offer hope. needs are disturbances in family dynamics manifested as child
3. Help the family identify and describe the nature of the stressors. abuse, substance abuse, illegal behavior, and emotional cutoffs.
4. Explore the family's appraisal of the situation, including its mean-
ing to members and their judgment of their ability to respond. Vulnerable Families
5. Provide information about the nature and demands of the stressor Vulnerable families are families at increased risk because of the
that may not be known to the family. intensity and clustering of stressors associated with life events
6. Help the family divide the tasks required by the stressor into man- (Gillis, 1991; Janko, 1994). Examples of families at high risk
ageable pieces.
for future health problems are families with members who are
7. Help the family explore current and alternative coping mechanisms.
chronically ill or have Down syndrome or alcoholism. Women
8. Validate and emphasize the use of internal family resources,
receiving Temporary Assistance for Needy Families often have
including personal and family strengths.
9. Pull in external sources of social support. health-related barriers that threaten their ability to leave wel-
10. Arrange for tangible sources of external support such as financial fare for work (Kneipp etÂ€al., 2011). These health-related con-
assistance, health care, home visitors, support groups, food assis- ditions which are at higher rates than women in the general
tance, and transportation. population include major depression, domestic violence, sub-
11. Encourage a positive reappraisal of the situation as the family stance abuse, and poor general health. Special events such as
moves from adjustment to adaptation to their new state. assaults, teen pregnancy, and sexual abuse can also predispose a
family to subsequent physical, emotional, and social problems.
Many vulnerable families live in social situations in which loss
seem unable or unwilling to change. The interface between of members through death, institutionalization, abandonment,
Â�multiproblem families and community/public health nurses is or incarceration is common. The combination of intense stress-
the focus of the remainder of this chapter. ors and depletion of resources can push the family beyond its
capacity to cope.
Multiproblem Families
A multiproblem family has needs in several areas simulta- Families with Negative Choices
neously: difficulty in achieving developmental tasks, illness Community/public health nurses assist families in coping with
or loss, inadequate resources and support, disturbances in stress by helping them identify their previous coping style, their
internal dynamics, or environmental stressors (see BoxÂ€13-6). resources, and their alternatives for action. For some families,
Multiproblem families are families in which combinations of however, coping with stress remains a problem even after nurs-
low functional level, multiple stresses, multiple symptoms, ing intervention because the choices for action are all negative
and lack of support interact to threaten or destroy the family's (Wilson, 1989). In some instances, none of the available choices
ability to meet the physical, social, and emotional needs of its will modify the problem, and sometimes the consequences
members. A family does not need to have disturbances in fam- of the choices are all negative and create more problems. For
ily dynamics to have multiple problems. Circumstances beyond example, suppose a family is dealing with a husband and father
the family's control and a pileup of demands can result in who has Alzheimer disease. The wife, who has assumed the
a family's having multiple problems. However, Â�disturbances caregiver role, is exhausted and needs to spend some time out
in internal dynamics predispose a family to having multiple of the house. However, her husband becomes anxious and more
problems. confused whenever any other person takes over his care. None
The multiproblem family in the following example has needs of the choices available to this family solves or completely alle-
in at least four categories: developmental tasks, illness or loss, viates the problem. The wife must choose among solutions with
inadequate support, and internal dynamics. negative implications. Families that must cope when all the
choices are undesirable are also a special-risk group.
Keith, 9â•›years old, has muscular dystrophy and attends a school Families in Poverty
in your district. His mother has been married twice. Her new
The impact of poverty, or living in a resource-depleted, hazard-
husband, Keith's stepfather, is abusive to Keith. A great deal
ous, or hostile environment, is also a factor that affects family
of conflict is present, so Keith recently moved to his grand-
coping. The poor, as individuals and as a group, are continually
mother's house. She is also caring for his two cousins, because
faced with multiple and chronic stressors, including frustration
their mother had died from a drug overdose and their father
over employment options, inadequate and unsafe housing con-
is in jail. Keith visits his mother on the weekends, but often an
ditions, repeated exposure to violence and crime, inadequate
argument breaks out and he is returned to his grandmother's
child care assistance, and insensitive attitudes and responses of
house early. None of the family members seems to be able to
health and social service agencies (Berne etÂ€al., 1990). As fam-
work out the problems. You suspect that Keith's mother lies to
ily coping abilities are strained by unpredictable and unrelent-
you and that she and her mother barely speak to each other.
ing stressors, mastery of the situation decreases. Relationships are
Keith is not only losing some muscular function but is also
strained, feelings of helplessness and hopelessness increase, and
having difficulty in school. He is aggressive and manipulative
self-esteem suffers (Cutrona etÂ€al., 2003). The spiral continues, as
in his classroom. His grandmother is not following through
people become anxious and depressed, feel powerless, and thus
with needed care for his braces, exercise, and skin care at home.
are less able to marshal energy to meet the next day's problems.
Poverty also brings its own set of health problems. Correlates different from those of other families. For example, Sachs and
of poverty include increased incidence of communicable dis- colleagues (1997) found that many low-income single moth-
eases, especially tuberculosis and human immunodeficiency ers with young children held unrealistic expectations for child
virus (HIV) infection; more episodes of illness; less use of pre- behavior, viewed their own parenting responsibilities as over-
ventive care; and higher rates of chronic disease, premature whelming, and perceived their children as unappreciative of the
death, occupational hazards, and unsafe housing. Unfortunate family unit. Discipline was often punitive.
correlates for children include delayed development, childhood Fulmer (1989) describes the family life cycle of poor families
depression and anxiety, and increased separation from fami- enmeshed in chronic unemployment and discrimination, vul-
lies into foster care. Poor neighborhoods may also have greater nerable to problems, and intruded on by various agencies that
environmental risks such as those from industrial sites, land- affect their lives. Constantly reminded of their lack of power in
fills, and toxic waste sites. Living within a poor area may con- the current system, some families turn to illegal activities to meet
tribute to excess mortality, independent of an individual's own their basic needs. Hines (1989) cautioned that many variations
health behaviors (Waitzman & Smith, 1998). Poor individuals can be found in poor families and described a shorter life cycle
are also more likely to be homeless and to lack access to health with three predominant phases (outlined in TableÂ€14-1). The
care (Berne etÂ€al., 1990). The recent large increase in the number four characteristics are: (1) the life cycle is more truncated (less
of working poor and unemployed in the United States is nota- time is available to allow unfolding of developmental stages),
ble. In 2010, the poverty rate in the United States was the highest and life transitions are not clearly delineated; (2) households
since 1993 (U.S. Census Bureau, 2011). The number of families are frequently headed by women and include extended family
in poverty was 9.2 million (11.7%). The number of families in members; (3) the life cycle is punctuated by numerous unpre-
poverty and the poverty rate increased for both married-Â�couple dictable life events; and (4) families have few resources available
families (3.6 million, 6.2%) and female-headed households and must rely on governmental assistance to meet basic needs.
with no spouse present (4.7 million, 31.6%).
Differences in family structures in poor families are often Families with Disturbances in Internal Dynamics
mentioned as the cause or source of multiple family problems. Some multiproblem families have disturbances in internal
In actuality, family structures can serve to strengthen resilience dynamics. Such families are often unable to provide for secu-
rather than undermine it. Many multiproblem poor families rity, physical survival, emotional and social functioning, sexual
have strong ongoing family connectedness even though single differentiation, training of children, and promotion of growth
parenthood or teenage birth is the norm. The three-Â�generational of individual members (North American Nursing Diagnosis
nature of these families adds support and buffers some of the Association [NANDA], 2009; Tapia, 1997). These families
stress (Chatman, 1996; Cooley & Unger, 1991). At times, how- are characterized by insufficient internal support, frequent
ever, the burden on the grandmother who is caring for younger or intense emotional conflict, inability to conform to societal
family members can be stressful for her and lead to poor out- expectations, and acting out of family members. It is unclear
comes for others in the family (Unger & Cooley, 1992). Poor if disturbances in dynamics lead to more family problems or if
families often have developmental phases or attitudes that are response to problems leads to unhealthy family dynamics.
TABLEÂ€14-1â•…â•‡FAMILY LIFE CYCLE OF THE POOR

STAGE CHARACTERISTICS
Unattached young adult • May start as early as age 11 or 12 years
• Young adult on his or her own not accountable to adults
• May need to distance self from burdens of family
• Attaches self to peers
• Blurring of boundaries between adolescence and young adulthood minimizes availability of role models
• Difficult to establish self in work
• Difficult to establish intimate relationships with partner
• Early transition to parenthood
• Missing accomplishment of early tasks weakens ability to accomplish later ones
Families with children • Occupies most of the life span
• Common to involve three- or four-generation households
• Often begins without marriage
• Combines tasks of two stages—the marital couple stage and family with young children stage
• Negotiation with extended family related to interconnectedness and role demands is difficult
Family in later life • Phase of the nonevolved grandmother (no growth for self)
• Grandmother involved in central childrearing role in old age
• Not likely to be empty nest
• Death may occur before or shortly after retirement
Data from Carter, B., & McGoldrick, M. (1989). Overview of the changing family life cycle: A framework for family therapy. In Carter, B. & McGoldrick,
M. (Eds.), The changing family life cycle: A framework for family therapy (2nd ed., pp. 3-28). New York: Gardner Press; Fulmer, R. (1989). Lower-income
and professional families: A comparison of structure and life cycle process. In Carter, B. & McGoldrick, M. (Eds.), The changing family life cycle:
AÂ€framework for family therapy (2nd ed., pp. 545-578). New York: Gardner Press; and Hines, P. (1989). The family life cycle of poor black families. In
Carter, B. & McGoldrick, M. (Eds.), The changing family life cycle: A framework for family therapy (2nd ed., pp. 513-544). New York: Gardner Press.
Family systems theory provides some thoughts about how occur during the formation of early attachments Â�predispose
the level of health of a family might develop. Multigenerational the parent–child relationship to problems. Separation of pre-
patterns that are passed down from one generation to another mature infants from their parents, prolonged hospitaliza-
can be adaptive or maladaptive. There is a great tendency to tions or Â�illness, unexpected crises such as homelessness or
repeat these patterns, especially considering that the family imprisonment, deaths, and emotional illnesses are examples
members have known no other family experience. Doing what of Â�disruptions in family life that can interfere with parenting
an individual knows, even if it brings unhappiness and failure, and the child's early development. Tension or lack of nurturing
is often easier than is changing behavior to something unfamil- Â�during the child's earliest interactions influences the growth
iar and unknown. and development of the child and the child's subsequent ability
The level of differentiation of a family is a crucial variable in to nurture his or her own children. Not only multigenerational
the appearance of symptoms (Kerr & Bowen, 1989). Families patterns but also perhaps even basic emotional health is passed
have varying levels of differentiation or ability to separate emo- from generation to generation.
tion from thought. Families on the low end of the Â�continuum BoxÂ€12-4 contains a list of healthy family characteristics. A
have greater difficulty living their lives in a thoughtful way. comparison list of characteristics of families with disturbed
Instead, these families respond to situations automatically in internal dynamics is presented in BoxÂ€14-2. The multiprob-
attempts to manage their high levels of anxiety. At the oppo- lem family may have disturbances in many of these areas, for
site end of the continuum are families with the ability to example, inadequate support, multiple stressors, and high Â�levels
Â�distinguish thought from feeling. These families have members of anxiety. Multiproblem families with disturbances in inter-
who are able to think of themselves as separate persons as well nal dynamics may also have dysfunctional family boundaries,
as group members and who can define life goals and Â�pursue unhealthy communication patterns, dysfunctional expression
them in a thoughtful way. Families on the thoughtful end of emotion, inadequate problem-solving skills, underorganiza-
of this continuum have fewer life problems than do families tion or rigid organization, unclear roles, and repetitive patterns
that are caught in automatic emotional reactivity. Most mul- of interaction that blame or shift responsibility.
tiproblem families tend to fall on the more emotional side of Scapegoating, or identifying one family member as the prob-
Â�differentiation of self. Family theory suggests that these Â�levels lem, is one pattern that may be used. Distancing and cutting
of differentiation are transmitted from generation to gener- off of family members can occur when the anxiety rises to the
ation through the process of projection, which is the degree point that family members can no longer tolerate contact with
of the child's relationship dependence or the extent to which each other. In some instances, it not unusual to see members
each child is involved in maintaining the emotional lives of the of a family who live on the same street but have not spoken to
Â�parents. Some researchers suggest that stressors and events that each other in years. Repetitive patterns of emotional conflict, in
BOXÂ€14-2â•…â•‡CHARACTERISTICS OF FAMILIES WITH DISTURBANCES IN INTERNAL DYNAMICS

• Developmental stages and tasks: The family has difficulty achiev- • Open or closed system: As the system closes, all variables and pat-
ing tasks at the stage-appropriate time. Situational and maturational terns become fixed and less able to adapt. Energy is used in dysfunc-
crises occur simultaneously. Tasks for the next stage are delayed or tional ways.
not accomplished. • Communication: Unclear, not honest, and indirect; contains incon-
• Roles: Patterns of expected behavior are not appropriate to age and gruent feelings and words; and is nonspecific. The family is not able
ability, and roles are rigidly assigned and are unable to support family to use communication as a mechanism to resolve conflict.
functioning. • Values: Do not provide guidelines for behavior acceptable to society
• Boundaries: Closed and impermeable or completely diffuse. and culture. Values are unable to be modified to adapt to changing
Members fail to allow appropriate exchange with the environment or times.
fail to define the family unit. Boundaries between subsystems have • Encouragement of autonomy and acceptance of difference: A
no clear generational lines and do not support a strong parental coali- balance does not exist between autonomy of members and the need
tion. Subsystem boundaries may be unclear, rigid, or diffuse. to be a cohesive group. Strong pressures to conform and to sacrifice
• Subsystems: As in most families, each member of the family belongs individual needs for the purpose of the group are present.
to several subsystems simultaneously: spouse, parent–child, sibling, • Level of anxiety: Extremely high. People in the family have difficulty
grandparent. However, subsystems may include inappropriate members. thinking and solving problems. Long-term anxiety tends to wear down
• Patterns of interaction: Repetitive and fixed. The focus is on one the ability of the family to function well.
member who is blamed, left out, or put down in the interaction. Family • Resources and social support: Family has few internal and exter-
cohesion is extremely enmeshed or disengaged. Communication pat- nal sources of support. Members who are available are not used to
terns of placater, blamer, superresponsible one, and distractor are their capacity or are overused. All families have some strengths, but
often used. Distance, conflict, projection, and overresponsibility or the strengths may be different from those expected by society.
underresponsibility are common. • Meaning, perception, and paradigm: The family agrees to allow
• Power: No clarity of role definition and appropriate rules. Power is myths and secrets to structure the meaning of many situations. Life
not shared, appropriate to age, or within the parental subsystem until problems are viewed as unsolvable problems rather than challenges.
the children are independent. The family views itself as powerless.
• External stressors: Very intense, numerous, and occur simultane- • Adaptability: Resilience is necessary for a family to be able to cope
ously. The family has little chance to adapt. Chronic illness adds to with changing demands. The family is not able to be flexible or is so
family stress. chaotic that cohesiveness and predictability are missing.
Developed by Marcia L. Cooley, PhD, RN. Copyright Elsevier.
which the conflict seems to be resolved and then erupts again, Â�

atmosphere that fosters trust, cooperation, and acceptance; but
do occur. These families often contain many active and inter- more importantly, a sense of hopefulness is maintained. The
locking triangles and may use this pattern with outsiders when family has several coping strategies, including using insight,
tension rises. Triangling in the social worker, police officer, or humor, spirituality, creativity, and boundary setting. Most
nurse helps relieve anxiety. important, the family will be able to take charge, communicate
with each other and the outside, and use the support of each
RESILIENCE other and external sources. Finally, the resilient family engages
in productive and adaptive activities to meet the family's own
What makes a family resilient or adaptive? What are the charac- needs and to meet society's expectations.
teristics of families that are able to bounce back from stressful
experiences? RESPONSIBILITIES OF THE COMMUNITY/PUBLIC
Garbarino (1992, p. 101) defined resilience as “the capac-
ity to develop a high degree of competence in spite of stress- HEALTH NURSE
ful environments and experiences.” The term resilience has Families that are defined as multiproblem families are often the
been used to describe an individual's response to adversity. most challenging, most time-consuming, and least rewarding
Many researchers propose that some trauma or major stressor families in a community/public health nurse's caseload (Fox,
must first be Â�present for resilience to develop. This view sug- 1989). Nurses often need support to continue working in situ-
gests that an individual develops resilience while experiencing ations in which their efforts are frustrated. As experienced and
trauma within a dysfunctional family. In contrast, the concept educated health care workers, we often expect that we will have
of Â�family Â�resilience proposes that family resilience parallels indi- the answers and that our expertise will be accepted and acted
vidual resilience. Family resilience may develop in response to on. This assumption is in direct conflict with the family's per-
a Â�specific adversity, but it may also be a response in any family ception of a health care worker as someone whom they are not
facing risks in life (Patterson, 2002). Family resilience can be able to trust and whose advice does not seem to affect their
defined as “the ability of the family to respond positively to a quality of life. If it is assumed that families have the right to
situation and emerge feeling strengthened and more resourceful self-determination and know what is best for themselves, then
than before” (Simon etÂ€al., 2005, p. 427). a conflict exists between the two ways of viewing family care.
Each family has risk factors and protective factors that work Each community/public health nurse must examine his or her
to promote competence to handle stress. McCubbin (1998) sug- own values and resolve this conflict in order to be effective in
gested that the protective factors are the family's coherence and caring for multiproblem families.
hardiness. Coherence is a fundamental coping strategy in which As a result of interviewing 32 public health nurses in 14 com-
the family emphasizes acceptance, loyalty, and shared respect munities representing 50,000 people in rural Canada, Browne
and pride to manage the stressor. Hardiness is an “internal sense etÂ€al. (2010) revealed that nurses understood that “social condi-
of control of life events and its meaningfulness and a commit- tions are quite literally embodied in people” (p. 29). This means
ment to learn and explore new experiences” (McCubbin, 1998, that the nurses recognized that families live through their past
p. 5). Lietz (2007) studied family resilience and uncovered sev- and present social conditions and are shaped “biologically,
eral protective factors that increase resilience. They are internal Â�psychologically, and interpersonally” by them. The nurses worked
and external social support, boundary setting, the ability to take simultaneously with family risks and capacities, vulnerability and
action or take charge, and communication. safety; recognized that risks and situations can change; and were
flexible with their Â�nursing responses. Nurse–family relationships
were facilitated by the nurses being nonjudgmental, fostering
participation, and Â�creating “safe spaces” in which family Â�members
could be open about their circumstances.
Assessment
Most of the time, but not always, multiproblem families Â�operate
at a low level of functioning, according to Tapia (1997) (see
TableÂ€13-5). Families at level I (chaotic families) are character-
ized by disorganization in all areas of life. In these extremely
immature families, adults may be unable to fulfill their roles and
responsibilities. Children or others may be expected to assume
these roles, which is inappropriate and interferes with normal
growth and fulfillment of nurturing needs. Physical and emo-
tional resources may be inadequate. Family members are often
depressed, with a sense of hopelessness and powerlessness.
These individuals may have little self-esteem, a high sense of
Four generations of one family. failure, and little reason to trust another health care worker who
comes with promises that are most often unfulfilled.
The resilient family will proceed through several stages Families at Tapia's level II (intermediate families) are able to
after the presentation of a stressor: struggling to survive, meet their basic survival needs but are immature and unable
Â�adapting, accepting, growing stronger, and sometimes helping to meet many needs of family members. These individu-
Â�others (Lietz, 2007). This type of family creates an emotional als are often defensive, unable to trust, and alienated from the
Â�
community. However, these families retain some hope and have pointed. The family may test the nurse while trying to deter-
some capacity to change and improve their functioning. mine his or her reliability and consistency. The nurse may even
Assessment of multiproblem families includes a three-Â� interpret this action as manipulation. However, this action is
generational time frame because many families are cooperating frequently a pattern that the family has found helpful in the
across generations to meet basic needs. Assessment should espe- past to maintain some control. Zerwekh (1992) described three
cially evaluate the interactions among the family's many needs, responsibilities of the community/public health nurse in
strengths, styles, functional level, coping patterns, resources and response to this pattern: (1) locating (tracking down) families,
supports, and past experiences with health care workers (see (2) building trust, and (3) building strength.
ChapterÂ€13). Special areas of focus should include the num-
ber and duration of stressors the family has experienced over Burton, a home health nurse, was about to visit the Carter
time, the family's perception of the events, an estimation of family when he realized that the assignment would be
the severity of any symptoms the family may be experiencing Â�difficult because of the family's past relationships with nurses.
(e.g., depression, alcohol use, physical abuse), and contacts with The Carter family had a history of bad experiences with home
other health care resources. Tools such as the Family Inventory nurses, including one nurse who was overbearing and critical.
of Life Events (FILE) by McCubbin and Thompson (1987) or Mr. Carter, who had lung cancer, actually had had an unnec-
the Family Systems Stressors–Strength Inventory (Mischke & essary hospital admission because a nurse did not believe
Hanson, 1991) may be especially helpful. The Family Coping Mrs. Carter when she called to ask the nurse for an immedi-
Index (Lowe & Freeman, 1981) helps determine coping pat- ate assessment of Mr. Carter's labored breathing. The Carters
terns, and the eco-map (Hartman, 1978) helps describe the had lost their medical assistance eligibility for not follow-
family's connection with resources. ing through with the agency's suggestions several times. The
Â�family blamed their loss of medical assistance on the agency.
Planning How would Burton deal with this understandable Â�reluctance
After analyzing the data, the nurse will have a better under- on the part of the family to accept a new nurse? He called
standing of realistic goals and expectations of what will Â�happen the Carters before he visited and introduced the idea that he
in his or her encounters with the family. Perfection should not wanted to start fresh with a family plan of care. He described
be sought. Goals should be concrete and realistic and mutu- the priorities he had identified—keeping Mr. Carter safe
ally defined by the family and the nurse. In the presence of and comfortable and making sure that the medical assis-
what seem to be overwhelming problems, identifying family tance coverage was monitored carefully; he then asked what
strengths is sometimes difficult for a nurse. The nurse's val- their priorities were. Mrs. Carter admitted tearfully that her
ues set up expectations that block his or her identification of husband seemed worse, and she feared his illness was near
strengths. As the community health nurse truly listens and asks its end. She was not sure that she wanted Burton's help but
the family to identify its strengths, they become more appar- allowed him to visit. He spent the visit working on the family
ent. As discussed in BoxÂ€12-3, Otto (1973) was one of the first priority, which was helping Mr. Carter be comfortable.
to emphasize family strengths. Karpel (1986) Â�suggested that
some personal strengths such as Â�self-respect, Â�protectiveness, When the time comes to identify problems, the nurse may
caring in action, hope, tolerance, affection, humor, and find that the family cannot agree on or clearly identify their
playfulness are often hidden. Relational strengths include
Â� problems. The family's ability to sort through multiple priori-
respect, Â�reciprocity, reliability, the ability to repair, flexibility, ties and clearly see their problems and what can be done may
and family pride. Karpel also suggested that loops of Â�family be weakened by anxiety and a sense of being overwhelmed. The
interactions repeat themselves to amplify resources and that family members may have no previous experience with this
symptoms can be reframed to allow people to see the situation style of thinking and so may resort to impulsive and automatic
in a positive way. For example, suppose one of the daughters patterns as explanations for their distress.
loses her job. When her sisters and brothers become aware of For the family to continue to engage in care, some commit-
this, the situation is redefined as one that allows her to spend ment and resources are necessary. Other needs may compete for
more time with her young children. The sisters and broth- priority. For instance, the usual time a nurse might meet with
ers engage in a series of telephone calls and conversations a family member is during the day. A mother who has a 9-to-5
in which all agree to offer a little financial help and a lot of job may be unable to take time off to keep up with nurse con-
Â�emotional support until the situation improves. This family tacts, and a mother caring for a toddler with an earache may
has Â�maximized its resources. find Â�herself at the pediatric clinic waiting to be seen and then
spend several hours getting home by bus. Families with fewer
Alterations in the Nurse–Family Relationship resources seem to have to work harder and deal with more
Sometimes, the multiproblem family's past experiences with obstacles to get done things that others take for granted.
health care workers have led the family to distrust other
encounters. After hoping to have some of its needs met and Mutual Goal Setting
then being left with problems that are unresolved, the family A mutual goal is one that is shared by both the family and the
may pull away or be reluctant to engage with another health community/public health nurse, meaning that the family and
care worker. Especially when values are different, the family the nurse agree on the need for the goal and agree to work
may play along with the nurse, feeding the nurse inaccurate together toward meeting it. Consistent with models of family
information that the family believes he or she wants to hear. stress and adaptation discussed in ChapterÂ€12, nurses should
Members may agree to make appointments and then not keep explore the meaning of the situation with the family. Carey
them, preferring to break the contact rather than be disap- (1989) identified the process of mutual goal setting as the
Â�
single most important skill to bring to multiproblem Â�families. Issues in Intervention
Individuals have a right to knowledge about themselves and Family Participation and Family Choice
to participate in decisions that influence their lives and health. Nurses who offer care to families in the community use two
Health care professionals have a responsibility to share infor- basic approaches. In the first, nurses approach families with
mation that helps individuals make informed decisions about the expectation that the members will participate equally
their care. Nurses’ education and knowledge sometimes get in with the nurse in the process of planning and implement-
the way of family interactions. People tend to resist being told ing care. Families are asked what problems they want or need
what to do and are, therefore, more likely to work toward goals to work on. Clients identify their own problems and mon-
they choose and support. Instead of investing himself or herself itor their own progress. Nurses assist the family by clarify-
in the outcome, paradoxically, the nurse should let go of the ing ideas, breaking problems down into more manageable
outcome and invest in respect and support of the client. units, helping families set priorities, and giving feedback and
Â�positive support. When a goal is reached, the family may start
Determination of Level of Intervention working toward a new goal.
Potential levels of intervention include the individual, small With less functional families, this nursing approach may not
interpersonal groups, the family as a unit, and the family within work. We have already discussed families that may not have the
the environment. How does the community/public health nurse ability to identify their needs or ask for specific kinds of help.
determine the appropriate level of intervention with multiprob- These families may have difficulty engaging and continuing in the
lem families? For some families, working with the family as a relationship. Impulsivity and competing demands may alter the
unit may not be possible because of access, time constraints, or ability to adhere to the care plan. With these families, the nurse
disconnected relationships. For example, the community/Â�public must alter the approach. From the beginning, the nurse must be
health nurse may be referred to work with a mother who has consistent and reliable in her or his contact. A regular and contin-
lost the right to see her children because of her history of abuse. ued physical presence on which the family can count is necessary
In multiproblem families, the nurse takes every Â�opportunity to to reassure the family that the relationship can be trusted.
work with any part of the family, recognizing that more optimal If the family cannot identify its own goals, the nurse acts as an
ways may be unavailable. information giver, sharing the assessments and diagnoses. Visual
Working at the individual level will include interventions or concrete portrayals of the assessment, for example, a pie chart,
directed at individual health problems and at strengthening a score on a test, or a photograph, may help engage the family's
individual functioning and resilience. For example, the nurse interest. The nurse can suggest possible goals but must carefully
who works to prepare the previously mentioned mother for validate whether the family shares the same concerns and wants
the return of her children may be educating her about par- to work toward the goals that the nurse suggests. If the family
enting skills, helping her find and maintain employment, and is uninterested, then the nurse Â�presents the assessment again
connecting her to resources in her community. Developing
Â� to gain feedback about the Â�client's Â�perception of the situation.
Â�personal strengths is always beneficial to someone in the family. The feedback process continues until a concern and goal that are
Working at the interpersonal level is often a choice the shared by the family are identified (Zander, 1996).
community/public health nurse will make. Multiproblem
Â�
Â�families will frequently exhibit problems in areas related to
interpersonal relationships, for example, inadequate prenatal
Â�
care, unsafe parent–child interactions, marital conflict, or
elder abuse. Neglected children can be at great risk for other
Â�problems, including Â�serious damage to emotional, physical, and
cognitive development. Chronic neglect is more a way of life
than it is a series of individual events (Turner & Tanner, 2001).
Helping subsystems within the family learn new ways of inter-
acting and coping ultimately helps the whole family (Niemeyer
& Proctor, 1995; Scannapieco, 1994).
Some thoughts about working with the family as a unit are
outlined later. For many family health nurses, this strategy is
preferred. Knowing that the family functions as a unit makes
the experienced nurse wary of addressing it in segments.
One argument asserts that the most appropriate role for a
nurse is at the macro level, or environmental level. In fact, the
realities of life for many multiproblem families are related to
factors that are beyond their internal control, factors known as
social determinants of health. Coping with exposure to envi-
ronmental hazards, health risks in air and water, violence in the
streets, deterioration of the neighborhood, inadequate educa-
tion, limited access to health care, and unavailability of adequate
employment would tax the resilience of any person or family.
Nurses who assume the role of advocate for families within a
larger social context may ultimately have the most impact on
family health (Williamson & Drummond, 2000). A caregiver grandfather reading with his granddaughter.
Incorporation of Evidence-Based Practice then be reframed and sometimes modified to be more Â�functional
Using evidence-based practice helps the nurse and family achieve for the family.
desired goals and outcomes. Reviews of evidence-based prac- Using circular communication is often helpful for Â�families
tice with multiproblem and vulnerable families have identified with multiple problems (Bell, 2003; Wright & Leahey, 2009). The
several principles that should be incorporated into the choice affect, cognition, and behavior of the individuals are observed,
of practices, including providing early intervention, offer- and the nurse gives feedback that illustrates the mutual
ing concrete support such as transportation and food during Â�influence each person has on another's feelings, thoughts, and
interventions, and arranging longer and more frequent sessions actions. As family members begin to understand this reciprocity
(Kumpfer & Alvarado, 2003). Nursing roles will vary and may or the effects one member has on another, breakthroughs can
include educator, facilitator of family decisions, liaison to com- Â�sometimes be achieved.
munity resources, provider of emotional support and direct Helping the family feel a sense of power can break through
care, and advocate for the client within the community systems, the hopelessness. Working with the family toward a small but
if necessary. achievable success helps empower it to take similar actions
Case management with maternal child health (MCH) fami- in the future (Dunst etÂ€al., 1989). There is a strong possibility
lies is prevalent among public health nursing agencies. High- of additional problems, however, and continued support and
risk MCH families tend to receive more home visits by nurses, Â�recognition of the family's attempts and strengths are Â�necessary.
more interventions, and have lower base-line health knowl- This assistance must be balanced against the family's possi-
edge, behaviors, and status than do lower risk families (Monsen ble tendency to depend on the nurse when it needs to learn to
etÂ€al., 2011). Therefore, family risk can be used for making develop itself (BoxÂ€14-3). The nurse becomes a compassionate
case-load decisions. Higher risk families can be defined by the and informed companion as the family struggles with its daily
total number of problems, plus the presence of income issues, tasks of living.
substance abuse, and mental health problems (Monsen etÂ€al.,
2011). Statistically significant improvement in MCH outcomes Nurse Self-Reflection and Self-Management
occurred consistently across several public health nursing Triangling is a fact of life with all families but especially with
agencies (Monsen etÂ€al., 2010). Antepartum/postpartum and families that are anxious (see ChapterÂ€12). Nurses cannot avoid
family planning problems in MCH families showed the great- triangles, but they can learn to manage themselves within them.
est improvement; neglect and substance use showed the least When tension rises in the family, the tendency will be for a Â�family
improvement (Monsen etÂ€al., 2010). member to try to escape uncomfortable feelings by pulling in a
Nurses who wish to promote the development of Â�resilience third or fourth or fifth person. This additional person serves
in individuals and families should pay particular attention to to distract the family from its original tension. The distraction
some interventions tested in the Â�literature. Interventions dem- does not always help the family move toward a problem solu-
onstrated effective in supporting Â�resilience in African American tion. When a community/public health nurse or anyone else is
youth include formation of strong ethnic–racial identity, con- pulled into a triangle through the family's wish for that person
tact with supportive social networks, and involvement in mean- to be closer and to take over, providing a calm and thoughtful
ingful activities in safe community environments (Barrow etÂ€al., presence can help diffuse the emotion. Instead of participat-
2007). Development of strong belief systems, optimism, and ing in the emotionality, the nurse should resist the Â�temptation
healthy communication Â�patterns has also proved effective in fos- to jump in to help and instead be a thoughtful observer in
tering resilience (Tusale etÂ€al., 2007). Van Riper (2007) found that the Â�situation. Asking questions, maintaining Â�neutrality, and
enhanced family Â�problem solving was significantly associated Â�demonstrating thoughtfulness will be most helpful.
with positive outcomes for families with children with Down During the contact, nurses should be aware of their tendency
Â�syndrome. All approaches emphasize the importance of develop- to feel hopeless, to discount the value of the time and effort
ing and using strong relational networks (Black & Lobo, 2008; spent with the family, or to feel angry and want to withdraw
Walsh, 2007).
The fact that some individuals and families respond to hard-
ships with resilience cannot always protect them from negative BOXÂ€14-3â•…â•‡STRATEGIES FOR WORKING
â•›
outcomes, however. And again, the individuals and families that WITH MULTIPROBLEM
cannot respond with resilience should not be blamed. Jaffee and FAMILIES: BEST PRACTICES
colleagues (2007) found that children residing in multiproblem
families with substance abuse, low social cohesion, and informal 1. Foster continuity of care.
social control are not likely to be resilient to maltreatment. This 2. Be patient—do not expect instant solutions.
provides evidence that the social context sometimes overrides 3. Help the family identify its strengths.
individual and Â�family efforts. 4. Work on small pieces of problems.
5. Help the family recognize opportunities for moving forward or
Families That Do Not Respond doing things differently.
The goals of the nursing contacts are not to fix the family or 6. When all choices are undesirable, help the family cope more
Â�positively with the choice that is made.
to address all the problems of family members. Helping Â�family
7. Ensure that all contacts are characterized by caring and respect.
members gain awareness of the distinctions between feelings
8. Organize possible sources of tangible support.
and behaviors may curb some of the impulsivity and encour-
9. Encourage use of sources of intangible support.
age members to think before they act. Unhealthy family Â�behavior 10. Remember that the ultimate goal is empowerment and resilience
patterns are recognized by describing and tracking them with of the family and development of individual self-esteem.
family members (Reimel & Schindler, 1994). The Â�patterns can
when family problems continue. Self-reflection is important

Martin, an older man who had been cut off from his family
for identifying one's own “assumptions, blind spots, and biases”
in the community, had multiple health problems, including
(Browne etÂ€al., 2010, p. 32). Many nurses build in regular sup-
emphysema, severe hypertension, fatigue, decubiti, depres-
port by talking with colleagues or making a plan to take care of
sion, and nutritional deficits. His disorganized family had
themselves in the midst of a heavy workload. Carefully defining
difficulty maintaining contact with him because of their
a nursing role that includes realistic expectations of self is one
own legal and parenting concerns and anger about past con-
way the nurse can help manage these feelings.
flicts. Shari, the community/public health nurse, worked on
getting Martin a continuing supply of food that he would
Realistic Goals and Outcomes eat (he rejected Meals on Wheels). His nutritional status
Although the successful community/public health nurse will improved, which led to decreased fatigue, lower blood pres-
not be able to move all families toward health, helping multi- sure, and healed decubiti. He was extremely worried about
problem families feel a sense of competency and power may the physical safety of one of the preschool children of his
assist them in developing more effective ways of managing fam- daughter, who was abusing substances and neglecting her
ily life. To believe that a family that may have had troubles for child. His sister agreed to care for the child in her home with
generations will be without concerns after limited nursing con- the permission of his daughter, who knew she was not able
tact is unrealistic. However, all families should be recognized as to function as a parent.
families of promise that have the potential for growth (Swadener
& Lubeck, 1995). Some examples of goals that can be achieved The family continued to have multiple problems, but
with multiproblem families are given in the sections that fol- two specific stressors were reduced, which helped the family
low. Specification of clear family outcomes helps the nurse and Â�members to maintain health and safety that year.
family direct efforts in a focused and prioritized way. TableÂ€14-2 Families may require help to reduce exposures to environ-
gives examples of some family outcomes. mental hazards. For example, Krieger etÂ€al. (2005) described the
successful work by public health nurses and community health
Selected Stressors Are Prevented or Reduced workers to reduce asthma triggers in homes. Other families may
The family may have many members with health or social prob- require help to move to a new home, as in the instance of a child
lems. Not all of these problems can be corrected. However, solid with lead poisoning living in a house with unsafe lead levels.
action aimed at one or two specific needs may improve the
quality of the family's life. Support System Is Strengthened
In the following clinical example, the community/public Multiproblem families report more feelings of loneliness and
health nurse successfully addressed the problems of (1) inade- social isolation, and less social support than other families
quate nutrition and (2) fear about safe child rearing. (Ortega, 2002; Wilkins, 2003). The feelings of isolation persist
TABLEÂ€14-2â•…â•‡FAMILY OUTCOMES
GOAL EXAMPLES OF FAMILY OUTCOMES
Selected stressors are prevented • The family will identify a number of stressors currently impacting the family.
orÂ€reduced. • At least one family member can identify a preventable or reducible stressor.
• At least one family member implements a strategy to prevent or reduce a stressor.
• The family verbalizes an awareness of the impact of decreasing the stressors.
Support system is strengthened. • The family will identify at least one human service resource available to them.
• The family will identify an advocate or person who can help them get information about available
human services.
• The family verbalizes a list of informal sources of social support.
• At least one family member tries using a social support not previously used.
• The family verbalizes blocks internally or externally to use of social support.
• The family verbalizes reactions to services offered.
Family organization is improved. • The family accepts a behavior of a member that respects individual difference.
• One overworked member sets limits on availability.
• The family negotiates a cooperative decision.
• The family rearranges roles necessary to maintain family functioning.
• The family develops a sense of tradition and identity.
• The family practices an activity dedicated to caring and continuity.
Coping processes are more adaptive. • The family can state some past ways of coping and effectiveness.
• At least one family member appraises the current challenge and degree of family effectiveness in
coping.
• The family agrees to try a new coping behavior.
• The family discusses the impact of the new coping behavior.
• The family increases their sense of competence and shares affirmation of the behavior with other
members.
even when the actual social network includes a large number of Coping Processes Are More Adaptive
members. Some families do not know about the resources avail- Many multiproblem families have learned dysfunctional coping
able to them or lack skills to access them. This may be Â�especially behaviors as part of their life. For a family that tends to blame
true for families new to the community. The nurse has Â�multiple others or depend on others to help it out of any situation, the
responsibilities in helping families use resources, such as those concept of planning and acting may be quite foreign. Drinking
for food, transportation, housing and health. These tasks can alcohol, acting out emotions, and procrastinating are examples
include identifying resources, helping the familyÂ� mobilize of unhealthy coping behaviors.
and use them, and sometimes limiting and regulating their In the following clinical example, the community/public
input (Feeley & Gottlieb, 2000). The nurse works at provid- health nurse assisted the mother to become more assertive in
ing Â�information or guiding the family through actions to access her problem solving.
these resources, but some sources of support may be Â�overlooked.
Family members who appear to have a low functioning level In one family, the son, Andy, had spina bifida and was
may be able to do more than expected. Once Â�support is started, extremely dependent on various health care systems and
feedback loops are set up that serve to continue the supportive social service agencies. The family became angry every
behaviors. Being supported feels good, as does being acknowÂ� time Andy had a problem while at school, with his Â�catheter,
ledged for providing the support. with his wheelchair, or with his braces. They blamed the
Consider the following clinical example in which resources Â�agencies or others for not managing his care correctly. When
were mobilized and support strengthened from within the a new set of braces caused a pressure sore on his skin, the
Â�family itself. Â�community/public health nurse coached the mother to take
action to Â�contact the supply company, which made needed
In one family, the grandmother had cancer and was being Â�adjustments. This success moved the mother to a more
cared for in the home. Zelda, her middle-aged daughter, Â�self-confident stance in dealing with her son's care.
was coping with caring for several preschoolers, maintain-
ing a job, and monitoring her 20-year-old daughter, who Community/public health nurses interface with families
had cognitive developmental delays. The daughter's help in serious trouble within communities. Avoiding multiprob-
was enlisted to bathe her grandmother and keep her com- lem Â�clients is increasingly impossible; in fact, the clients who
pany. Although the daughter had not been counted on as need nurses the most have multiple problems. Experienced
a resource in this family before, once her potential was Â�community/public health nurses develop competencies in help-
tapped, she was delighted to be able to help. Zelda got some ing multiproblem families find solutions (BoxÂ€14-4). To gain
respite for a time before the grandmother entered a hospice access to these Â�families, nurses need to examine their own values
program. and approach families with respect and a willingness to allow
them to define their care. Nurses who learn to expect less than
Family Organization Is Improved Â�perfection from themselves and the families they care for can be
The chaotic family may have little experience with a more extremely Â�influential as mutual progress is made in little steps.
ordered existence and may not recognize the benefits of sim- Restoring a family's sense of power and hope greatly enriches a
ple structuring and rules. The very rigid family may never have nurse's satisfaction.
experimented with a different way of doing things. Assisting the
family in making minor changes in organization may help it BOXÂ€14-4â•…â•‡COMPETENCIES FOR
move in the needed direction. COMMUNITY/PUBLIC HEALTH
How a family's organization is improved depends on the NURSES WORKING â•›WITH
unique circumstances. Creative thinking and personalized
MULTIPROBLEM FAMILIES
interventions were displayed by the community/public health
nurse who worked with the following family. The community/public health nurse working with multiproblem
Â�families must demonstrate competence in the following areas:
Marylee, 7â•›years old, was not attending school. She stayed • Engaging families that are distant, resistive, or disorganized or that
home to take care of her mother, who was often “ill.” Her have had previous negative experiences with the health care system
mother, who had dropped out of school herself at age 16, • Assessing individual member's safety within the family context and
would turn off the alarm clock in the morning and sleep late, taking immediate action to protect a threatened member
and, as a result, Marylee missed the school bus. Repeated • Applying knowledge of the relationship of family diversity to family
attempts by the school system to address the problem failed. strengths, family style, and family functioning
With the community/public health nurse's help, Marylee's • Identifying the interrelationships of multiple family problems while
mother asked an older neighbor who rose early to call her helping the family choose a priority for intervention
every morning at 7:30. With the older neighbor's support, • Intervening with a family group with frequently changing Â�membership
the mother began to see herself as able to parent Marylee, or attendance
and, as a result, Marylee's school Â�attendance improved. • Communicating hopefulness
• Brokering contacts with multiple agencies and services available to
the family
In this family, the external support system was first strength-
• Maintaining an awareness of one's own feelings of helplessness
ened to help Marylee's mother improve her organization. The
and frustration
nurse might have had the neighbor call Marylee directly to • Helping the family perform activities that add to a sense of power
awaken her, but that would have bypassed the responsibility of and competence
the mother to parent her own child.
KEY IDEAS
1. Multiproblem families include families in crisis and families Strategies to counteract this failure include locating (track-
with chronic problems. ing down) the family, creating trust, and building strength
2. Some families can be supported through a crisis and will (Zerwekh, 1992).
regain their previous level of health. Strategies for working 7. A community/public health nurse makes choices about
with families in crisis include identifying stressors, refram- the level of intervention (individual, family subsystem,
ing appraisals, locating resources, and considering alterna- family as a unit, or family within the environment) based
tive ways to cope. on the family assessment and on practical limitations to
3. Families at risk for multiple chronic problems include practice.
vulnerable families, families with negative choices, fami- 8. A community/public health nurse considers the level of
lies in poverty, and families with disturbances in internal family functioning when making choices about realistic
dynamics. goals and specific interventions.
4. All families have some strengths, which must be tapped for 9. Realistic goals in families with multiple, chronic problems
intervention to be successful. include reducing stressors, strengthening the support sys-
5. Resilience is a quality of individuals and families that helps tem, improving family organization, introducing more
them rebound and deal with intense stress and everyday life. adaptive coping behaviors, and altering the environment.
Some protective factors associated with resilience include The goals of nursing contact do not include trying to “fix”
internal and external social support, boundary setting, tak- the family.
ing charge, and communication (Lietz, 2007). 10. Maintaining and communicating hope are especially
6. Nurse–family interventions may be influenced by the fam- important for community/public health nurses working
ily's previous negative contacts with the health care system. with multiproblem families.

Working with a Multiproblem Family
The Walker family consists of Edna, 29; William, 31; and their children, care unit. He had problems with his lungs and has subsequently been
Mary, 13; Sean, 9; and Mark, 3½. The Walkers are a struggling urban small for his age and has frequent colds and illnesses. The family
family living in their third apartment within the last 2 years. William has Â�managed at that time with the help of Edna's mother and father and
a high school education but no formal job training. He has supported her neighbors. Edna's father drove her to the hospital and Edna's mother
the family off and on with his job as a house painter. He has a back watched her children. William was working at the time, and the Â�family
injury and works sporadically because of his physical problems and the had a health insurance plan. They pulled through that illness with a
limited availability of work. Their average annual income is $31,000. sense of pride about their ability to manage it and a commitment to
The Walkers’ financial situation adds to the constant stress within the each other.
Â�family. Although the Walkers care for each other, their interactions are
usually disorganized and tense. Assessment
Mr. and Mrs. Walker were married when he was 18 and she was After receiving the referral, the community/public health nurse makes
16. Edna has an eighth-grade education, having dropped out of school an appointment to meet the Walkers; but when she arrives, no one is
after experiencing learning problems. She is a very concrete learner, home. She later learns that the Walkers had gone to the clinic for Mark's
has never worked, and has no job skills. Edna is currently 70â•›lb over- asthma appointment but that their automobile would not start on the
weight and smokes approximately 1 pack of cigarettes a day. She way home. At a second scheduled appointment, the Walkers again are
spends most of her day caring for the children or talking on the not there. Later, by telephone, she finds out that Edna's mother fell and
Â�telephone with her mother, who lives about 15 miles away. Edna's had to be taken to the hospital. The appointment is rescheduled. Edna
mother tries to be Â�supportive of the family but is getting older. She is careful to be there on this occasion and has obviously attempted to
used to baby-sit and help the family out financially but has not been clean up the house and make herself presentable. She has on lipstick
able to do so recently because of her own health problems and her and has carefully combed her hair and set out cookies and coffee for
lack of transportation. the nurse.
Mary, in the seventh grade, is a help to her mother. She has few out- Mary, who is home from school that day with a cold, pops in and out
side interests other than watching television and occasionally cooking. of the room during the visit. The nurse meets with Edna, William, and
Her younger brother, Sean, has been diagnosed with a learning disabil- Mark; Sean is at school. William has just returned from trying to get
ity and is failing in school. Mark, a preschooler, has asthma in addition temporary work, but he has been unsuccessful.
to elevated levels of lead in his blood. During the initial visit, the community/public health nurse asks
The family's health problems require frequent clinic appointments, Â�questions, completes a family assessment form (BoxÂ€14-5), and has
but the Walkers’ automobile is often nonfunctional. Relations with the Â�family begin to help her construct a genogram (FigureÂ€14-1). She
the health care clinic are strained because of the clinic's perception is also observing the family's interactions and the environment. She
that the Walkers are noncompliant. The stress of making it to these inquires about connections with community resources through use of an
appointments leads to frequent cancellations and sporadic contact Â�eco-map (FigureÂ€14-2, A).
with the clinic. Earlier, when the community health nurse first entered the house,
This family has survived an earlier bout with illness. When Mark was William was in the bedroom. Edna yells for him to come out several
born, he was premature and spent 2â•›months in the neonatal Â�intensive times and finally goes to the bedroom to get him, complaining about
Continued
BOXÂ€14-5â•…â•‡FAMILY ASSESSMENT GUIDE WITH DATA OF THE WALKER FAMILY

I. Identifying Data
Name:â•‡ Walker
Address:
Phone:
Household members (relationship, gender, age, occupation, education):
William Father M 31 Part-time house painter High school
Edna Mother F 29 Homemaker Eighth grade
Mary Daughter F 13 Student, seventh grade
Sean Son M 9 Student
Mark Son M 3½
Financial data (sources of income, financial assistance, medical care, expenditures):â•‡ $31,000 per year income; no health insurance; applied
for medical funds for children with special needs for Mark's medicines
Ethnicity:â•‡ English/Irish descent
Religion:â•‡ None practiced
Identified client(s):â•‡ Mark
Source of referral and reason:â•‡ Asthma clinic for repeated failure to keep appointments
II. Genogram (see FigureÂ€14-1)

Include household members, extended family, and significant others
Ages or date of birth, occupation, geographic location, illnesses, health problems, major events
Triangles and characteristics of relationships
III. Individual Health Needs (for each household family member)

Identified health problems or concerns:â•‡ William: back injury with pain; Edna: concrete learner, obese, smokes; Mary: little socialization; Sean:
school failure
Medical diagnoses:â•‡ Sean: learning disability; Mark: asthma, elevated lead level
Medications and immunizations:â•‡ Mark up to date on immunizations; no asthma medications in house; and prescriptions not refillable
Physical assessment data:â•‡ Mark: temperature: 98.4â•›°F; pulse: 86 beats/min; respirations: 18 breaths/min; breath sounds clear; no Â�wheezing; good hydration
Emotional and cognitive functioning:â•‡ Mark: age-appropriate play
Coping:â•‡ Strained relations with asthma clinic caused by unkept appointments; Edna frightened by Mark's asthma
Sources of medical care and dental care:â•‡ None, except well-child clinic and asthma clinic for Mark
Health screening practices:â•‡ Not explored
IV. Interpersonal Needs

Identified subsystems and dyads:â•‡ Spousal, parent-child, sibling
Prenatal care needed:â•‡ Not applicable
Parent–child interaction:â•‡ Little concern re: Sean's school failure
Spousal relationships:â•‡ Married 13â•›years; traditional spousal roles clear
Sibling relationships:â•‡ “Get along OK”
Concerns about elders:â•‡ Maternal grandmother (gm) recently ill and hospitalized with a fall
Caring for other dependent members:â•‡ Not applicable
Significant others:â•‡ Not applicable
BOXÂ€14-5â•…â•‡ FAMILY ASSESSMENT GUIDE WITH DATA OF THE WALKER FAMILY—CONT'D

V. Family Needs
A. Developmental
Children and ages:â•‡ 13, 9, 3½
Responsibilities for other members:â•‡ Mary helps mother; has few outside interests
Recent additions or loss of members:â•‡ None

Other major normative transitions occurring now:â•‡ None
Transitions that are out of sequence or delayed:â•‡ Development of personal interests and peer relationships for Mary
Family proceeding at expected sequence:â•‡ Might use anticipatory guidance

Tasks that need to be accomplished:â•‡ Learning successes for Sean; socialization for Mary; school readiness for Mark
Daily health promotion practices for nutrition, sleep, leisure, child care, hygiene, socialization, transmission of norms and values:â•‡ Adequate
hygiene; maternal gm was only baby-sitter; nutrition not explored
Family planning used:â•‡ Tubal ligation
B. Loss or Illness
Nonnormative events or illnesses:â•‡ Maternal gm in hospital
Reactions and perceptions of ability to cope:â•‡ Edna worried about care of her mother following hospital discharge
Coping behaviors used by individuals and family unit:â•‡ Cannot visit because of lack of transportation
Meaning to the family:â•‡ Threat

Adjustments family has made:â•‡ None yet, seems paralyzed
Roles and tasks being assumed by members:â•‡ Edna assuming most responsibility, Mary's responsibility increased
Any one individual bearing most of responsibility:â•‡ Edna

Family idea of alternative coping behaviors available:â•‡ No ideas right now
Level of anxiety now and usually:â•‡ High
C. Resources and Support (see FigureÂ€14-2, A)

General level of resources and economic exchange with community:â•‡ Low
External sources of instrumental support (money, home aides, transportation, medicines, etc.):â•‡ Unreliable care; chronic financial stress; able
to buy only necessities
Internal sources of instrumental support (available from family members):â•‡ Maternal gm baby-sat before her illness
External sources of affective support (emotional and social support, help with problem solving):â•‡ None
Internal sources of affective support (who in family is most helpful to whom?):â•‡ Maternal gm
Family more open or closed to outside?â•‡ Does not actively seek resources
Family willing to use external sources of support?â•‡ Yes
D. Environment
Type of dwelling:â•‡ Third-floor apartment; walk-up; dirty yard and stairs
Number of rooms, bathrooms, stairs; refrigeration, cooking:â•‡ Two bedrooms, one bath; working stove, refrigeration, heating; decorated; cluttered
because of inadequate storage
Water and sewage:â•‡ Public
Sleeping arrangements:â•‡ Parents together; boys together; Mary on folding bed in living room
Types of jobs held by members:â•‡ Painter
Exposure to hazardous conditions at job:â•‡ Yes—paint and height
Level of safety in the neighborhood:â•‡ Moderate crime and air pollution
Continued
BOXÂ€14-5â•…â•‡ FAMILY ASSESSMENT GUIDE WITH DATA OF THE WALKER FAMILY—CONT'D

Level of safety in household:â•‡ Peeling paint in hallway of 60-year-old building; unlit stairs; working smoke detector; no pets; dust could be
allergen for Mark
Attitudes toward involvement in community:â•‡ Only recently moved to apartment; “keep to themselves”
Compliance with rules and laws of society:â•‡ Very compliant
How are values similar to and different from those of the immediate social environment? This family has higher expectations for self than for
neighbors; expects members to follow rules and contribute to each other
E. Internal Dynamics
Roles of family members clearly defined?â•‡ Yes
Authority and decision-making rest where?â•‡ Health care with Edna
Subsystems and members:â•‡ See Interpersonal Needs section
Hierarchies, coalitions, and boundaries:â•‡ Mary helpful to Edna; spouses’ activities are goal directed, and roles complement each other
Typical patterns of interaction:â•‡ Expression of feelings by children; Edna blames William
Communication, including verbal and nonverbal:â•‡ Spouses: some intense verbal interactions; Edna: more vocal, complains
Expression of affection, anger, anxiety, support, etc.:â•‡ Anxiety, hope
Problem-solving style:â•‡ Deal with immediate needs
Degree of cohesiveness and loyalty to family members:â•‡ Cohesive, caring, loyal, “stick together”
Conflict management:â•‡
VI. Analysis
Identification of family style:â•‡ Disorganized (see ChapterÂ€13)
Identification of family strengths:â•‡ Ability to share; commitment to each other
Identification of family functioning:â•‡ Tapia level II
What are needs identified by family?â•‡ Edna: care for her mother, Mark's asthma, better housing; William: work, car repair
What are needs identified by community/public health nurse?â•‡ See problem list in Analysis section of Nursing Process in Practice box
Hospitalized
from fall
Grew up in orphanage 8th grade education

High school education Wm. Edna Learning problems
Back injury 31 29 Overweight
Sporadic work as painter Smokes
Mary Sean Mark

13 9 31/2
"Fine" Learning Asthma
School absences disability Elevated blood lead
Failing in
school
KEY OF STANDARD SYMBOLS

Male A Adopted child Separation
Female Pregnancy Twins (this case boys)
Marriage relationship Miscarriage or abortion Intensity of relationships:

overclose
Parent-child
relationship Death Conflictual
D
Relationship Divorce Distant
FIGUREÂ€14-1â•‡The Walker family genogram. (Adapted from Cain, A. [1981]. Assessment of family
Â�structure. In J. Miller & E. Janosik [Eds.], Family-focused care [p. 117]. New York: McGraw-Hill.)
Vocational
rehab
Edna's Edna's
mother mother
Job Job
Wm. Edna Wm. Edna
Child
daycare
Mary Sean Mark Mary Sean Mark
Dept. of
Social C/public
Services health
nurse
School Clinic School Clinic

School School
A B
KEY
Strong connection
Tenuous connection
Stressful connection
Direction of energy flow
FIGUREÂ€14-2â•‡A, Eco-map of Walker family on first home visit. B, Eco-map of Walker family
after 6â•›months of nursing care. (Adapted from Hartman, S. [1978]. Diagrammatic assessment of family
Â�relationships. Social Casework, 59, 470. Reprinted with permission from Families in Society [http://www.Â�
familiesinsociety.org], published by the Alliance for Children and Families.)
his behavior to the nurse. They sit on opposite sides of the room, with William:
Edna doing most of the talking. Mark runs back and forth between them, • Impaired physical mobility related to previous back injury as evi-
carrying a piece of paper torn from the telephone book on which he is denced by (AEB) decreased range of motion (ROM)
coloring. • Chronic pain related to previous back injury AEB complaints of physi-
The apartment, which is in a poorer section of the city, is on the third cal pain and decreased physical activity
floor of an older building, with trash in the yard. The stairs up to the
apartment are dirty and unlit, and the paint is peeling. The Walkers’ Edna:
apartment is cheery, with some curtains and knickknacks. Space • Imbalanced nutrition: more than body requirements related to
appears to be a problem because some of the pots and pans are stored excessive food intake AEB obesity
in a corner in the front room, the kitchen table is covered with bills and • Ineffective health maintenance related to denial of effects of smoking
schoolbooks, and the family shares two bedrooms. AEB continuation of smoking and “I don't feel any effects from smok-
ing now” statement
Analysis • Deficient knowledge of health maintenance and effects of smoking
On discussing the situation with the family, the community/public health related to cognitive limitation/learning disorder and lack of teaching
nurse identifies the following family health needs: the family is experi- AEB continuance of smoking around son with asthma
encing demands from normal growth and development, is coping with
illness and the external stresses of a hard job market and the family's Mary:
environment, and has inadequate resources. The nurse does not believe • Impaired social interaction related to lack of transportation and
that severe disturbances in family dynamics exist but is concerned nearby friends AEB self-reported lack of friendships
about parenting style and communication in the family. Family strengths • Delayed development AEB delay in performing developmental skills
include the ability to share and a commitment to make things work out typical of age group
for all members. The family has demonstrated some resilience since
Mark's birth but has lost some resources and has more stressors to deal Sean:
with since then. The nurse identifies the family style as disorganized but • Deficient knowledge of educational subjects related to cognitive
somewhat receptive and the family level of functioning as Tapia level II impairment/learning disorder AEB failing grades in school
(see ChapterÂ€13). • Situational low self-esteem in response to learning disorder diagno-
She compiles the following list of problems specific to individuals, sis related to failing grades AEB statements such as “It's not worth
subsystems, the family, and the environment: trying to learn. I can't learn anyways.”
Continued
Mark: Long-term goals include (1) safe care for Edna's mother, (2) stabilization
• Ineffective airway clearance related to tracheobronchial narrowing of the family income, (3) appropriate treatment and family response for
AEB wheezing Mark's asthma, and (4) a move to a dwelling that has no chipping paint.
• Poisoning related to flaking, peeling paint in the presence of young Goals that the community/public health nurse would like to achieve
children AEB increased lead levels in blood but that are not yet seen as needs by the family include further assess-
• Risk for delayed development related to lead poisoning ment and improved family response to Sean's learning disability, sup-
port for Mark's developmental functioning, and increased socialization
Subsystems: for Mary. Edna's smoking and weight are also targets of concern, as is
• Concern about Edna's mother's health and well-being the family's repertoire of coping strategies.
• Expenditure of resources for Edna's mother following hospitalization
Implementation
Family Unit:
Because the family is functioning at Tapia level II and the family style is
• Compromised family coping
considered disorganized, the community/public health nurse alters her
• Readiness for enhanced resilience
approach to the family. She takes special care to set realistic short-term
• Limited social contact
goals that can be achieved within a week. She is aware that the family style
Environment: may necessitate frequent changes in goals and plans and is careful to keep
• Residence: presence of environmental hazards (lead) her contract with the family clear and reasonable on both sides. Her goal is
• Income: difficulty buying necessities and no health insurance to take small steps so that the family can begin to see some successes and
• Neighborhood: moderate crime and pollution to pay special attention to pointing out these successes and what the fam-
Edna and William are asked their perceptions of what is happen- ily did to achieve them. She will shape and role-model behaviors toward
ing and what they would like to work on. William is most concerned more successful coping. However, crises must be managed first. The fam-
with finding work and keeping the automobile running. Edna is wor- ily developed a sense of coherence and feeling of competence after Mark's
ried about her mother and how she will cope by herself when she is birth. Helping the family restore these feelings is important. Finding more
released from the hospital and about Mark's asthma, which frightens connections with sources of relational support within the community is also
her. She is less concerned about Sean's school problems or Mark's essential. With this family, the unpredictable should be expected and must
lead poisoning and thinks Mary is doing fine. Her wish for the family be considered as the family moves toward maintaining itself.
is for them to get their own house with a yard in which the children
can play. When asked how she and William get along, she just shrugs Evaluation and Outcomes
her shoulders. After 6â•›months, the nurse and the family are able to see some successes.
William has been evaluated by the vocational rehabilitation department
Planning and is waiting to hear about retraining as a security guard. Edna has
Before formulating a plan of care, the nurse analyzes the data and heard about a program that trains daycare mothers and is considering
tries to determine priorities. She is concerned about what the Â�family taking a job herself. Her mother fell again and has been placed in a reha-
identifies as its needs and what she and the health care system bilitation nursing home that is on the opposite side of the city. The family
can realistically help with, and about setting some realistic goals. cannot get to the nursing home very often but did visit her near Christmas.
Together, she and the family come up with the following short-term Mark has been reevaluated at the asthma clinic, and medications have
goals: been prescribed. Edna gives the medicine more regularly now that the
• To contact the health care system about Edna's mother within the nurse has taught her how it helps prevent asthma attacks. Edna says
next 3â•›days and determine what plans are being made for her care that she is more comfortable now because she can recognize these
after discharge attacks earlier. She usually goes outside to smoke but has not cut down
• To arrange for alternative transportation for Mark and Edna to get to on the number of cigarettes. Overall, the family is now connected with
the clinic for next week's appointment more community resources (see FigureÂ€14-2, B).
• To call the state vocational rehabilitation department to get informa- Although little has changed with Mary or Sean, the state department
tion for William about job retraining of social services is finding funds to help move the family into new hous-
• To apply for the state Children's Health Insurance Program (CHIP) for ing because of Mark's lead poisoning. This housing does not have a
the three children yard, so a home with a yard will remain Edna's dream for a while longer.
1. In what ways do family environment, family dynamics, Do you agree that dysfunction or inadequacy in the family
and family stress influence how an individual will cope and should be considered when someone is being judged for a
behave? What has been the greatest influence for you? crime? Why, or why not?
2. Pick a major social problem in which you already have 4. In a small group, discuss the ways in which your family has
some interest (e.g., pollution, climate change, poverty, teen coped with problems in the past. How much pileup of stress
Â�pregnancy, drug abuse, violence). In what ways might a com- was occurring at the time? What resources did you use? What
munity/public health nurse intervene with regard to this were your coping strategies? Would you use these strategies
environmental issue to advocate a change for family health? again? What would have helped your family at that time? Can
3. Read your local newspaper, paying particular attention to you envision help from a community/public health nurse?
the events and crimes occurring that day. How many of these Why, or why not?
news items are related to symptoms in families—that is, fami- 5. Role-play a visit of a community/public health nurse to a
lies in which the family unit is unable to support its members? family that has multiple problems. Have someone set up the
situation so that no matter what you do, the situation seems 7. Identify which family you would be more comfortable work-
unresolvable. Break and discuss your feelings and reactions ing with—a family in crisis or a family that has chronic prob-
to this situation. lems. Why?
6. Role-play the same visit with the same family, but this time, 8. Spend some time with magazines, scissors, and glue.
have the director set up the situation so that the family mem- Compose a collage that depicts the life of a family with which
bers are confidentially instructed to feel some hope and will you are interacting in the community. What does the collage
attempt to work on a little piece of the issues. Break and dis- evoke in you and in others in your group?
cuss your feelings and reactions to this situation. What was 9. Locate a family that has experienced a particular hardship.
different? Note how that family copes with life now.

Information about each of the following organizations is found National Council on Child Abuse and Family Violence: http://
on its website: www.nccafv.org/
Asian American Legal Defense and Education Fund: http:// Nurse-Family Partnership: http://www.nursefamilypartnership.org/
aaldef.org/ Office for Civil Rights: http://www2.ed.gov/about/offices/list/ocr/
Child Welfare League of America: http://www.cwla.org/ index.html
Consumer Credit Counseling Services: http://www.nfcc.org/ Office of Head Start: http://www.acf.hhs.gov/programs/ohs/
The Finance Project: http://www.financeproject.org/ U.S. Department of Health and Human Services: http://www.
The Incredible Years: Parents, Teachers, and Children Training hhs.gov/
Series: http://www.incredibleyears.com/ The following are national toll-free hotlines:
Mixed Folks: http://www.mixedfolks.com/mfc/Welcome.html Child Abuse Hotline: (800) 422-4453 [(800) 4 A Child]
National Association for the Advancement of Colored People: Domestic Violence Hotline: (800) 799-7233 [800-799-SAFE]
http://www.naacp.org/content/main Elder Abuse (Victim Assistance) Hotline: (800) 879-6682
WEBSITE
STUDY AIDS
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U N I T
4
Community as Client
15 Community Assessment
16 Community Diagnosis, Planning, and Intervention
17 Evaluation of Nursing Care with Communities
392
CHAPTER
15
Community Assessment
FOCUS QUESTIONS
What is community-focused nursing? What is a general systems framework for assessing
How are communities defined? communities?
What are the critical components of a community? What are the factors to consider in assessing the health of
How are groups and aggregates considered different types of communities?
populations? What are the sources of data regarding communities?
What are different types of community boundaries? What are the approaches to community assessment?
What are the goals of communities? How do community/public health nurses analyze
What are the frameworks for assessing communities? community data?
CHAPTER OUTLINE
Community Assessment: Application to Community/Public Tools for Data Collection
Health Nursing Practice Personal Observation
Community Defined Existing Data Sources: Secondary Data
Literature Review Surveys
Critical Components of a Community Interviews with Key Informants
Basic Community Frameworks Meetings with Community Groups
Nursing Theories Applicable to Community Geographical Information Systems
Assessment Approaches to Community Assessment
Nursing Frameworks for Community Assessment and Comprehensive Needs Assessment Approach
Practice Problem-Oriented Approach
Systems-Based Framework for Community Assessment Single Population Approach
Overview of Systems Theory Familiarization Approach
Components to Assess Analysis
KEY TERMS
Aggregate Community competence Phenomenological
Asset Community resiliency Population
Census tract Geopolitical Population “at risk”
Community Group Target population
Community capacity Healthy community
The community/public health nurse is concerned with the Healthy communities have “environmental, social, and
health of the individual, the family, populations, and the com- Â�
economic conditions in which people can thrive” (Quad
munity (American Nurses Association [ANA], 2007). This Council of Public Health Nursing Organizations, 1999, p. 3).
unit focuses on applying the nursing process with the com- A healthy community is one in which residents are happy with
munity as client. What is the role of the nurse in population- their choice of location and which exhibits characteristics that
focused nursing? What does it mean to be a nurse who is would draw others to the location. The majority of commu-
responsible for the health of a community? Where does the nity residents are relatively functional for their age and health
nurse start in considering community? What is a healthy, com- status. What are other characteristics of a healthy community?
petent community? Kotchian (1995) suggested that a healthy community would
393
394 CHAPTER 15â•… Community Assessment
be a safe Â�community with little crime, supportive interaction it functions. Assessment tools provide a framework, a method
between families and neighborhoods, a healthy environment of Â�systematically gathering important information to help the
(e.g., clean air, clean water, safe food), good schools, available nurse and other health care professionals know the community.
and good quality health care services, and a sense of commu- How does the nurse become acquainted and familiar with
nity cohesion. Green and Kreuter (2005) identified affordable a community? One way is to read about a community throÂ�
housing and the availability of employment as prerequisites for ugh newspapers, community histories, and objective statisti-
healthy communities. cal reports. Another way is to visit the community, talk to the
Besides these factors that immediately and obviously affect people, and attend meetings—that is, be with the people. A visit
health, many social circumstances and other less tangible issues to or a walk or a drive through the community provides a feel
affect community living. For example, high crime rates and for the community that cannot be obtained from just reading
high levels of poverty in a neighborhood can seriously affect about it. The walk or drive-through is frequently referred to as
the health and welfare of residents. Ervin (2002) suggested that a windshield survey. Being in the community allows the nurse to
a healthy economy is key to a functional, healthy population. subjectively experience a community and to learn how commu-
Although difficult to quantify, most people can identify char- nity members experience their community.
acteristics of a healthy community that would influence their Take a moment to reflect on this scene:
decision to reside there (Box 15-1).
You are driving down a city street on a warm, sunny day. The
row houses you see are in various physical states; some are
COMMUNITY ASSESSMENT: APPLICATION TO painted and appear to be cared for, and others are in disre-
COMMUNITY/PUBLIC HEALTH NURSING PRACTICE pair and dilapidated; no grass is growing in the yards, and
the street is littered with trash. People are sitting on the steps
Assessment, the first step of the nursing process, forms the foun- and front porches, talking and watching the traffic pass by.
dation for determining the client's health, regardless of whether Several young female adolescents are sitting on the steps
the client is an individual, a family, or a community. Nurses holding infants. Children of different ages are playing on the
gather information by using their senses, as well as their cog- sidewalk and in the streets. The neighborhood is alive with
nition, past experiences, and specific tools. These data are ana- noise and activity. As you continue your drive, you enter an
lyzed to make diagnoses about the community's health status area in which the houses are detached. The houses have small
and allow the nurse to answer the question, “How healthy is this yards with green grass that are carefully maintained, and the
community, or what are its strengths, problems, and concerns?” streets are lined with lovely flowering trees. A few adults are
The assessment process affords nurses the opportunity working in their yards; a few children are playing in a nearby
to experience what it is like to be in the community, to get to park. The scene is very quiet.
know its people and their strengths and problems, and to work
with them in planning and implementing programs to meet What is it like for residents who live here? Would you like to
their unique needs. Just as all individuals and families are dif- live here? What kinds of things would lead you or others to want
ferent, communities, too, are different. What makes one com- to live here?
munity different from another? To understand, nurses must In the preceding example of community, two neighbor-
get to know the community, its people, its purpose, and how hoods are presented, geographically close but different.
Who lives in the two neighborhoods? What would it be like
to live in these communities? What would it be like to be a
BOXÂ€15-1â•…â•‡COMPONENTS OF HEALTHY community health nurse responsible for the health of these
COMMUNITIES communities? What type of nursing care do you think this
community needs?
• Low crime rates Before we go any further, we need to define community. What
• Good schools is the meaning of this term? Does community mean only the
• Strong family life neighborhood in which one lives, or does it have other meanings?
• Robust economy, good jobs
• High environmental quality (clean air, water)
• Accessible and quality health services COMMUNITY DEFINED
• Adequate housing
If you were to ask five people to define the word community, you
• Civic involvement
would probably get five different answers: “a place where people
• Nice weather
• Good transportation (roads, public transportation) dwell,” “a group of people with common interests,” “a place with
• Wide variety of leisure activities specific boundaries.” Some people may speak about an aca-
• Exposure to the arts demic community, a religious community, or a nursing com-
• Reasonable taxes munity, and others may define community as the neighborhood
or city in which they live. Depending on the circumstances, each
Data from Braverman, B., Crews, V., Lee, A.C., etÂ€al. (2010) The best definition is correct.
places to retire. Money, 39(7), 64-80; Perdue, W. C., Stone, L. A.,
In this text, community is defined as an open social
& Gostin, L. O. (2003). The built environment and its relationship to
the public's health: The legal framework. American Journal of Public
Â�system that is characterized by people in a place who have
Health, 93(9), 1390-1394; Garb, M. (2003). Health, mortality and common goals over time. The term is applicable to a variety
housing: The “Tenement Problem” in Chicago. American Journal of of Â�situations. A community includes a place and groups or
Public Health, 93 (9), 1420-1430. aggregates. An aggregate is any number of individuals with at
CHAPTER 15â•… Community Assessment 395
least one common characteristic (Williams, 1977). The terms Place

population group and aggregate are synonyms for population Traditionally, communities were described in relation to geo-
(Williams, 1977). A population is a collection of individuals graphical area. However, population aggregates such as older
who share one or more personal or environmental charac- adults, the poor, people with acquired immunodeficiency syn-
teristics, the most common of which is geographical location drome (AIDS), or any population in which the members share
(Schultz, 1987). How a person defines community depends one or more common characteristics, goals, or interests are
on the situation and that person's purpose. To community sometimes used to identify a community for assessment pur-
health nurses working for a county health department, com- poses. Therefore, communities may be defined by one of two
munity might mean a geographical area and its residents designations: (1) geopolitical (spatial) or (2) phenomenological
(population) such as the county or health district to which (relational). Figures 15-1 and 15-2 illustrate some geopolitical
they are assigned. This description is the classic definition of and phenomenological communities.
community. Nurses working with the homeless, older adults, Geopolitical. The geopolitical community is a spatial
or a special interest group (e.g., smokers) may define com- designation—a geographical or geopolitical area or place. This
munity as people with common characteristics (aggregate) view is the most traditional in the study of community.
within a specific place. Geopolitical communities are formed by either natural or
human-made boundaries. A river, a mountain range, or a val-
Literature Review ley may create a natural boundary; for example, the Chesapeake
Community health literature offers a variety of defini- Bay separates Maryland into the eastern and western shores.
tions.Â€ Behringer and Richards (1996) described community Human-made boundaries may be structural, political, or legal.
as a web of people shaped by relationship, interdependence, Streets, bridges, or railroad tracks may create structural bound-
mutual interests, and patterns of interaction. Shamansky and aries. City, county, or state lines create legal boundaries. Political
Pesznecker (1981) provided an operational definition of com- boundaries may be exemplified by congressional districts or
munity considering the following three factors: (1) who (people school districts.
factors), (2) where and when (space and time factors), and (3) Why does a community/public health nurse need to be con-
why and how (for what purpose?). Ervin (2002) stressed that cerned about geopolitical boundaries? A geopolitical view of com-
community assessments always occur at a particular time, for munity focuses the nurse's attention on the environment, housing,
example, July 2011, or during the year 2012. transportation, education, and political process subsystems. All of
Anderson and McFarlane (2010) define community in terms these elements are related to geographical locations as well as to
of a core dimension (people) and eight subsystems: (1) physical the population composition and distribution, health services, and
environment, (2) education, (3) safety and transportation, (4) resources and facilities. Statistical and epidemiological studies are
politics and government, (5) health and social services, (6) com- frequently based on data from specific geopolitical areas.
munication, (7) economics, and (8) recreation. Phenomenological. Most people initially think of commu-
Other authors define community by describing types or cat- nity in terms of geographical location. Another way of thinking
egories. Communities may be geographically or socially bound about community is in terms of the members' feeling of belong-
(Hawe, 1994); categorized as emotional, structural, or func- ing or sense of membership, rather than geographical or political
tional (Archer, 1985); or defined in terms of relational and ter- boundaries. Such a community is a Â�phenomenological com-
ritorial bonds (Turner & Chavigny, 1988). munity, a relational rather than a spatial designation. A sense of
One of the most comprehensive definitions of the term com- place emerges through the members’ awareness of their experi-
munity found in community health literature was formulated ences together. This place is more abstract than a geopolitical
by Higgs and Gustafson (1985): “A community is a group of place but is just as real to its members. People in a phenom-
people with a common identity or perspective, occupying space enological community have a group perspective that differenti-
during a given period of time, and functioning through a social ates them from other groups. A group consists of two or more
system to meet its needs within a larger social environment.” people engaged in an interdependent relationship that includes
This definition is most closely related to the concept of commu- repeated face-to-face communication. A group's identity may
nity discussed in this text. be based on culture, beliefs, values, history, common interests,
characteristics, or goals. Examples of phenomenological com-
Critical Components of a Community munities include populations of people with common inter-
For the purpose of this text, a community may be defined as a ests such as a common religious conviction or professional or
community if three critical components or defining character- academic interest; with common beliefs such as beliefs about
istics are included: (1) people, (2) place, and (3) social interaction human rights including women's rights or racial equality; or
or common characteristics, interests, or goals. All communities with a common goal such as Students Against Drunk Driving
contain all three of these components. (SADD), whose common goal is to decrease alcohol-related
accidents among students who drive.
People Another example of a phenomenological community is a
Population is the most obvious of the necessary community community of solution. This type of phenomenological commu-
components. The number of people included in the community nity has special significance for health planning. The National
depends on the other two critical components. A population Commission on Community Health Services (1966) suggests
can be a relatively small number (a group of 20 pregnant ado- that when health services are considered, the boundaries of each
lescents enrolled in a clinic) or a large number of people (a city community are established by the boundaries within which a
of one million). The ages, gender, race/ethnicity, religion, occu- problem can be identified, dealt with, and solved. A community
pations, and socioeconomic status may be similar or diverse. of solution includes (1) a health problem shed (i.e., an area that
FIGUREÂ€15-1â•‡ Geopolitical communities. In geopolitical communities, place is designated by a

geographical or political boundary. The people who live, work, learn, and play in the community
constitute the population. In most suburban and urban geopolitical communities, the individu-
als know only some of the residents on a face-to-face, personal basis. In less densely populated
rural areas, most people may know each other on a personal basis. (© 2011 Photos.com, a division
of Getty Images. All rights reserved. A, Photos.com #200393342-001)
has similar health problems) and (2) a health marketing area this interaction varies from community to community depend-
(i.e., an area that has similar solutions to the problem or an ade- ing on needs and values. In a geopolitical community, this
quate supply of health resources to meet the problem). interaction may go beyond talking to one's neighbor and may
For example, an oil spill in the Chesapeake Bay would affect include interactions with agencies and institutions within the
more than one county. Parts of several counties in Maryland community. In a phenomenological community, this attribute
and Virginia may be affected. All of the communities affected is inherent. A phenomenological community exists because
become the health problem shed. All of the communities that of a common interest or feeling of belonging (Dreher &
join together and pool their resources to meet the need create Skemp, 2011).
a health marketing area. Figure 15-3 illustrates one city's com- Each of us lives in a geopolitical community, but we may be
munities of solution. The concept of a community of solution is members of several phenomenological communities. Figure 15-4
especially important in coordinating health care and decreasing illustrates one individual's community membership.
duplication and fragmentation of services.
Social Interaction or Common Interests, Goals, BASIC COMMUNITY FRAMEWORKS

andÂ€Characteristics Now that we have defined the concept of community, how
Communities, similar to families, have their own Â�patterned do you approach or study the community as a client? There
interaction among individuals, families, groups, and Â�organizations; are many theoretical approaches to communities. Perspectives
FIGUREÂ€15-2â•‡ Phenomenological communities. In phenomenological communities, place is des-

ignated by a sense of belonging among its members. Although all human communities exist in
a physical place, the members of a phenomenological community are bound together by their
interpersonal connectedness rather than by geography. For example, individuals may belong
to the U.S. military community, even though they live throughout the entire world. A sense of
belonging occurs in phenomenological communities such as clubs, schools, gangs, senior cen-
ters, businesses, and churches and other religious organizations.
on Â� community come from diverse fields of study, includ- Hanchett, 1988). Many nursing theories view the commu-
ing anthropology, sociology, epidemiology, social psychol- nity as the environmental system influencing individuals and
ogy, social planning, and nursing. Community/public health families.
nurses have adapted and used theories from other disciplines. Only a few nursing theories view the community as client
Several frameworks that are especially helpful in community/ (Hamilton & Bush, 1988). Goeppinger and colleagues (1982)
public health nursing include developmental, epidemiological, proposed the development of a community assessment tool
Â�structural–functional, and systems Â�frameworks. BoxÂ€15-2 pro- using Cottrell's characteristics (1976) of a competent commu-
vides examples of frameworks used to study communities. nity as a framework. Community competence is based on eight
variables: (1) commitment, (2) self and other awareness and
Nursing Theories Applicable to Community Assessment clarity of situation definitions, (3) articulateness, (4) communi-
Most nursing theories were developed for individual cli- cation, (5) conflict containment and accommodation, (6) par-
ents, not communities (Alligood & Marriner-Tomey, 2010; ticipation, (7) management of relations with the larger society,
trade The theories of Johnson (1980), Roy (Roy & Andrews, 1999),
King (1981), Neuman (Neuman & Fawcett, 2002), and Watson
(Rafael, 2000) may be used to view the community as client. All
State line N theories are based, in part, on general systems theory. As dis-
lu tion
l
so cussed in ChapterÂ€1, general systems theory can be applied to
Medica
Medical
area
Center any social system, including a community. TableÂ€15-1 presents
unity of
a c views of the health of a community from the perspectives of

these nursing theories.
mm o
Nursing Frameworks for Community Assessment

nc
tio
and Practice
lu
ol
e
p
lin
Several frameworks have emerged that are either nurse devel-

ir A
t y
oped or used in public health practice. Two such frameworks

un
City
Co
X view the community as partner. Anderson and McFarlane's

W E (2010) Community as Partner model and Helvie's (1998)
b Energy Theory are nurse-developed frameworks. Both views
consider community as a network of interrelating relation-
n
t io
ships, characteristics, and supports. Using these models,
olu
W
at community/public health nurses act in partnership with
er ofs
co others (health care professionals and community members)
ntr
y unit
o l to address the community's health concerns (ANA, 2007).
com
m
Several models are based on the epidemiological framework.

Two of these models have particular value to community
health nurses: the GENESIS and MAPP models. All four mod-
S
els are influenced, to some degree, by systems theory and are
FIGUREÂ€15-3â•‡ Communities of solution for city X. Note that health briefly summarized in Box 15-3.
solution boundaries extend beyond city, county, and state lines.
A, Because of air currents, air pollution may be displaced to the
northwest. B, Because of the topography of the land, the water and SYSTEMS-BASED FRAMEWORK FOR COMMUNITY
sewage drain toward the southeastern portion of the state, which ASSESSMENT
constitutes another “health problem shed.” If the state and neigh-
boring states joined together to solve the problem, this would con- Although many useful strategies and frameworks are available
stitute a health marketing area. C, A similar principle holds true for community assessment, the assessment tool used in this text
for the medical trade area: the state emergency medical services is based on systems theory. A systems framework ensures that the
system territory includes part of the adjoining state to the north.
(Adapted from National Commission on Community Health Services.
dynamics within and external to each system, or community, are
[1966]. Health is a community affair. Cambridge, MA: Harvard Press.) identified and explored. In addition, the tool incorporates aspects
of the structural–functional framework (which identifies commu-
and (8) machinery for facilitating participant interaction and nity goals and analyzes internal community functioning) and the
decision making (Cottrell, 1976; Moorhead etÂ€al., 2008). Most of epidemiological framework (which analyzes the health status of
these characteristics of a competent community are community the people, or populations, within the community).
processes that can contribute to the inclusion and participation The advantage of this systems-based community assessment
of community members. tool is that it incorporates multiple frameworks simultaneously.
Social Health
Social Women’s Bowling Fairfield Community Center

League of Northern VA Weight Training Classes
Residence Social/Education
Farleigh Section of Fairfax Ladies Stock Club

Alexandria, VA
Religious
Social
First Baptist Church
of Arlington, VA Enterprise Book Club
Social Work Education

Den Mother: Cub Scout Private Consulting Business George Mason University
Troop 52 Wash, DC/VA/MD Area Graduate Program
FIGUREÂ€15-4â•‡ One person might be part of many communities in the course of daily life. (© 2011
Photos.com, a division of Getty Images. All rights reserved. Photos.com #87786476)
BOXÂ€15-2â•…â•‡BASIC FRAMEWORKS USED TOâ•›

â•› ASSESS COMMUNITIES
Developmental Framework Â�
susceptibility to injury, illness, or premature death. To improve health
Information about the community is collected from several points in time status and reduce risk in high-risk populations, nurses must work with
because communities change (McCool & Susman, 1990). Exploring the communities to identify and change, where possible, the factors that
history of the community allows the community health nurse to consider contribute to the populations’ vulnerability (ANA, 2007).
the past. For example, even if a community has inadequate resources Health programs and health policies aimed at reducing vulnerability to
for treatment of substance abuse, it may currently have many more poor health must address a broad range of factors. Refer to other chap-
resources than it did 5â•›years ago. ters for more in-depth discussions of risk factors: demographic factors
Changes in a community are related to the needs of the population, in ChapterÂ€7, socioeconomic and cultural factors in ChapterÂ€10, human
changes in the societal context, changes in the physical environment, behavior in ChapterÂ€18, high-risk populations in ChapterÂ€21, and environ-
and the history of the community itself. For example, the U.S. popula- mental factors in ChapterÂ€9. Unit VII addresses the subject of community
tion is currently aging; as the population ages, more health services are support for three vulnerable populations: persons with disabilities, chil-
needed for older adults. Loss of population within a community may dren, and older adults.
result in deterioration of existing buildings. An incorporated area may
change its form of governance from a city manager and council to a city Structural–Functional Framework
mayor and council. Structural–functional approaches to community emerged from anthro-
Single events and trends should be considered. Events may be linked pology and sociology. As social systems, communities have structures,
with the age of the community (e.g., the opening of the first local health processes, and functions. Structures are the parts of the community,
department office), with changes in the environment (e.g., the closing of and their organization and processes are the interactional patterns that
a business because of shifts in the national economy), and with unex- change with time. Functions are the purposes and actual outcomes that
pected situations (e.g., a flood) (McCool & Susman, 1990). Patterns of result from community structures and processes. This approach asks:
change may form trends. For example, trends in the health status of the What structures and patterns of human interaction foster community
community members are identified by analyzing epidemiological data goal achievement?
from several points in time. The following functions of the community can be identified:
• Creating and distributing goods and services
Epidemiological Framework • Providing socialization
An epidemiological perspective focuses on the health of the population. • Controlling social behavior
In this approach to community assessment, the nurse identifies persons • Providing a sense of identity and mutual support
who are at greater risk of illness, injury, disability, and premature death • Coordinating, controlling, and directing activities to attain other
so that targeted interventions aim at reducing the risk or preventing the community goals (Katz & Kahn, 1966; Warren, 1987)
problem (Merrill & Timmreck, 2006). These social functions of the community may be achieved through a
A recipe does not exist for identifying which epidemiological data should variety of social structures and processes. In other words, the same or
be collected about a community. As discussed in ChapterÂ€7, more data similar results can be achieved in different ways. Communities differ by
exist regarding mortality and the use of hospital services in the United degree of autonomy, presence of service areas, psychological identifica-
States than exist about morbidity and the use of primary care services. tion, and pattern of relationships (Warren, 1987).
However, we do know that health problems are not distributed evenly A large urban area would generally be more autonomous and pro-
among all persons but, instead, vary with human characteristics such as vide employment, a varied production of basic goods and services, its
age, gender, and socioeconomic status. Additionally, human behavior, own police authority, and a network of formal groups that socialize
quality of social support, and degree of environmental hazards are impor- and support the people. A suburban community might supply a strong
tant factors that contribute to the distribution of health and the well-being social network and support of its members but be less autonomous
among populations. Because of this fact, nurses who work with communi- with fewer opportunities for employment and no formal production of
ties must consider the different health needs among various aggregates goods. A rural community might have a strong social network and also
(e.g., older persons, pregnant women, workers in a specific occupation, provide some employment. Both suburban and rural communities may
poor individuals). The concept of aggregate/population is essential when be dependent on a larger urban area for the functions of production
using an epidemiological approach to community assessment. and distribution. A community may have multiple service areas. For
example, the suburban community may consist of two school districts,
Health Disparities and At-Risk/Vulnerable Populations one election district, and the market area of two hospitals. The degree
Epidemiological data can identify which populations in a community to which members identify with the locale may be strong or weak.
are at higher statistical risk for experiencing illness, injury, or prema- A community's relationship with other communities and the larger soci-
ture death. All populations have some risk, but risks for multiple illness ety affects the community. For example, many of the structures within
conditions and premature death are much higher for specific popula- a community, such as a hospital, nursing home, or home health agency,
tions (Adler & Rehkoph, 2011). Community health nurses need to explore may be owned by corporations outside the community. Communities
the multiple factors that contribute to health disparities among vulner- must be concerned with their internal functioning and their relationships
able portions of the population. Vulnerability is the predisposition or to their social environments.
If considered useful, a developmental framework can be incor- responding and adapting to internal and external stimuli. The
porated to explore the history of the community. responses are aimed at developing and maintaining a sense
of balance or equilibrium. The systems model (Figure 15-5)
Overview of Systems Theory serves as a tool to help the nurse identify, collect, and organize
A systems framework views the community as a dynamic appropriate data, including the critical components and their
model in which the community is constantly in the process of relationship to each other.
TABLEÂ€15-1â•…â•‡PERSPECTIVE ON THE
â•› The components of the systems model for both geopolitical
HEALTH OF COMMUNITIES and phenomenological communities are the same and consist
of the following:
IN SELECTED NURSING
• Boundaries: factors that separate a community from its envi-
THEORIES
ronment and maintain the integrity of the community
THEORIST HEALTH OF A COMMUNITY • Goals: purpose or reason for which the community exists
Dorothy Johnson Successful community functioning and • Characteristics: physical and psychosocial characteristics of
adjustment to environmental factors the community that affect behavior
Sister Callista Roy Effectiveness of the community in • External influences: resources or stressors from the suprasystem
accomplishing its functions and adapting to • Internal functioning: structures and processes of the com-
external stimuli munity, divided into four functional subsystems: economy,
Imogene King Quality interactions between individuals, polity, communication, and values (University of Maryland
groups, and the entire community that School of Nursing, 1975)
contribute to community functioning and • Outcomes: products, energy, and information created within
development the community, including health behavior and health status
Betty Newman Competence of the community to function of the population(s) and degree of community competence
and maintain balance and harmony in the • Feedback: information that is returned to the system regard-
presence of stressors ing its functioning
Jean Watson A healthy community is a holistic community, Although the components of geopolitical and phenomeno-
one which is able to integrate social and logical communities are the same, the types of data collected
personal resources and capacities to attain
and the resources for those data vary. The environment external
or maintain health for its members
to the community in Helvie's model (1998) is referred to as the
Data from Anderson, E., McFarlane, J., & Helton, A. (1986). Community- suprasystem in our model (von Bertalanffy, 1968). For the dis-
as-client: A model for practice. Nursing Outlook, 34(5); Hanchett, E. cussion on the holistic assumptions and review of general sys-
(1988). Nursing frameworks and community as client—Bridging the tems theory, refer to ChapterÂ€1.
gap. Norwalk, CT: Appleton & Lange; Alligood, M. & Marriner-Tomey,
A. (2010). Nursing theorists and their work (7th ed.). St Louis: Mosby;
Components to Assess
Dixon, E. (1999). Community health nursing practice and the Roy
Adaptation Model. Public Health Nursing, 16(4), 290-300; Rafael, A. R. Box 15-4 presents the basic systems model for community
F. (2000). Watson's philosophy, science, and the theory of human caring assessment, identifies important data to collect, and suggests
as a conceptual framework for guiding community health practice. possible data sources. Website Resource 15A expands the
Advances in Nursing Science, 23(2), 34-49. information on the tool in Box 15-4. The tool differentiates
BOXÂ€15-3â•…â•‡SAMPLE NURSING FRAMEWORKS FOR COMMUNITY ASSESSMENT

ANDÂ€PRACTICES
COMMUNITY-AS-PARTNER MODEL community) influences. The nurse works to identify stressors and to plan
The community-as-partner model evolved at the University of Texas strategies to bring stressors into balance and improve health.
School of Nursing at Galveston. Based on Betty Neuman's system model
of a total-person, the community-as-partner model focuses on two cen- EPIDEMIOLOGICAL FRAMEWORK MODELS
tral factors: the community as partner and the nursing process (Anderson GENESIS
& McFarlane, 2010). The community is composed of a core population General Ethnographic and Nursing Evaluation Studies in the State
and eight subsystems. These are depicted visually as a wheel with the (GENESIS) was developed by the University of Colorado School of
population at the hub surrounded by the subsystems. The subsystems Nursing. This model integrates epidemiological and ethnographic data to
are physical environment, education, safety and transportation, politics develop a comprehensive view of a community's health status and health
and government, health and social services, communication, economics, needs (Stoner etÂ€al., 1992). Areas of assessment include history, politics,
and recreation. The core population and each subsystem may be influ- services, economies, employment, education, environment, and a com-
enced by other segments, as well as by stressors, beyond the community munity's sense of belonging. Community members’ feelings about health,
(external factors). The community/public health nurse works in partner- health needs, and values are incorporated in the assessment process.
ship with the community to plan, implement, and evaluate strategies to
reduce stressors, reestablish equilibrium, and prevent future problems. MAPP
Interventions address primary, secondary, and tertiary prevention. Mobilization for Action through Planning and Partnerships (MAPP) is
a tool designed for use by local health departments in planning with
HELVIE ENERGY FRAMEWORK geopolitical communities to create and implement a community health
The community (population) is an energy field that is ever changing improvement plan (National Association of County and City Health
(Helvie, 1998). The community influences and is influenced by other Officials [NACCHO], 2008). The tool emphasizes community ownership
energy fields or subsystems in the environment such as health, educa- of the process. It also helps instruct nurses and other public health per-
tion, and economics. Changes in the community environment may come sonnel in the most effective ways to use collected data to develop effec-
from internal (between community components) or external (outside the tive intervention plans.
From National Association of County and City Health Officials. (2008). A community approach to health improvement. Washington, DC: Author.
Retrieved May 21, 2011 from http://nacho.org/toppres/infrastructure/mapp/upload/MAPPfactsheet-systempartners.pdf; Stoner, M., Magilvy, J., &
Schultz, P. (1992). Community analysis in community health nursing practice: The GENESIS Model. Public Health Nursing, 9(4), 223-227.
ENVIRONMENT
(Includes Suprasystem)
Bo
ry
External Influences
da
un
un
da
Money
Bo
ry
Facilities Outcomes
Human Services COMMUNITY Health Behaviors
Health Information Health Status
Legislation
Values
EXTERNAL FEEDBACK
FIGUREÂ€15-5â•‡ Community as system.
how the model would be used for both geopolitical and phe- Â�
definition of a community determines its boundaries. Consider
nomenological community assessments, and suggests some of the boundary as the skin or outside limit of the community.
the questions nurses would need to ask. The following discus- Establishing the boundary helps the nurse determine what data
sion examines the important features in each component in the will be collected and considered internal to the community, in
assessment process. other words, community information. Defining the boundary also
identifies the suprasystem, the environment outside the commu-
Boundaries nity. Data collected from the suprasystem are considered external
The essential first step in community assessment is identify- influences, or inputs, and may impact or influence the community.
ing the boundaries or parameters of the community. Remember Boundaries, similar to the skin of an individual, maintain
that a community is defined in terms of the three critical compo- the integrity of the system and regulate the exchange between
nents: people, place, and social interaction or common Â�interests. The a community and its external environment, the Â�suprasystem.
BOXÂ€15-4â•…â•‡COMMUNITY ASSESSMENT TOOL: A SYSTEMS-BASED APPROACH

1. Identify the boundaries of this community. housing). Phenomenological: a visit to the Â�community, health and
a. People membership records, surveys, interviews with key informants.
b. Place 4. Identify the suprasystem and explain the importance of looking at the
c. Social interaction—common goals, interests, or characteristics suprasystem during a community assessment.
Sources of data: Geopolitical: maps, census tract maps, librar- 5. Which external influences from the environment (suprasystem) are
ies, city clerks, health departments, printed material describing resources? Which are demands?
the community. Phenomenological: interviews, printed material Resources Demands
describing the community (e.g., pamphlets), philosophic and mem-
Money:
bership statements.
2. Identify the goals of this community. Facilities:
Sources of data: Geopolitical: charter of incorporation, Human services:
printed material about the community, interviews of key infor- Formal:
mants (e.g., community leaders). Phenomenological: printed
material about the community, statement of philosophy and Informal:
goals, interviews of key informants (e.g., community leaders, Health information:
community members). Legislation:
3. Describe the community's physical and psychosocial characteristics. Values of suprasystem
a. Physical characteristics (i.e.,Â€what external values
(1) How long has the community existed? affect this community?):
(2) Obtain demographic data about the community's members
(age, race, gender, ethnicity, housing, density of population). Sources of data: Geopolitical: windshield survey, census
(3) Identify physical features of the community that influence tract data, GIS databases, health planning agencies, libraries,
behavior. city/county clerks, Chamber of Commerce, printed matter about
b. Psychosocial characteristics the community, telephone books listing places of worship and
(1) Religion schools, a visit to the neighborhood (for information on set factors
(2) Socioeconomic class of the suprasystem), written surveys, local realtors (for informa-
Sources of data: Geopolitical: census tract data, geographi- tion on housing). Phenomenological: a visit to the suprasys-
cal information system (GIS) databases, health planning agencies, tem, health and membership records, surveys, interviews with
libraries, city/county clerks, Chamber of Commerce, printed matter key informants.
about the community, telephone books Â�listing places of worship and 6. Internal functions: identify resources and demands within the com-
schools, a visit to the neighborhood (for Â�information on set factors munity that influence its level of health. (See pp. 405-407 and
of the community), written surveys, local realtors (for information on Website Resource 15A for additional details.)
BOXÂ€15-4â•…â•‡ COMMUNITY ASSESSMENT TOOL: A SYSTEM-BASED APPROACH—CONT'D

a. Economy a. People factors:
Areas of assessment include formal and informal human services; (1) Describe the general trends regarding size of community.
money; facilities, equipment, and goods; education; analysis of econ- (2) What are the trends in mortality and morbidity?
omy subsystem functioning. Are the services, facilities, finances, and (a) What is the mortality rate?
education in this community accessible, adequate, and appropriate? (b) What are the major causes of death?
Sources of data: Geopolitical: budget, interviews, drive or walk (c) What major diseases and illnesses are present?
through the community, telephone book, and service directories. (d) Who are the vulnerable groups? What are the risky
Phenomenological: budget, interview, surveys. behaviors?
b. Polity: Describe the political system within the community used to (e) What presymptomatic illness or problems might be
attain community goals. expected?
Areas of assessment include basic organizational structure, for- (f) What is the level of social functioning in this community?
mal and informal leaders, pattern of decision making, methods of (g) What types of disabilities or impairments, or both, are
social control, and analysis of polity subsystem. What is the ratio present or might be found in this community?
of demands to resources? Sources of data: Geopolitical: local and state vital sta-
Sources of data: Geopolitical: organizational chart and tistics (available through local and state health depart-
charter, interviews and meetings with the community, laws. ments); Morbidity and Mortality Weekly Reports (MMWR),
Phenomenological: by-laws, procedure and policy books, published by the Centers for Disease Control and Prevention
attending meetings, being with the group. (available at libraries and health departments); reports
c. Communication: Describe the communication within the commu- of screening programs; interviews with key informants.
nity that fosters a sense of belonging and provides identity and Phenomenological: agency or community records, inter-
support to its members. views with key informants, review of the literature pertain-
Areas of assessment include nonverbal communications, ver- ing to aggregates (e.g., literature about older individuals will
bal communications, and analysis of communication subsystem. provide information about most morbidity and mortality).
How well does the community communicate a sense of identity or b. Environmental factors
belonging to its members? How adequate is the communication? (1) Physical environmental factors: What is the quality of the
Sources of data: Geopolitical: interviews, newspapers, kiosks, physical environment (air, water, land, housing, work or home
meetings, visit to the community. Phenomenological: interviews, environment)?
newsletters, meetings, classes, committees, being with the community. (2) Social environmental factors: What is the emotional tone
d. Values: Identify the ideas, attitudes, and beliefs of community and stability of the population?
members that serve as general guides to behavior. Sources of data: Geopolitical: visit to community; reports
Areas of assessment include tradition, subgroups, environment, such as Air Quality Index (AQI). Phenomenological: visit
health attitudes and values, homogeneity versus heterogeneity of to community.
values and beliefs, and analysis of values subsystem. How well does 8. Describe feedback from the environment about the community's
the community provide guidelines for the behaviors of its members? functioning.
Sources of data: Geopolitical: surveys of agencies to determine 9. Make inferences about the level of health of this community.
utilization, surveys of community members, newspapers, and com- â•›a. What are some actual health problems or needs?
munity announcements. Phenomenological: observation and b. What are some potential health problems or needs?
interaction with members, charts or records, surveys of members. â•›c. How well is the community working to meet its health needs?
7. Health behavior and health status (outcomes). What is its proposed action to meet its health needs?
(Be sure to refer to the community assessment tool in Website d. How has the community solved similar problems in the past?
Resource 15A for this portion of the assessment, because some â•›e. What are the strengths of the community?
differences exist between the geopolitical community and the phe- 10. Identify one actual or potential health need for which you, as a
nomenological community.) nurse, could plan an intervention.
Adapted from Community Health Faculty, Undergraduate Program, University of Maryland School of Nursing. (1975). Community assessment tool.
Baltimore: University of Maryland School of Nursing.
Boundaries of a geopolitical community are spatial and U.S. population every 10â•›years. Census tract data are valuable
concrete; they can be natural or human made, as discussed ear- for health planning. Census tract maps are available in librar-
lier. Because the boundaries of geopolitical communities are ies and health departments. Figure 15-6 illustrates how an area
real and concrete, they are often visible on maps. For example, is incorporated into a census tract. Website Resource 15B
the Potomac River and the Maryland state line can be visual- provides additional information on census tracts.
ized on a map as indicators of the boundaries of Washington, The boundaries of phenomenological communities are
DC. The Rocky Mountains divide the western part of the more relational or conceptual than are geopolitical boundar-
United States from the Great Plains. The river and moun- ies and usually relate to the reason the community exists or to
tains are natural boundaries and the state line a human-made the criteria for membership. To determine the boundary of a
boundary. phenomenological community, the following questions would
Another type of human-made boundary is a census tract. be asked:
The U.S. Census Bureau divides the United States into census • Why does the community exist?
tracts for the purpose of reporting demographic data about the • Who can belong?
1002
1001
3012
Oak Lone
3011 3012
3011
Block Group 3 3013 1004
3014
Block 3014 2002

2004
3014 3013 2005 2003
2007
Piney Hollow Road
2006
Block Block Group Census Tract 5.02

FIGUREÂ€15-6â•‡ Census small-area geography map illustrates the relationship between block 3014
(the smallest geographical area of the census), its block group (several adjacent blocks 3011,
3012, 3013, and 3014), and census tract 5.02, which contains other block groups. (From U.S. Bureau
of the Census. [2001]. Introduction to Census 2000 data products [Publication No. MSO/01-ICDP, June 2001].
Washington, DC: U.S. Department of Commerce.)
• What criteria are necessary for membership? hold these beliefs. In a phenomenological community, the cri-
• What brings the members together? teria for membership often define the boundary's permeabil-
For example, the boundary of the nursing community would ity or openness. A geographical community that has a gated
be its criterion for membership—that is, the person must be a entrance and homes that cost $350,000 or more is imperme-
nurse to belong. The boundary of a Cub Scout pack would be able to people with an annual income of $25,000 to $30,000.
the criteria of age (7 to 10â•›years old) and gender (boys). Communities with greater variety of housing prices and rental
units would be open to more people; thus the boundaries
The Morgan Center is a nutrition center for frail older persons. would be permeable.
The center consists of 25 senior participants, 1 site manager, The openness or closeness of a community has implications
and 3 staff members. To attend Morgan Center, the partici- for health planning. A closed, rigid system is resistant to change,
pants must be 65â•›years of age or older, live in Allen County, be whereas an open, flexible system is more receptive to change
classified as frail (having difficulty with at least one activity of and to help from the health care delivery system.
daily living [ADL]), and be continent. The goals of the Morgan Suprasystem. Once you have determined the boundary of the
Center are to provide socialization, encourage ADLs, and ensure community, anything outside the boundary becomes the supra-
adequate nutrition for its clients. system. No system (individual, family, or community) can exist
in isolation. Therefore, every client system operates within a
A nurse assessing the community might determine some larger system. The larger system, the suprasystem, is defined as
characteristics from the data provided. This community is a the environment external to, or outside of, the community that
phenomenological community; it is an aggregate of frail older affects the community system. The suprasystem of a geopoliti-
adults attending Morgan Center. The criteria for membership cal community is concrete. For example, the immediate supra-
(65â•›years of age and older, residents of Allen County, frail, system of Ridgely's Delight, a neighborhood in Baltimore, is the
and continent) determine the boundaries. Another way to city of Baltimore. The suprasystem of Baltimore is the state of
define the community would be to view the Morgan Center Maryland. Identifying a specific suprasystem for a geopolitical
in its entirety, including frail older adults, the site manager, community is usually easier than it is in a phenomenological
and the staff. In this case, the criteria for membership change community.
to persons who work at or attend the center. Either defini- In a phenomenological community, the suprasystem
tion is correct, depending on the reason or purpose for the becomes anything outside of the community that affects or is
assessment. affected by the community. Identifying a single suprasystem for
As you can see, the parameters of the community must be a phenomenological community is sometimes difficult; many
defined because they determine what data will be collected. In suprasystems may be found. For example, what is the supra-
the first situation, the nurse will collect data about frail older system for an aggregate such as the older individuals in Orange
persons only, and the site manager and the staff will be external County? It might be the Orange County Office on Aging, the
influences to the community; in the second example, the nurse entire Orange County government, the American Association
will collect data about frail older persons, the site manager, and of Retired Persons, or the Orange County Social Security Office,
the staff as part of the community. Boundary definition is espe- all four of these entities, or these four entities and still others.
cially important when examining the external influences and The sources of external influences from the larger society must
the internal functioning of a community. be examined, such as legislation, services, and money that influ-
Permeability of Boundaries. The boundaries of any system ence (positively or negatively) the older adult community. For
may be relatively permeable (open) or impermeable (closed). some phenomenological communities, however, identifying a
For example, entrance or membership into a religious commu- specific suprasystem may be possible. For example, Girl Scout
nity may be contingent on accepting certain beliefs and rituals, Troop No. 201 is a phenomenological community; its suprasys-
making the boundary impermeable to someone who does not tem is the Girl Scouts of Central Ohio.
Goals The type, condition, and amount of housing and density

Goals of communities vary with the type of community, but of the population are environmental factors that have impli-
in general, they are focused on maximizing the well-being of cations for health. Crowded living conditions have long been
members, promoting survival, and meeting the needs of the associated with the increased transmission of some commu-
community members. What are the goals of the community in nicable diseases (e.g., tuberculosis, pediculosis). Also impor-
which you live? Are they to provide safe housing for residents? tant to note is the condition of the housing and whether
One goal of the Morgan Senior Center is to provide social- housing is available and financially accessible to people in
ization for its members. The community health nurse can the community. The type and condition of housing may say
assess the goals of the community by asking questions such a lot about the resources and values of the people living in
as, “What is the purpose of the community?” A written state- the community.
ment of the community's philosophy and goals, if available, is In a phenomenological community, the environment
another source. or the place in which the group meets might be examined.
This review takes into consideration the environmen-
Characteristics tal factors and the aesthetics that contribute to or interfere
Characteristics are the physical, biological, and psychosocial fac- with members’ ability to feel comfortable in the physical
tors of the community. These characteristics are often referred to environment.
as demographics. Characteristics are usually not easily changed, or Physical features of the community can influence the com-
they change slowly. munity's behaviors. A community with fences around all houses
Physical Characteristics. Physical characteristics include (1) demonstrates preference for privacy and may imply little social
the length of time the community has been in existence, (2) per- interaction or the presence of dogs or pools. A school with open
tinent demographic data about the community's members (e.g., classrooms influences the interaction among students. Other
age, race, gender, ethnicity, education, income, housing, density physical features such as living or working in a community with
of population), and (3) physical features of the community that toxic substances may influence the level of health of the resi-
influence behavior. dents or workers.
The length of time the community has been in existence Psychosocial Characteristics. Psychosocial characteristics
(the age of the community) has implications regarding stabil- that affect the emotional tones of the community include reli-
ity, health care services, and needs. On the one hand, a very new gion, socioeconomic class, education, occupation, and marital
community may have few services simply because supply has status. Some ways these characteristics may affect health behav-
not caught up with demand. On the other hand, communi- ior include the following:
ties that have been in existence for a long time may have many • Religion: Beliefs may involve the use or nonuse of contra-
resources, or they may have resources that reflect past popula- ceptives, abortion, living will, circumcision, and organ
tion needs but not the current needs (if population shifts have donation.
occurred). • Socioeconomic level: Poverty reduces access to health care ser-
Pertinent demographic data such as age, race, gender, eth- vices and increases health risks (see ChaptersÂ€4 and 21).
nicity, and density of the population have significant meaning • Educational level: Higher education levels are associated with
in the planning of health care services. By looking at the age, higher rates of preventive health behaviors.
race, and gender of members of the community, the commu- • Occupation: A person's livelihood may influence the risk of
nity/public health nurse can make some inferences about pos- disease or injury. For example, coal miners are prone to sili-
sible health care needs. A community with a large population of cosis and lung cancer, computer users to carpal tunnel syn-
older individuals will have very different needs from persons of a drome, or sedentary white-collar professionals to coronary
community with a predominantly young population. Generally, artery disease.
older individuals need more services than do younger persons. Collecting demographic information can provide the nurse
Race is a factor in certain diseases (e.g., sickle cell anemia in with some idea of the possible health needs of the community.
the African American population; Tay-Sachs disease in Jewish Looking at a number of people with common characteristics
populations). A population with an unusually high number and planning programs to meet their unique health care needs
of women will need more women's health care services, and a are the basis for aggregate/population health planning. Sources
community with a high number of adults may need blood pres- of demographic information are identified later in Tools for
sure screening programs to detect early hypertension. Data Collection.
Ethnicity is reflected in customs, beliefs, and values and
may affect how the community addresses certain health External Influences
practices (refer to ChapterÂ€10). The community/public All communities have external influences that affect their func-
health nurse must understand these customs and beliefs tioning. External influences are matter, energy, and informa-
when assessing needs and planning interventions. In some tion that come from outside the community—that is, from the
areas, the cultural and ethnic backgrounds of the population suprasystem. External influences may be either resources (assets
have become the basis for the community. Some cities have or strengths) or demands (liabilities or weaknesses) on the com-
sections that reflect the ethnic and cultural heritage of cer- munity and may be mandated (required) or voluntary. Some
tain groups (e.g., Little Italy or Chinatown in San Francisco). of the most important external influences are money, facilities,
Groups such as the Sons of Norway, the Sons of Italy, and the human services, health information, legislation, and values of
Polish Home Club have formed phenomenological commu- the suprasystem. Some of the areas to explore for each of these
nities on the basis of their ethnic and cultural heritages. influences are summarized here:
• Money. Outside sources would include taxes, state or fed- When assessing individual human functioning, it is essential
eral funds, contributions, grants, or endowments. Finding to determine areas of strength as well as areas of need. Nurses
money that may be used to fund health services is important. work with individuals to build on their strengths to overcome
• Facilities. Look for the following potential outside facilities: and adapt to health deficits. The same is true when assessing a
health care facilities such as hospitals, health maintenance community. Asset models of community assessment stress the
organizations (HMOs), nursing homes, home care agencies, positive abilities and capacities of communities to identify their
and facilities and clinics that promote safety and transpor- own health problems and plan solutions. Such a model encour-
tation. Consider accessibility of facilities regarding location ages community participation and has the potential to empower
and cost, as well as transportation and attitude of staff. Ease communities. Community resiliency is the ability of a com-
of access and low cost are resources; excessive distance and munity to use its assets and resources to adapt to adversity and
poor staff attitudes are demands. improve its capacity (Kulig, 2000; Moorhead et al., 2008; Racher
• Human services. These resources may be formal or informal. & Annis, 2008). Community capacity may include social par-
Examples of formal human services include professional ticipation, sense of community, networks among organizations,
resources, nurses, physicians, the local health department, and skills, knowledge, and leadership necessary “to promote
Â� future
health insurance companies. Examples of informal services are community health and welfare” (Trickett etÂ€al., 2011, p. 1411).
often voluntary services, individuals, and organizations such Economy. The goal of the economy subsystem is production
as religious groups and other volunteer support groups for and distribution of goods and services. Economy includes catego-
a variety of health conditions (e.g., Alcoholics Anonymous). ries such as human services; money; facilities, equipment, and
Physicians and nurses outside the community who will see goods; and education. These factors are the same as those dis-
community members are a resource; physicians or clients who cussed in the assessment of external influences. However, the
will not accept community members are a demand. factors to examine here are those within the community itself.
• Health information. Health information is communicated 1. Human services. Services available within the commu-
through printed matter, radio, television, the Internet, or nity may be either formal (e.g., nurses and physicians) or
person-to-person. If the suprasystem has helpful informa- informal (e.g., volunteers). Questions to ask include the
tion but does not have an effective way to communicate this following:
information, this represents a demand. • What human services are available within the community
• Legislation. This type of influence takes the form of laws, to meet the community's health needs?
policies, and procedures that may affect a community in • Are services adequate and sufficiently accessible to meet
either a positive (resource) or a negative (demand) manner. the community's needs, or are services available only to a
The geopolitical community has laws that affect the commu- certain segment of the population, for example, persons
nity's health, including environmental pollution and zoning who can afford to pay for or have transportation?
laws; the phenomenological community can be affected by • Are the human services responsive to the needs of the
external legislation, policies, and procedures. For example, community?
legislation affects the health and health care of older adults 2. Money. What is the budget? How does the community get
(the Older Americans Act and Medicare legislation). its money? How is revenue generated from within the com-
• Values of the suprasystem. Consider if the suprasystem's munity? What are the fund-raising activities? For what is the
values are consistent or inconsistent with the values of the money spent?
community. When the two sets of values are consistent, lit- 3. Facilities, equipment, and goods. What health care facilities
tle conflict takes place, and there is increased likelihood that (e.g., hospitals, clinics, home health agencies, nursing homes,
the suprasystem will be supportive of community requests. daycare centers) are available within the community? How are
When the two sets of values differ, conflict is more likely, and they used? Are they accessible, appropriate, and adequate for
the suprasystem will be less supportive of community needs the population in the community? Does the facility have the
and requests. equipment and supplies it needs to produce its goods? What
Data Sources for Suprasystem Information. Because the exter- does it produce? What is its contribution to the larger soci-
nal influences come from the suprasystem, obtaining data about ety? For example, is this a high-technology geopolitical com-
the suprasystem is important. Where can these data be found? munity that supplies research and development, or is it a
A wealth of information is provided by review of the suprasys- phenomenological community (e.g., Mothers Against Drunk
tem budget, local telephone book and newspapers, health or Driving [MADD]) that provides support to its members and
human service directories, and information and referral ser- information to the larger suprasystem? These are examples of
vices; systematic tours of services and agencies; interviews with positive production (resources). Producing a negative effect
members of the community; and review of legal and policy and on the larger society is possible for a community. For example,
procedure books. a community with many drug abusers may produce a negative
effect (demand) on the system and the suprasystem. A com-
Internal Functions of the Community munity with many illegal drug users will require more health
Internal functioning of the community occurs through its care services and put greater demand on health care facilities
internal structures and processes. For the purpose of data col- than would a community with fewer drug users.
lection and analysis, the tool examines four functional areas: 4. Education. Education assists people in learning how to func-
economy, polity, communication, and values (University of tion productively in society so it is included in this subsystem.
Maryland School of Nursing, 1975). Resources and demands How are the members educated? In a geopolitical commu-
may be found within each of these subsystems. nity, we can examine the numbers and types of schools, as
well as the level of education. In a phenomenological com- enforced through police, sheriffs, law agencies, courts, and
munity, we examine the needs for education of the group the government; examples include curfews, speed limits,
and what types of education are taking place. For example, and “blue laws” governing the sale of alcohol. In a phenom-
what education about pregnancy is being provided to preg- enological community, the rules are the control enforced by
nant adolescents? bylaws, policies, and procedures. The norms in a geopoliti-
In addition to assessing these factors, we need to begin to cal community are social sanctions enforced by the members
analyze the findings. Are the resources and assets outweighing of the neighborhood and by institutions such as the schools
the demands? Are the finances, services, facilities, and educa- and faith communities, whereas in a phenomenological
tion appropriate, accessible, and adequate to members of the community, the group (e.g., peer pressure among adoles-
community? What is the ratio of demands to resources and cents) enforces the norms.
assets? Communication. The goal of the communication subsystem is
Polity. Polity is the politics of a community. The goal of pol- to provide identity and support to its members—that is, to pro-
ity is coordination, control, and direction of activities to maintain vide a sense of belonging. People in the community offer group
the community and attain the system goals. Formal government, participation in exchange for support and identity from the
as well as informal leadership, serves these functions. The polity community.
subsystem of a community provides organizational structure, The communication subsystem includes the many affective
leadership, decision making, and social control to its members relationships that exist among community members. These
in return for members’ compliance and support. relationships provide the emotional tone of the community.
1. Organizational structure. The organizational structure rep- Emotional tone is communicated through nonverbal as well as
resents the way in which a population group has organized verbal communication.
to facilitate collective action and to exert some control over 1. Nonverbal communication. What personality or emotional
its collective behavior. An organizational chart of a commu- tone is communicated to you when you visit the community?
nity will provide information about how the community is Does it feel warm and inviting? Does it feel cold and hostile?
organized, its formal leadership positions, and its decision- How do members describe their community? What are the
making process. How is the community organized? Is it nonverbal messages that the community communicates to
an incorporated city with a mayor and city council? Is it a the external environment and among community members?
charter government? Is it a volunteer group with no elected How are strangers and newcomers treated?
leaders? 2. Verbal communication. Who communicates with whom? Is
2. Leadership. Both formal and informal leadership are pres- communication horizontal (egalitarian) or vertical (hierar-
ent in any group; identifying both types is important. Who chical)? How is communication achieved (e.g., by newspa-
are the formal leaders? Formal leaders may be elected or per, television, radio, social media, newsletters, posters, fliers,
appointed; they have the authority in decision making, but person-to-person communication, informal gatherings, for-
informal leaders often have the power. To effect any kind of mal meetings)? What is the focus of the communication? Is
change, a thorough understanding is needed of both the for- it “business” or goal directed, social, or a combination? When
mal and the informal leadership dynamics. For example, if does the communication occur?
a strong leader pattern prevails, attention should be placed Values. The goal of the values subsystem is to provide guidelines
on reaching and convincing the leaders before any attempt is for behavior. This component addresses the general orienting
made to contact the target population (i.e., the population principles that guide the socialization and behavior of mem-
in which change is desired). bers of the community. Community members accept and con-
3. Decision making or problem solving. Finding out how the form to the standards of the community in return for approval.
community approaches its problems and its pattern of Important to examine are patterns of behavior that reflect val-
decision making is important. To effect any type of change, ues, beliefs, standards, culture, and ethnic background (see
the individual must know not only whom to approach but ChapterÂ€10) because these patterns help determine the health
also how the community has acted in the past to solve its action pattern of the community. The patterns of behavior that
problems. What is the decision-making process? Who have are examined include traditions, presence of identifiable sub-
been the key decision makers for health issues? How have groups, aesthetics and environment, health, and homogeneity
problems been approached and solved in the past? What of the group.
problem-solving approaches have not worked in the past? 1. Traditions. Some communities are steeped in tradition, and
Answers to these questions will provide a basis for deter- others have few traditions. Traditions often reflect the eth-
mining the action pattern of the community and how capa- nic background of a community's members and can also
ble it will be at solving its problems (Freeman & Heinrich, vary with the age of the community. A new, young commu-
1981); they will also give the nurse a clue as to what role is nity may have no or only a few traditions, whereas an older
necessary in planning health programs. A community that community may have many long-standing traditions. The
is relatively competent may be quite independent and func- celebration of traditions often provides a sense of identity
tion with a minimal amount of assistance from the nurse. A to a community's members and stability to the community.
dependent community may need the nurse to take a more In considering the impact of traditions, a nurse may need
active and direct role in developing leadership skills of to address the following questions: Are traditional ways
community members. followed, or is individuality stressed? Are kinship bonds
4. Social control. This refers to the rules and norms of a com- strong, or is each individual expected to cope with his or
munity that affect behavior. The rules in a geopolitical com- her own problems? What traditions are upheld? How are
munity usually refer to local laws or control measures, often they celebrated?
2. Subgroups. Subgroups may be present within a community. a younger population or an older population, or staying the
For example, subgroups may exist based on ethnic or racial same? How mobile is the population?
identity, social class, and age of community members. These 2. Trends in mortality and morbidity. Trends in mortality and
identifiable subgroups have their own values, customs, prob- morbidity are indicators of a community's health status (see
lems, and strengths. ChapterÂ€7). Medical cause of death is a valuable indicator.
3. Aesthetics and environment. Observation of the environment For example, a high infant mortality rate may reflect evi-
can tell you a lot about what the people value. That is, do dence of inattention to or lack of value for preventive health
they value clean, tidy environments that are pleasing to the care and identifies a need to provide preventive prenatal
eye? Is the environment in decay or disrepair, showing little health services. However, medical cause of death alone may
or no evidence of attention to aesthetics (because the focus is be inadequate because the causes of diseases may be related
on survival and basic life support instead)? to personal or social phenomena. For example, extreme
4. Health. People vary with regard to the value and priority they poverty is a social condition that contributes to cause of
place on health. To assess needs and plan health care, nurses death. In the example just given, the high infant mortality
must know what the community values in the way of health. rate may be caused by a combination of inadequate preven-
Even though health care professionals value preventive tive health care services and malnutrition related to poverty.
health, a given community may not. The people in the com- Epidemiological questions the community health nurse will
munity may have some very different ideas about what they want to address are the following: What are the trends related
want in a health care program. If health care professionals do to death and illness? What is the mortality rate? What are
not consider the community's needs and values, then health the major causes of death? What major diseases are present
care programs will not be effective. Therefore, it is impor- in the population? What is the prevalence or incidence of
tant to answer questions such as the following: What types of diseases?
health facilities are used? How often are they used? What are 3. Mortality. Consider the number of deaths, age-specific rates
the attitudes about health, health care, and health care proof death, and the major causes of death in the community.
fessionals? What priority do members place on health? How If working with a geopolitical community, this information
do community members define health? (See ChapterÂ€18.) can be obtained from local and state vital statistics and health
5. Homogeneity. Is the community homogeneous or heteroge- departments. Additionally, the Morbidity and Mortality
neous in its beliefs and values? Communities may be very Weekly Report, published by the Centers for Disease Control
similar in their values or very diverse. The level of homo- and Prevention (CDC), is available online.
geneity or heterogeneity influences the community health 4. Morbidity. The nurse must know what diseases and condi-
nurse when planning care. In more heterogeneous commu- tions are present in a community and their incidence and
nities, interventions need to be tailored to the various and prevalence. For a geopolitical community, these data can be
different subgroups and populations. obtained by reviewing statistics collected officially. In a phe-
nomenological community, the nurse would need to col-
Outcomes (Health Behavior, Health Status, Community lect data by surveying records, preparing questionnaires, or
Competence) arranging interviews. In the United States, morbidity data
Outcomes include measurable, health-related behaviors and are not systematically collected and are, therefore, sketchy
health status of the populations in the community. Outcomes and inadequate in scope.
also include community competence. Outcomes influence the 5. Vulnerable aggregates and risky behavior. Is the population
community and its suprasystem(s). The health status of the “at risk” of developing certain health conditions or prob-
community includes two interrelated factors: people and envi- lems? What risky or vulnerable types of behavior are present
ronment. Identifying trends in health behavior and health sta- in this community? Groups may exist within a geopoliti-
tus over time, rather than simply looking at health behaviors at cal community who do not have a disease or condition that
one point in time, gives a clearer picture of health outcomes. requires medical care but do have a personal or social condi-
We will look first at people factors and then at environmental tion that makes them unusually susceptible or lowers their
factors. ability to deal with disease or disability (see ChapterÂ€21).
People Factors. People factors that the community health Examples include the homeless, people living below the
nurse needs to investigate include general trends, trends in mor- poverty level, multiproblem families, and malnourished
tality (death) and morbidity (illness), the presence of vulner- and pregnant adolescents. Risky behaviors include those
able groups or aggregates with at-risk behaviors, the prevalence that place people at risk for disease. For example, intrave-
of presymptomatic illness, and the level of social function- nous drug use is a risky behavior associated with the human
ing. All of these factors impact or reflect the health status of a immunodeficiency virus (HIV) infection; cigarette smoking
community. increases the risk of lung cancer; and driving without a seat
1. Growth trends. The stability and growth of the community belt is associated with vehicular trauma.
have implications for health and health planning. Therefore, 6. Prevalence of presymptomatic illness. What is the prevalence
the nurse must examine the current size of the community of presymptomatic illness in a community? Although pre-
and compare it with its original size or size at a particular cise data on the prevalence of a presymptomatic illness are
point in time. Is the community growing or decreasing in difficult to obtain, estimates based on special surveys or
size? What is the relationship between the birth and death screening programs can be made (see ChapterÂ€19). Some
rates (geopolitical community)? What is the relationship examples of presymptomatic illness are increased blood
between immigration and emigration? What are the changes pressure, increased blood cholesterol level, and seropositive
in demographic characteristics? Is the community becoming HIV individuals.
7. Level of social functioning. What is the level of social func- Indicators of the health status of the social environment
tioning in a community? The level of social functioning include the emotional tone of the community, the stability
refers to the quality of life and the relationship of depen- of the population (an extremely mobile population or rapid
dency to independency in a community. If a large number turnover of members in either a geopolitical or a phenome-
of people are dependent on a small number for support or nological community can be a measure of dissatisfaction and
help, the demand on the community for resources would be instability within the community), levels of violence, and the
much greater than if the proportions were balanced. People reported quality of life in the community. The quality of life
may be dependent for a variety of reasons such as age, lack may include personal satisfaction with the community as well
of finances, illness, or disability. For example, a community as the measures of community competence previously dis-
that has a high preponderance of older individuals will need cussed in this chapter.
more health facilities and services because of the increased
medical needs of that age group. As you learned in ChapterÂ€7, Feedback
ratios are used to show relationships. A dependency ratio Feedback may be internal or external. Internal feedback is infor-
shows the proportion of dependents to independents. An mation from within the community that helps the commu-
example of a dependency ratio is shown as follows: nity monitor its functioning. For example, if the city council or
township receives information that tax revenues are lower than
Dependency ratio = projected, the community may need to modify its budget and
Population under 18 years + population > 65 years reduce spending.
Population of persons between 18 and 65 years External feedback is information from the suprasystem and
larger environment about a community's functioning. This
For example, Elmhurst has a population of 6784 people. type of information provides an opportunity for the commu-
According to the census information, 1604 people under the nity to modify itself, adapt to changing environmental con-
age of 18 and 2422 people over the age of 65 live in the area. ditions, and negotiate interchanges with its environment. For
To calculate the dependency ratio: example, community health nurses within a local health depart-
ment may receive information about new state guidelines that
1604 (under 18) + 2422 (over 65) require directly observed medication therapy for persons with
= 1.45 newly diagnosed tuberculosis. This information would neces-
2758
sitate that the nurses institute these services. Dialogue between
This ratio means that there are almost 1.5 dependent per- nurses in the local and state health departments and with com-
sons for each person considered to be able to care for others. munity members would help determine realistic ways to initiate
8. Disabilities and impairments. Are disabilities or impairments such services. In this case, feedback from the suprasystem man-
present? These disabilities or impairments can be physical or dates that the community institute new services in response to
emotional. People with impairments or disabilities require changing guidelines.
special care from the community (see ChapterÂ€26). Therefore,
the nurse must identify the numbers of people and the types TOOLS FOR DATA COLLECTION
of impairments or disabilities to identify whether the needs
are being met by the community or if further services are Community health nurses can use a systems analysis frame-
necessary. work to guide data collection for a community assessment.
Environmental Factors. Environmental factors include the Where does the nurse go to collect all of these data? What tools
physical and the social environment. Indicators of the health are needed? Figure 15-7 identifies many of the data sources
status of the physical environment include the air, food, and used to assess a community. An important tool is the use of
water quality; the adequacy of housing; and the quality of home, self, particularly your senses. Of course, an automobile or
school, and work sites (see ChapterÂ€9). Solid waste disposal and other means of travel, a map, and a few resource materials are
hazardous waste disposal are also relevant. also helpful.
Personal Observation National Data

and Windshield Survey (i.e., Census Data)
Published Local Sources

Community (i.e., Libraries,
Survey/s Newspapers)
Community
Assessment
Survey of Demographic and
Community Epidemiology Data
Members
Key Informants Focus Groups

FIGUREÂ€15-7â•‡ Sources of data for community assessment.
Personal Observation are not national samples, they are large community samples that
Use your eyes, ears, nose, hands, and body to inspect, auscultate, allow conclusions to be made about demographic risk factors
palpate, and percuss the community. You can tell a lot about a and the long-term effects of various health-related behaviors on
community just by using your own senses. morbidity and mortality. Schools of public health are conduct-
• Eyes. What do you see? Describe the people, what they are ing longitudinal epidemiological studies in several communi-
doing, and the environment. ties, including Alameda, California; Evans County, Georgia;
• Nose. Smell the environment. Is it pleasant, polluted, fresh, or Framingham, Massachusetts; and Ypsilanti, Michigan. Findings
stale? appear in health care research and professional journals.
• Ears. Is the community noisy or quiet? Are the people talking
State and Local Sources
to one another?
• Palpate and percuss. What is the feeling of the community? Is it ChapterÂ€7 defines vital and demographic data. Local and state
warm, open, and friendly, or is it cold, hostile, and suspicious? health departments collect and disseminate information about
Be alert and collect data at every opportunity. A simple drive the vital statistics in their localities. County and city planning
through the community, called a windshield survey, provides an and zoning boards often have current demographic data and
opportunity to observe, listen, and collect information provided a list of many resources. Health department websites, agency
in the guide. Website Resource 15C provides a guide for col- records, libraries, business people, the clergy, telephone books,
lecting data in a windshield survey. During your visit to the and service directories are additional sources of information.
community, talk to the people—the community members and The Robert Wood Johnson Foundation in collaboration with
leaders, health care professionals, clergy, real estate agents, and the University of Wisconsin Population Health Institute (2011)
business people. These individuals can tell you a lot about the developed County Health Rankings for each state's counties. The
community. Read about the community in newspapers, litera- report is found at http://www.countyhealthrankings.org/. Within
ture, or printed materials distributed by the community or by each state, counties are ranked using traditional health mortal-
other organizations. Look for bulletin boards, kiosks, informa- ity outcomes, as well as health behaviors, clinical care, social and
tion centers, or cable television programs in which community economic factors, and the physical environment.
activities and information are posted. Many local areas publish a community resource guide that
includes resources within a given geographical area. These
books are often written in an annotated bibliographic format
Existing Data Sources: Secondary Data and are valuable resources to a community health nurse. Check
National Sources with the health department or the health and welfare council in
Many sources of demographic and epidemiological data already your area to see if one is available.
collected can be used and are often available on the Internet.
The National Center for Health Statistics, a federal agency estab- Surveys
lished to collect and disseminate data about the health of U.S. If you cannot locate sources of data for the community under
residents, conducts the National Health Interview Survey. Many study, you may need to develop a survey to obtain needed infor-
other agencies and organizations collect data on specific dis- mation. This alternative is especially true when working with
eases, conditions, or aggregates. Box 15-5 lists some of these data segments of a geopolitical community in which the only data
sources. The United States Government Manual, available from available may be for a larger area that includes the commu-
the U.S. Government Printing Office (2002) in Washington, nity segment under study. Surveys are also needed in a geopo-
DC, is a good reference for information about federal programs litical community when different, more specific information is
and agencies that have health data. Most states have at least one desired. In a phenomenological community, developing data
library designated as a depository for federal publications. Your collection tools may be necessary because data may not be
local librarian can refer you to the nearest depository. available.
The U.S. Census Bureau collects information on the demo- Surveys include a series of questions that the Â�investigator asks
graphic characteristics (age, gender, race, ethnicity, socioeco- to obtain information from individuals within a Â�population.
nomic level, marital status, educational level, and housing) of Questions help describe the prevalence, distribution, and
the U.S. population every 10â•›years. Although these data are valu- interrelationships of health and illness conditions, beliefs, atti-
able, if you are using 2010 data in the year 2014, the data may tudes, knowledge, or health-related behaviors within a popu-
need to be supplemented with other, more current data. State lation (Polit & Beck, 2010). Ideally, surveys should be written
and local planning offices use a variety of statistical methods in the primary language of the persons being surveyed.
to estimate the size of populations between censuses. The cen- The purpose of a survey might be to collect demographic
sus data are helpful for viewing patterns over time to identify data, obtain information on assets and problems, conduct a
trends. Census tract information is available in the reference needs assessment, identify utilization patterns of services and
section in some libraries, in local and state health departments, facilities, or determine health interests of community mem-
and online. bers. The survey may be written or verbal. Written surveys
Many special interest groups collect and publish data about can be mailed or conducted on a person-to-person basis. Low
their particular group. For example, the American Heart return rates and the cost of mailing are the major disadvan-
Association, the American Lung Association, and MADD have tages of mailed surveys. Interviews or questionnaires often
publications that provide useful information about their respec- yield additional valuable information because direct contact
tive topics and the aggregate characteristics. can be made with community members. However, surveys,
Longitudinal research is being done with large populations whether done by mail, face-to-face, or on the telephone, are
in several areas of the United States. Although these populations time consuming.
BOXÂ€15-5â•…â•‡SAMPLE SOURCES OF HEALTH AND POPULATION DATA*

PUBLIC HEALTH SERVICE, CENTERS FOR DISEASE No. 52, Design and Operation of the Survey of Adult Transition and
CONTROL AND PREVENTION Health, 2007. (PHS) 2010.
Website: www.cdc.gov Series 2, Data Evaluation and Methods Research. Studies new Â�statistical
Morbidity and Mortality Weekly Report (MMWR) methodology, reports on data evaluation and methods research. Example:
Publishes provisional and summary data on reportable infectious dis- No. 151, Education Reporting and Classification on Death Certificates
eases and other health concerns by state. Reports include special topics in the United States. (PHS) 2010.
of health concerns related to trends, control, or treatment recommenda- Series 4, Documents and Committee Reports. Final reports of major com-
tions and other health-related discussions. MMWR is available on line mittees concerned with vital and health statistics and documents.
at www.cdc.gov/mmwr. Series 15, Data from Special Surveys. Statistics on health and health-
related topics not part of the continuing data system for the National
NATIONAL CENTER FOR HEALTH STATISTICS, Center for Health Statistics. Example:
HYATTSVILLE, MD No. 3, Summary Statistics from the National Survey of Early Childhood
Website: www.cdc.gov/nvss.htm Health, 2000. (PHS) 2002.
Vital and Health Statistics Series Series 20, Data on Mortality.
For Community/Public Health Nursing Practice (series Series 21, Data on Natality, Marriage, and Divorce.
are periodically updated with new volume numbers): National Health Statistics Report, Special reports concentrating on a
Series 5, International Vital and Health Statistics Reports. Compares specific health issue or topic and annual data summaries.
U.S. vital and health statistics with other countries. Examples:
Series 10, Data from the National Health Interview Survey. A continuing No. 38, Home Health Care and Discharged Hospice Care Patients:
national household interview survey that reports on illness; acciden- United States, 2000 and 2007. (PHS) 2011.
tal injuries; disability; mental health and substance use; the use of No. 36, Sexual Behavior, Sexual Attraction, and Sexual Identity in the
hospital, medical, dental, and other services; as well as other health- United States: Data from the 2006-2008 National Survey of Family
related topics. Examples: Growth. (PHS) 2011.
No. 248, Summary Health Statistics for the U.S. Population: National Health, United States. Annual report presented to the President and
Health Interview Survey, 2009. Public Health Service. (PHS) 2011. Congress. In 2010, the report entitled Health, United States, 2010 Â�highlighted
Includes incidence of acute conditions and episodes of persons death and dying.
injured, disability days, physician contacts, prevalence of chronic
conditions, limitation of activity, and self-assessed health status. BUREAU OF THE CENSUS, DEPARTMENT OF
Data estimates are reported by subgroups of population, including COMMERCE, WASHINGTON, DC
by age, gender, race, income, and geographic region. This publica- Website: www.census.gov
tion is updated yearly. Statistical Abstract of the United States
No. 249, Summary of Health Statistics for U.S. Adults: National Compiles detailed statistics at the city, county, state, and national levels
Health Interview Survey, 2009. (PHS) 2011. on births, marriages, divorces, and deaths. Available online or selected
No. 247, Summary of Health Statistics for U.S. Children: National statistics published in book form approximately 2â•›years after the report-
Health Interview Survey, 2009. (PHS) 2011. ing year ends.
No. 246, Family Structure and Children's Health in the United States: National Vital Statistics Report
Findings from the National Health Interview Survey 2001-2007. Provides provisional up-to-date tallies on births, marriages, divorces,
(PHS) 2011. and deaths on a monthly basis. Data are usually published 3 to 5â•›months
Series 11, Data from the National Health Examination Survey, the National after data are gathered.
Health and Nutrition Examination Survey, and the Hispanic Health and Current Population Reports
Nutrition Examination Survey. Data collected by direct examination, test- Series are periodically updated with new volume numbers.
ing, and measurement of national samples of population are the basis for Current Population Reports, Series P-25
estimates of prevalence of specific diseases and their distribution in the Reports on population estimates and projections with local, state, and
U.S. population with respect to physical, physiological, and psychological national summaries. Example:
characteristics. This series has infrequent publications. Examples: P25-1139, Coastal Population Trends in the United States 1960 to 2008.
No. 250, Body Composition Data for Individuals 8 Years of Age and Current Population Reports Series P-23, Special
Older: U.S. Population, 1999-2004. (PHS) 2010. Studies
No. 248, Trends in Oral Health Status: United States, 1988-1994 and Provides a wide range of sample survey and census data on demo-
1999-2004. (PHS) 2007. graphic, social, and economic trends in the United States. Examples:
Series 13, Data on Health Resources Utilization. Statistics on the uti- P23-211, The Older Foreign-Born Population in the United States: 2000.
lization of health manpower and facilities providing long-term care, P23-210, The Big Payoff: Educational Attainment and the Synthetic
hospital care, and family planning services. Examples: No.Â€169, Estimates of Work Life Earnings.
Ambulatory Medical Care Utilization Estimates for 2007. (PHS) 2011. P23-209, 65 + in the United States: 2005. Published December 2005.
No. 167, The National Nursing Home Survey: 2004 Overview. (PHS) 2009. Current Population Reports, Series P20
For Advanced Practice and Nursing Researchers: Reports of population characteristics for subgroups of the population.
Series 1, Programs and Collections Reports. Reports describe general Examples:
programs of the National Center for Health Statistics, its offices and P20-563, Fertility of American Women: 2008.
divisions, and the data collection methods used. Example: P20-561, America's Families and Living Arrangements: 2007.
*Most states have at least one library designated as a depository for government publications. Your local librarian can refer you to the nearest
depository. Most government publications are available online.
BOXÂ€15-5â•…â•‡ SAMPLE SOURCES OF HEALTH AND POPULATION DATA—CONT'D

Current Population Reports, Series P-60 CENTERS FOR MENTAL HEALTH SERVICES,
Reports on consumer income issues. Examples: SUBSTANCE ABUSE, AND MENTAL HEALTH
P60-238, Income, Poverty, and Health Insurance Coverage in the SERVICES ADMINISTRATION
United States: 2009. Performs targeted sample surveys on mental health and addictions.
P60-232, The Effects of Taxes and Transfers on Income and Poverty Surveys are also done on specialty mental health organizations every
in the United States: 2005. 2â•›years.
GOVERNMENTAL ACCOUNTING OFFICE U.S. DEPARTMENT OF JUSTICE, BUREAU

Website: www.gao.gov OF JUSTICE STATISTICS
Develops and publishes reports requested by all branches of the fed- Performs national crime victimization survey that samples households
eral government, including health-related issues. Usually reports are for crime incidents, victims, and trends in violence and crime.
done in response to policy issue. Example: President's Emergency Plan
for AIDS Relief: Efforts to Align Programs with Partner Countries HIV/ OCCUPATIONAL SAFETY AND HEALTH
AIDS Strategies and Promote Partner County Ownership. (GAO 10-836). ADMINISTRATION
Published September 20, 2010. Concerned with workplace safety. Conducts workplace safety inspec-
tions and issues regulations regarding workplace safety procedures.
CONGRESSIONAL BUDGET OFFICE
Website: www.cbo.gov U.S. ENVIRONMENTAL PROTECTION AGENCY
Develops and publishes studies requested by members of Congress on Collects data on airborne and water pollution via 4000 stations nation-
policy issues, including health issues. Example: Effects of Using Generic wide. Has reporting systems that track water and waste discharge and
Drugs on Medicare Prescription Drug Spending. September 2010. toxic chemical releases.
If communities have small populations, surveying the entire the value of proceeding with your intervention as initially
population is best. When surveying the entire population is designed would be in question. You might conclude that no
impractical because of time, cost, or difficulty reaching the com- knowledge deficit really exists or that you need to increase the
munity members, random sampling of the community is recom- sophistication of the material to be taught.
mended (Polit & Beck, 2010). Random sampling allows the results
from the sample to be generalized to the entire population. Interviews with Key Informants
Interviews with key informants—people in the community and
In one urban city, nurses who were interested in determining leaders of the community—are valuable sources of data. These
the dietary habits of middle-school children used a survey
Â� interviews and conversations can provide focus as well as a great
approach. A food habits questionnaire was distributed to deal of information. The community health nurse should use
223 sixth-grade, seventh-grade, and eighth-grade students every opportunity to interact with the people in the commu-
(Frenn & Molin, 2003). Surveys were distributed during sci- nity. These individuals are the richest sources of information
ence class after parental approval was obtained. Of the 223 about their health status, interests, community problems and
targeted students, only 2 did not complete the survey. strengths, and possible solutions.
Interviews may be open ended in which the interviewer
Whenever you develop a tool or survey, be sure to first per- starts by asking a few broad questions. Interviews also may be
form a pilot study with a small sample of a similar population. highly structured, using formal surveys. To prevent misunder-
That is, if you are planning to survey elementary school chil- standings, interviews should be conducted in the primary lan-
dren, have five or six children of the same age complete the guage of the persons who are being interviewed. When using
survey. The pilot study helps determine whether the survey the primary language is not possible, bilingual interviewers or
was tailored to the characteristics of the study population with translators will be needed.
respect to reading level and the time needed to complete it. In Vulnerable populations can be targeted. For example, in
addition, the pilot study can help illuminate any ambiguous or preparation for developing an intervention program to prevent
confusing directions or whether any questions are asked that childhood obesity, Fineholt, Michael, and Davis (2010) engaged
allow different interpretations. rural high school students in a 12-week photovoice project. The
Either the survey format or specific questions might need goal was to engage youth in the assessment of community char-
to be altered on the basis of the results of the pilot study. acteristics they believed had an effect on children's food choices
Directions may need to be clarified, the time allowed may need and physical activity. Each student was provided with two
to be lengthened, or the survey itself may need to be shortened. disposable cameras to take photographs and participate in
Questions may need to be modified to reduce confusion or to sessions to analyze the photos and identify thematic problems
obtain more detailed information. and strengths related to childhood obesity in their commu-
When conducting a knowledge survey, knowing if the pilot nity. Public awareness was increased when the youth presented
group can answer all or most of the questions without a health their findings at multiple community meetings. Similar assess-
intervention would be helpful. For example, if you were plan- ments can be conducted with the chronically mentally ill, older
ning a health education program on safety and found that the adults, the disabled, or the formerly homeless living in other
pilot group was able to correctly answer most of the Â�questions, communities.
Meetings with Community Groups TABLEÂ€15-2â•…â•‡PROS â•›AND CONS OF DATA

Community forums are regular or special public meetings that COLLECTION METHODS
provide an opportunity to obtain input from members of the
DATA COLLECTION
community regarding their opinions about needs, services, or
METHOD PROS CONS
specific health-related topics. Forums can be open to the entire
community, or they can focus on a small segment or subgroup Surveys written Reliable Low return rate;
of the community. Town meetings are one example of a com- costly (i.e., mailing
munity forum. The advantage of the forum approach is that it and printing costs)
is a relatively cost-efficient and cost-effective way of obtaining Verbal (person-to- Good return rate; Time consuming
person or by participants may
opinion data from the community.
telephone) provide additional
Focus groups are conversations held in a group with a small
information that is
number of people (usually 5 to 10) to identify different percep-
valuable
tions and experiences about a subject (Polit & Beck, 2010). Focus Interview of key Inexpensive: valuable Biased view
groups are usually held with more than one group to identify informants subjective data that
patterns in perception. For example, focus groups might be held may be difficult to
in a community early in the assessment process to identify pat- obtain on written
terns or themes regarding perceived community strengths and survey
health problems. Community forums Provide opportunity May be difficult to
Focus groups can be used to include vulnerable and pre- for wide variety of keep the forum
viously underserved members of a community to under- community members from becoming a
stand their health problems and strengths and to identify to supply input grievance or gripe
possible culturally competent interventions. A health edu- on wide range of session
cator describes the process of using a community network topics regarding
strategy in a Midwestern state to identify needed and cultur- community; may
ally appropriate health care services for underserved Korean find an otherwise
immigrants (Kim etÂ€al., 2002). Four different resource groups unidentified need
participated, including representatives of the Korean commu- Census tract data Readily available; Collected only every
nity, Korean health care professionals, and representatives for show trends over 10â•›years
the targeted population of low-income Korean immigrants. time
To succeed, the authors used group participants to identify Preexisting reports Readily available; May not include
(1) an appropriate service site accessible to the target popula- and publications show trends over data for specific
time community being
tion, (2) appropriate communication strategies to inform the
assessed by nurse
target group of available services, and (3) the mental health
needs of the target population as well as the barriers to seek-
ing mental health services. In another example, in focus group
conversations with women in abusive relationships, nurses This expanded analysis fosters improved health planning
were able to identify facts that inhibit, support, or sustain a and evaluation by providing a visual presentation for Â�specific
woman's ability to leave and stay out of an abusive relation- health issues (Nykiforuk & Flaman, 2011). The CDC has
ship (Lutenbacher etÂ€al., 2003). multiple examples of GIS maps documenting the occurrence
As you can see, many types of data collection can be used. of chronic diseases in the United States. Several metropolitan
Only a few examples have been described here. TableÂ€15-2 areas, for example, Indianapolis, have publicly accessible GIS
summarizes the pros and cons of various methods of data data as do several cities coordinated by the Urban Institute
collection. (Riner etÂ€al., 2004) (see Website Resources 15D, 15E, and
15F for additional information about GIS and an example
of a GIS map for Heart Disease Death Rates by County.
Geographical Information Systems
Geographical information systems (GIS) are computer-based APPROACHES TO COMMUNITY ASSESSMENT
programs used to store and statistically manipulate geo-
graphical and location-based data to provide visual maps. Just as the assessment of the individual or family can be
Traditionally, public health professionals plotted communi- approached in a variety of ways, so also can the assessment of a
cable disease outbreaks on wall maps; these could be over- community. The approach taken depends on the type of com-
laid with transparent sheets to show changes in cases over munity and the reason for the assessment.
time. Computers allow multiple data to be overlaid. Data can
include demographics, morbidity and mortality, cases of com- Comprehensive Needs Assessment Approach
municable diseases, reported health behaviors, housing types, As the name implies, comprehensive needs assessment is the
distribution of health facilities and services, and sources of most thorough assessment of the community; it is also the most
environmental exposures, among others. This assists public traditional and the most time consuming. In the comprehensive
health practitioners to analyze health disparities, disease out- approach, the nurse begins with the total community (geopo-
breaks, availability and use of resources, and the relationship litical or phenomenological) and uses a systematic process to
of environmental exposures with health problems (Choi etÂ€al., assess all aspects of the community to identify or validate actual
2006; Riner etÂ€al., 2004). and potential health problems.
the same, but it is more narrow in scope because it focuses on

In the previously cited example, Kim and colleagues (2002)
one population. Data and literature are collected related to the
described the comprehensive process nurses used in con-
health behaviors and health status of the specific population.
ducting an assessment among Chicago area Korean immi-
grants to determine what culturally appropriate health
education and services were needed. First, interviews with The Farm Worker Family Health Program (FWFHP) is a
selected Korean community leaders were conducted, fol- 13-year-old partnership that serves migrant farm workers
lowed by interviews with selected health and social services (a single population). The partnership comprises five col-
providers. Next, focus groups of the targeted Korean immi- leges and universities, a federally funded farm worker health
grant were conducted. Periodic assessments and reevalua- clinic, the local school system, and area health education cen-
tions were conducted over the 4-year development phase for ters (AHEC) (Connor etÂ€al., 2007). The purpose of the part-
this bilingual, interdisciplinary project. nership is to increase the delivery of health care services to
migrant farm workers and their family members. An urban
school of nursing coordinates the partnership in the south-
Problem-Oriented Approach east United States. Undergraduate nursing students and
In the problem-oriented approach, the community/public nurse practitioner students work with students from other
health nurse assesses a community in relation to a specific topic professional schools to supplement services of the clinic and
or health problem. The nurse begins the process with the prob- the summer school for children of migrant families.
lem or topic area and then assesses a specific community in rela-
tion to that subject.
Familiarization Approach
A group of nursing students was interested in the subject of Familiarization involves studying data already available about a
AIDS. The group's community/public health clinical course community (e.g., census tract data, surveys, and other official
expected the students to plan and implement a community- data from the health departments). This approach helps the
oriented health project. Because of their particular interest, community/public health nurse focus on special populations
they decided to do an AIDS-related project (the problem). The (aggregates or groups) that have similar characteristics and
literature review identified potential communities in which may have health care needs. TableÂ€15-3 provides examples of
AIDS was a serious problem. census tract data to be used in the geopolitical case study at the
Potential aggregates for intervention included intrave- end of the chapter. Information from these data indicated that
nous drug abusers or sexually active homosexuals. The lit- many children and adolescents lived in this census tract. Having
erature also identified the need for health-promotion and identified the youth as a target population, the community
illness-prevention programs for sexually active adolescents health nurse would focus the assessment on this aggregate.
and female sexual partners of intravenous drug users. The
students chose an adolescent population of eleventh grad- Peterson and colleagues (2002) described using secondary
ers and assessed the population in relation to the topic. As a data sources to document the health-promotion needs of cer-
result of a survey, the students determined that a knowledge tain church attendees. Demographic data from the National
deficit regarding HIV transmission existed, and a primary Vital and Morbidity Statistics, the task force of the National
prevention program was developed. Institutes of Health Women's Health Research Agenda, and the
Healthy People 2010 National Health Objectives were used to
In another community, in response to local concerns about support the need for a midlife women's health-promotion
the health needs of older adults, a community assessment of program designed to increase physical activity and reduce
Escalante, Arizona, was completed. The assessment led to the risk of cardiovascular disease.
development of a multifaceted intervention model designed
to improve and maintain the functional health of community ANALYSIS
seniors (Nunez etÂ€al., 2003). The Escalante Health Partnership
has a two-pronged intervention approach. First, community The areas of consideration for data analysis include commu-
resources such as city officials, hospitals, community leaders, nity assets, major problems, major health-related problems,
and health professionals were targeted to expand the coalition current and proposed community action for problem reso-
so as to increase participation and expand services to seniors. lution, and the community's pattern of action involving past
Second, community seniors were targeted with the intent of problems.
reducing disease and disability in this vulnerable population. When applying a systems analysis to the data, three param-
eters are used to make inferences about the level of health:
Single Population Approach • Congruency must exist among the physical, psychological,
Some community/public health nurses may be employed by a and social data and imperatives.
health department or a nonprofit organization to work with a • The community requires a minimum amount of energy to
single population. In the single population approach, the com- function (efficiency).
munity/public health nurse assesses one population in a com- • The health status behaviors must be satisfying to the popula-
munity (e.g., women of reproductive age, teenagers, homeless tion and the community (University of Maryland School of
persons, migrants). The nurse begins the process with defining Nursing, 1975).
the population and then assesses the population in a specific Physical imperatives include safe air, food, and water.
community. Often, the population has already been determined Nonabusive interpersonal relationships are an example of
to be an especially vulnerable one. The process of assessment is a psychosocial imperative. For an example of efficiency,
TABLEÂ€15-3â•…â•‡2000 CENSUS TRACT

â•› DATA FOR CENSUS TRACT 1 IN CITY X (TO USE â•›WITH THE
â•›
NURSING PROCESS IN PRACTICE: A GEOPOLITICAL COMMUNITY)
Note: Bolded data are answers to the Geopolitical Community Assessment starting on page 417
NUMBER PERCENTAGE* NUMBER PERCENTAGE*

I. Population statistics 7924 Native of United States 7838 98.9
â•… A. Total population Native of foreign country 82 1.0
â•… B. General characteristics or mixed
â•…â•…1. Race Foreign born 4 0.1
White 8 0.1 â•…â•… 2. School enrollment 3785
Black 7899 99.7 Elementary 2544 67.2
â•…â•… 2. Age (years) by gender High school 834 22.0
Male College 108 2.9
Total 3408 43.0 â•…â•… 3. Years of school completed
Under 5 548 6.9 Persons 25 and over 2217
â•‡5–9 743 9.4 No school completed 50 2.3
10–19 1280 16.2 Elementary, 1–4 194 8.8
20–34 401 5.1 Elementary, 5–7 531 24.0
35–54 293 3.7 Elementary, 8 333 15.0
55–64 89 1.1 High school, 1–3 615 27.7
65–74 33 0.4 High school, 4 427 19.3
75 and above 21 0.3 College, 1–3 47 2.1
Female College, 4 or more 20 0.9
Total 4516 57.0 Median school years 9
Under 5 522 6.6 completed
â•‡5–9 782 9.9 â•…â•… 4. Mobility of residents,
10–19 1323 16.7 1985-1990
20–34 930 11.7 Same house 3791 50.1
35–54 701 8.8 Different house
55–64 140 1.8 Central city 1744 22.0
65–74 80 1.0 Other part of SMSA 72 0.9
75 and above 41 0.5 Outside SMSA 20 0.3
â•…â•… 3. Persons per household Mean = 4.48 Abroad 11 0.1
â•…â•… 4. Type of family Unknown 2116 26.7
Total number of families 1586 â•…â•… 5. Means of transportation
Families with children under 18 1363 85.9 and place of work
Husband–wife families 471 29.7 Total number of workers 1620
Families with other male head 42 2.6 a. Transportation
Families with female head 1002 63.2 Private auto (driver) 234 20.6
â•…â•… 5. Marital status Private auto (passenger) 245 15.1
Male Bus 931 57.5
Total (over 14) 1502 Subway, train 0 0
Single 878 58.4 Walk 102 6.3
Married 543 36.2 Work at home 0 0
Separated 39 2.6 Other 8 0.5
Widowed 31 2.1 b. Place of work
Divorced 11 0.7 Inside SMSA 1149 70.9
Female City X central 118 7.3
Total (over 14) 2577 business district
Single 1036 40.2 Remainder of City X 874 54.0
Married 572 22.2 Surrounding counties 156 9.6
Separated 582 22.6 Outside SMSA 14 0.9
Widowed 246 9.6 Not reported 457 28.2
Divorced 141 5.5 â•… D. Labor force characteristics
â•… C. Social characteristics â•…â•… 1. Employment status
â•…â•… 1. Nativity, parentage, and Male
country of origin Age 16 and over 1285
All persons 7924 In labor force 832 64.7
SMSA, Standard Metropolitan Statistical Area.

*Numbers may not add up to 100% because of rounding or missing data.
TABLEÂ€15-3â•…â•‡2000 CENSUS TRACT DATA FOR CENSUS TRACT 1 IN CITY X (TO USE WITH THE
NURSING PROCESS IN PRACTICE: A GEOPOLITICAL COMMUNITY)—CONT'D
NUMBER PERCENTAGE* Number Rate per

Female 100,000
Age 16 and over 2334 III. Vital statistics
In labor force 938 40.2 A. Births
Total live births 140 18
â•…â•…2. Occupation
Neonatal deaths 3 21.4
Total employed 1596
(before 28â•›days of age)
(age 16 and over)
Infant deaths (before 1â•›year 2 14.2
Professional, technical, 90 5.6
of age)
and kindred workers
Premature single live births 20 3
Managers and 37 2.3
Single live births 140 18
administrators
Live births to mothers
Sales workers 75 4.7
Below 17â•›years of age 32 4
Clerical and kindred 260 16.3
Below 20â•›years of age 67 17
workers
Live births to mothers
Craftsmen, foremen, and 136 8.5
With inadequate 11 78.6
kindred workers
prenatal care
Operatives 365 22.9
With less than tenth grade 33 235.7
Laborers 125 7.8
education
Service workers 403 25.3
Live births to mothers with five 23 164
Private household workers 105 6.6
or more children
â•… E. Income characteristics
B. Mortality (SMSA)
â•…â•… 1. Mean income $14,220
Total deaths 36 454
â•…â•… 2. Source of income
Maternal deaths 1 13
Number of families 1525
Coronary heart disease 7 88
Wage or salary 806 52.8
Cancer 7 88
Self-employed 18 1.2
Stroke 0 0
Farm self-employed 0 0
Diabetes 2 25
Social Security 200 13.1
Liver cirrhosis 2 25
Welfare 501 32.9
Influenza and pneumonia 1 13
â•…â•… 3. Income below the poverty level 742 48.7
Drug dependence 1 13
Number of families
All accident deaths 3 38
II. Housing characteristics
Motor vehicle deaths 0 0
Total units 1770
Homicides 7 88
Vacancy status 6 0.3
Suicides 1 13
Owner occupied 138 7.8
Congenital anomalies 4 50
Renter occupied 1626 91.9
IV. Morbidity: reportable diseases
Lacking plumbing 9 0.5
Total incidence 498 6285
Number of rooms
Tuberculosis (all forms) 2 25
1–2 21 1.2
Syphilis 19 240
3–4 1013 57.2
Gonorrhea 462 5830
5–8 734 41.5
Hepatitis B 3 38
9 or more 2 0.1
Hepatitis A 1 13
Median 4.3
Chickenpox 11 139
Persons per room
Mumps 2 25
1.00 or less 1035 58.7
Rubella 1 13
1.01–1.50 534 30.3
Salmonellosis 7 88
1.51 or more 195 11.1
Shigellosis 2 25
Contract rent (per month)
Streptococcal infection 1 13
Less than $300 21 1.5
Lead poisoning 1 13
$301–349 41 3.0
Bacterial meningitis 1 13
$350–449 48 3.5
HIV 7 88
$450–549 471 34.6
$550–649 489 36.0
$650–749 239 17.6
$750–849 49 3.6
$850 or more 1 0.7
No cash rent 2 1.5
Â�
consider communities X and Y. Both have similar health Through analysis of the relationships between the compo-
behavior trends related to the incidence of heart disease in nent parts of a community system and its external environment
Â�
their communities. However, the average length of hospital stay (suprasystem), the health status of the community may be
in community X and the cost of treatment are 20% higher than determined; its strengths, assets, and health needs identified;
those in community Y. From these data, the nurse can infer that priorities established; and programs planned and implemented.
community X is not operating as efficiently as community Y. The next chapter focuses on analysis of the data and planning
Similarly, a community may appear to have an acceptable level and implementing appropriate interventions.
of health, but community members may express dissatisfac- The Nursing Process in Practice box describes a geopolitical
tion about the way they are treated at health care facilities. From community and a phenomenological community. Use the com-
these data, the nurse can infer that the community is not func- munity assessment tool in Box 15-4 to organize the data available
tioning up to its capacity because it is not meeting one of the for each community. Then, compare your assessments with the
parameters. completed assessment tools included for each of the applications.
KEY IDEAS
1. Community/public health nurses assess communities to 6. Influences from the suprasystem and the internal processes
determine the assets and critical health needs as a basis for of the community may be positive (resources) or negative
planning and implementing effective nursing care. (demands).
2. A community contains three essential elements: people, 7. For the community/public health nurse, the process of data
place, and social interaction or common characteristics. collection in community assessment may include observing
3. An organized framework for gathering data will help the the community, interviewing community members, review-
community/public health nurse comprehensively assess a ing community records, reading local newspapers and peri-
community and identify missing information. odicals, examining government documents, reviewing the
4. Developmental, epidemiological, structural–functional, and professional literature, and conducting surveys of commu-
systems frameworks may be used to assess communities. This nity members.
text uses a systems framework for community assessment. 8. A community/public health nurse may approach community
5. The first step in community assessment is determining the assessment comprehensively or focus on a preselected health
community's boundaries. The boundaries help the nurse problem or population.
identify which processes and resources are internal to the
community and which affect the community from the exter-
nal environment, or suprasystem.

A Geopolitical Community and a Phenomenological Community
A GEOPOLITICAL COMMUNITY* to attempt to reduce crime. This program resulted from combined efforts
Census tract 1 (CT 1), located in city X, is bounded on the north by First of the local police, church leaders, school officials, and the city council.
Avenue, on the south by Tenth Avenue, on the west by A Street, and on the City X has a mayor and a city council, with one city council member basi-
east by J Street. Although this CT is zoned for residential use, previously cally representing CT 1.
existing stores are allowed to remain but cannot expand. Most people CT 1 suffers from moderate air and noise pollution. The major source
within this CT do not know that CT boundaries exist. Therefore, the resi- of pollutants is traffic, which contributes sulfur dioxide, carbon monox-
dents do not form any real bonds based on location alone. Neighborhood ide, and hydrocarbons. Several industries, an airport, and a train station
schoolyards and recreation centers, a library, a multipurpose center, and are located within a 10-mile radius of this CT and also contribute pollut-
churches help contribute to a sense of community. Several clubs and orga- ants. Residents benefit from both city water and a city sewage system.
nizations within the CT also contribute to a sense of community, includ- Drinking water is chlorinated and fluoridated.
ing various church groups, Boy and Girl Scouts, the urban 4-H Club, the In times of need, community members tend to turn to certain people
senior citizens center, the Young Men's Christian Association (YMCA), Big within the community for advice and assistance. These individuals include
Brothers and Big Sisters, and a soup kitchen. Churches within the CT are church leaders, the director of the YMCA, a worker at the soup kitchen,
primarily Baptist, Methodist, or storefront churches. This community rec- the manager of Paul's Corner Store, and the owner of Gibby's Pawn Shop.
ognizes several church leaders as community leaders. Within the CT are numerous small businesses such as restaurants,
CT 1 is located in an inner city area. The streets look relatively clean, barbershops, cleaners, fast-food carryouts, corner markets, pawn-
but some alleys and backyards have litter and broken glass. Stray dogs shops, and taverns. Numerous appliance, bakery, clothing, discount
abound, and places for rats to breed are abundant. The crime rate is department, drug, florist, food, furniture, hardware, hobby, indus-
almost twice that of city X overall. Property crime rates are higher than trial supplies, jewelry, liquor, shoe, and wig stores are located within
are violent crime rates. A police station is located within the CT, and the CT. Most local stores extend credit but are also more expensive
a fire station is nearby. The city coordinates emergency medical ser- Â�compared with larger stores outside of the CT. Local food stores
vices. A neighborhood watch program has recently been implemented accept food assistance cards. Several large shopping centers and
*Adapted from Kidd, C. (1985). Case study: Geopolitical community. Baltimore, MD: University of Maryland School of Nursing Undergraduate
Program.
â•‡â•‡â•‡THE NURSING PROCESS IN PRACTICE—CONT'D

malls are located outside the CT; some of these are accessible by bus, community. Bolded data in the following assessment match data that
and others are accessible only by automobile. The CT is part of one are bolded in TableÂ€15-3.
school district composed of six elementary schools (grades K through
5), two junior high schools (grades 6 through 8), and one senior high Geopolitical Community Assessment of CT 1
school (grades 9 through 12). Boundaries
Two community/public health nurses from the nearby district office of the • People: residents of CT 1 number 7924 people.
city health department are assigned to provide nursing services to these • Place: this is a geopolitical community with defined borders.
schools. One nurse is assigned to the elementary schools, and the other is
1st Ave. N
assigned to the junior and senior high schools. Each nurse spends 1â•›day (8
hours) per week divided among her assigned schools. According to state
law, the nurses must follow up on designated communicable diseases
and required immunizations as their top priorities. Health problems com-
Cenus
A St.
J St.
monly referred to the nurses include communicable diseases and rashes, tract #1
W E
minor first-aid problems, pregnancy, chronic illnesses (e.g., diabetes, sei-
zure disorders, asthma), head lice, personal hygiene, and dental problems;
requests for birth control information and vision screening are also made.
Occasionally, the public health nurse teaches a class or large group S
10th Ave.
on a health-related topic. Within four blocks of the CT is a Head Start
Program offering daycare for children ages 2 to 5â•›years from 7:00â•›am to
• Common interests or goals: the residents live in the same area.
5:30â•›pm Monday through Friday. A waiting list is necessary, and families
• Suprasystem: city X. Look at the suprasystem to identify the resources and
must be eligible on the basis of income.
demands from outside the community (inputs) that affect the community.
Within the CT are one physician (general practice), one dentist, and one
podiatrist. A Planned Parenthood office is located outside the CT but is Goals
accessible via the bus line. The district office of the city health department The goals of any geopolitical community are to promote the survival and
is located a few blocks from the CT and provides maternity, well-baby, maximize the well-being of the community. No specific goals are listed
well-child (through age 6â•›years), sexually transmitted disease, immuniza- in the description.
tion, and chest radiography services. Home-visiting services are provided
to home health care clients and to some clients as follow-up to clinic ser- Characteristics
vices. Located next to the district health department is the inner city com- Physical Characteristics
munity mental health center, which provides five basic services: therapy, 1. Length of existence is not identified but might be determined by a
partial hospitalization, crisis intervention, referral to inpatient psychiatric review of city history.
settings, and consultation. The Inner City Nursing Home is a 314-bed long- 2. Demographic data (see TableÂ€15-3 for the source of the answers pro-
term care facility that offers skilled nursing care for convalescent, chroni- vided in this section):
cally ill, and aged clients. Although the home is located near the CT, the • Age: the largest age group is 10 to 19â•›years old (1280 boys + 1323
occupants of the facility are drawn from a much larger geographical area. girls = 2603 of 7924 total population, or 33%).
The majority of CT residents use one or more of three public and • Race: almost exclusively African American (99%).
nonprofit hospitals. Hospital emergency department services are used • Gender: more girls and women (57%) than boys and men (43%) in
extensively for acute care; hospital outpatient department services are the community.
used less frequently. These three hospitals accept all third-party reim- • Ethnicity: the community consists of mostly native-born citizens of
bursements and charity cases. Outside the CT but within a 20-mile the United States (98.9% native-born children of native-born
radius are various other health care facilities, including two private parents).
home health agencies, six hospitals (some private and some public), • Characteristics of housing: most individuals rent (1626 of 1770
and numerous physician and dentist offices (most requiring payment households, or 92%) and live in small housing units. The median
at the time of service). Health-related and social-related associations number of rooms is 4.3. Most residents pay between $450 and
and organizations outside the CT, but providing services to those who $649 per month (471 + 489 = 960 of 1626 renters, or 59%).
need it, include the Agricultural Extension Service, American Cancer • Density of population: the population is rather dense, with an aver-
Society, American Diabetic Association, American Heart Association, age of 4.48 persons in each household.
American Red Cross, Association for Retarded Citizens, Birthright, 3. Physical features of the community: the CT is urban, is relatively
Child Development Center, Childbirth Education Association, Crisis clean, and has residential and business areas.
Intervention, Services for Children with Special Needs, Drug Abuse
Center, Family and Children's Society, Family Crisis Center, Goodwill Psychosocial Characteristics
Industries, Health and Welfare Council, La Leche League, League 1. Religion: the two denominations with the greatest number of
for the Handicapped, Legal Aid Bureau, American Lung Association, churches are Baptist and Methodist.
Meals on Wheels, National Association for the Advancement of 2. Socioeconomic class: this community is poor, with a mean yearly
Colored People, March of Dimes, Poison Control Center, Public Housing income of $14,220. Forty-nine percent of families live below the pov-
Authority, Rape and Family Abuse Center, Right to Life, Salvation erty level (742 of 1525), and 33% are on welfare (501 of 1525).
Army, United Way, and Vocational Rehabilitation Center. 3. Education: the median level of education is ninth grade; only 3% of
TableÂ€15-3 presents 2000 census tract data for CT 1. Use that table individuals 25â•›years of age and older have some college education (67
and the CT description to complete an assessment of this geopolitical of 2217).
Continued

4. Occupation: the three largest job categories for workers in this com- their marital status as either married or single. The community health
munity are service jobs, operative jobs, and clerical positions. nurse would want to explore the reasons for the discrepancy to reach a
5. Marital status: marital status data are collected on residents 14â•›years clearer understanding of the marital status of community residents.
of age and older. Twenty-seven percent of persons report that they are 6. Family composition: the community consists primarily of young fami-
married (1115 [543 men + 572 women] of the eligible population of lies, the majority of which are headed by single females. Thirty per-
4079 [1502 men + 2577 women]). Forty-seven percent report their mari- cent of households are headed by a husband and wife; 63% are
tal status as single (1914 [878 men + 1036 women] of 4079). Note headed by single women. Eighty-six percent of all households have
the discrepancy between the number of men and women who list children under the age of 18â•›years.
External Influences from the Suprasystem

Resources Demands
Money No information is given about budget inputs or financial demands on the community from the suprasystem.
The community health nurse should attempt to gather additional data on the question.
Facilities Inner-City Community Mental Health Center
Inner-City Nursing Home Nursing home is not exclusive to community.
Shopping centers and malls Shopping access is limited.
District office of city health department
Planned Parenthood Office
Six hospitals
Two private home health care agencies
Industry, airport, and train station (may provide employment) These entities contribute pollutants to the community.
Formal human services Numerous physicians and dentists
All social and health agencies listed at the end of the community
description (e.g., Poison Control Center and American Cancer
Society)
City water and sewer
Emergency medical services
Head Start Program
Bus transportation
Health information May be provided by the same social and health agencies listed at the
end of the community description. The nurse would need to find out
which of these do and which do not provide health information and
education to the community.
Legislation No information is available at this time. However, the community health nurse should be aware of or attempt to discover what
city legislation affects the community (e.g., City X Board of Education would determine school policies and plans and direct the
activities of all schools in the city, including those in this community).
Values Crime rate of city X is less than that of the CT. City X's
environmental pollutants affect the community.
Internal Functions of the Community

Economy
Resources Demands
Formal human services Public health nurses in schools Services of school nurses are limited.
Scouts
Urban 4-H Club
Big Brothers and Big Sisters clubs
Police
One physician, one dentist, one podiatrist Services are not adequate to meet the needs of the community.
No daycare facilities, community colleges, or technical schools are in
the community.
Informal human services Church groups There are higher prices in local stores compared with those outside
the CT.
Number of small businesses that extend credit and
accept food stamps

Resources Demands
Facilities, equipment, goods Schools No parks or shopping malls
Churches Lack of cars for transportation
Recreational centers High property crime rate
Library Environmental hazards such as stray dogs and rats
Senior Citizen Center
YMCA
Money Little is known about this topic. One area to explore would include an appraisal of the money acquired and spent within the
community. Because this community is part of a larger city, the budget for infrastructure support would come from the city.
Information might be obtained about the taxes collected from residents of this community and that amount compared with
the money spent by the city on providing services to the community. Is more money collected by the city than is spent on
community needs, or is more money spent on community needs than is collected from residents?
Education Little is known about how members are socialized and educated to function productively. The educational level of this community
is low, and many members live below the poverty level. Many of the persons who are employed are employed in occupations
that require little advanced education.
Analysis of Economy: The community has relatively few resources • Verbal: Informal communication occurs wherever people gather and
to meet the health-related needs of its members. The economy of the talk (e.g., the corner store, in churches, in other group activities). A
area is relatively weak in terms of goods and services, including many bulletin board is used to post notices, but it is not known if any com-
demands that are not being met. In planning health services for this munity newspapers or periodicals are published.
community, funding should be considered. The nurse should explore get- Analysis of Communication: A variety of opportunities for social gather-
ting funding sponsors or city funding or should pursue grants from phil- ing and exchange of information are available. Little evidence exists to sug-
anthropic and government sources. gest that the community has the capacity to communicate easily with all
its members (e.g., a newspaper). In planning health care, the nurse should
Polity be aware of the usual avenues of communication within the community so
• Organizational structure: The community is part of city X; it does not that he or she can use them to gather and disburse information to members.
have its own organizational structure. In reference to communication on health-related matters, the nurse
• Leaders: The formal leaders include the local representative to the would want to know if community residents express their needs and con-
city council, church leaders, and local business owners. The informal cerns to health care providers and whether health care providers seek
leaders include the manager of the corner store, the pawnshop owner, out or listen to community concerns. Do health care providers communi-
the worker at the soup kitchen, and the director of the YMCA. cate among themselves? Are they involved in coordinating services? Do
• Patterns of decision-making: Because this community is only a por- providers determine the care and service needs by themselves? More
tion of the larger city, many of the decisions that affect it are prob- information is needed.
ably made from outside the community. For example, the City X Board
of Education makes the decisions related to the local schools. Some Values
of the questions a nurse might want to ask to get additional informa- • Traditions: No information is available in the description on commu-
tion in this category include the following: Does the council member nity traditions.
meet with other leaders and community members to address con- • Subgroups: There are a number of subgroups and aggregates that
cerns and problem solve, or does he or she make decisions with- can be identified by church attendance, age, and education. With the
out community input? How have past decisions been made? The number of churches within the community, a subgroup of individuals
Neighborhood Watch Program started with the combined efforts of who are actively involved in religious practices is apparent. The age
local police, church leaders, school officials, and the city councilman. of the population would indicate a substantial number of young indi-
• Methods of social control: In any geopolitical community, the police viduals (under 18â•›years old) as a subgroup. Single mothers as heads of
enforce the rules. Norms are established by schools, churches, neigh- household are another aggregate, and the median educational level
borhood expectations, family standards of conduct, and peer group reflects a large subgroup with minimal high school experience.
influences. The nurse would need to interview community members • Environment: The streets are clean; back alleys and backyards are lit-
to get a sense of the norms set by the community; no information is tered with debris and glass, providing a haven for rats. Stray dogs are
available at this point. present. The crime rate is higher than that in the city, and residents
Analysis of Polity: The community has a mix of formal and informal are subject to both property and violent crime. The environment is
leaders, but little is known about the norms representative of the com- relatively stark, and adherence to certain laws (e.g., littering, leash
munity. The nurse would need more data to complete an assessment of laws) is lax. The higher crime rate indicates a community that may
polity. In planning health care for the community, the nurse would be contain a higher proportion of residents who are less concerned with
especially interested in discovering which community norms might be adhering to laws related to private property and personal safety than
compatible with health care or health-seeking behavior. is contained in the city as a whole.
• Health: Community residents tend to rely on community hospitals for
Communication their health care needs. The emergency department is used more fre-
• Nonverbal: Residents feel a sense of community or belonging. Many quently than is the outpatient department, indicating that members
clubs and organizations are available for residents. place a greater priority on acquiring health care services when ill than
Continued

on seeking preventive health care. Nothing is known from the data who survive with congenital health problems. In addition, the literature
about residents’ attitudes toward health professionals. indicates that teenage mothers have a greater number of infants with
• Homogeneity versus heterogeneity: The community appears to be learning disabilities; thus, this community might be expected to experi-
homogeneous with respect to race, socioeconomic status, education, ence this problem. To validate this expectation, the nurse might survey
and residential maintenance. With the existing high crime rate and families, Head Start Program leaders, and school officials.
the organization of a Neighborhood Watch Program, the community is
apparently divided in its attitudes toward crime; however, many resi- Environmental Factors
dents appear to be concerned about personal safety. • Physical environment: Houses are crowded and not well kept. The air
Analysis of Values: Because of the degree of homogeneity, commu- contains a significant number of pollutants (i.e., sulfur dioxide, carbon
nity members appear to share similar values. Church groups and church monoxide, hydrocarbons). The city provides sewer and chlorinated
attendance are valued, as is parenthood. Community members are and fluoridated water. No additional information about the quality of
moderately concerned about the physical appearance of their property. the water supply is available.
Education and preventive health care are not especially valued, depend- • Social environment: The community is relatively stable; many resi-
ing on the level of education and the type of health care services used. dents have remained in the area for some time, but they are subjected
The nurse would need to consider community values in planning health to a high rate of crime and the stress that accompanies concerns for
programs or services to ensure community participation. personal and family safety.
Level of Health
Outcomes (Health Behaviors and Health Status) • Actual needs: Many health concerns can be identified from the exist-
People Factors ing data, including congenital anomalies; maternal, infant, and neo-
• Size: information to identify trends related to the size of the commu- natal deaths; sexually transmitted diseases, particularly syphilis,
nity is inadequate. The nurse would need population statistics over gonorrhea, and HIV infection; poverty; heart disease; deaths from
several time periods to determine whether this community is grow- drugs and cirrhosis; cancer; chickenpox; and air pollution.
ing, losing members, or remaining relatively stable. The total births • Potential needs: A knowledge deficit may exist about community resources
during this time are greater than the total deaths. A majority and the unacceptability or inaccessibility of community resources. The
of residents who were surveyed reported that they have lived rates of deaths from drugs and cirrhosis suggest that drug and alcohol use
in the same home or in a different home in the same general is higher than are national rates. Congenital anomalies might be related
area. The two factors seem to indicate a growing population that is to fetal alcohol syndrome, but more information is needed about the types
not very mobile and remains within the community limits. of such anomalies before a correlation can be determined.
• Mortality and morbidity: The mortality rate is 454 per 100,000 popu- • Community action: Some community action has been taken related to
lation. The three most common causes of death are heart disease, crime reduction, but community action related to health needs is not
cancer, and homicides. The most common communicable dis- available. One way to ascertain the community's response to health
eases are gonorrhea, syphilis, and chickenpox. Several vulner- needs would be to determine how the community has acted to solve
able or high-risk groups can be identified: pregnant adolescents and other health-related problems or if it has not acted to solve past health
their infants, sexually active teens, and poor individuals. The com- problems. Either way, the nurse will have information that will help
munity has many young mothers. The nurse can use pregnant adoles- determine whether the community can effectively address health issues.
cents to illustrate some of the presymptomatic illnesses or problems
that might be expected in this community: poor nutrition and anemia, A PHENOMENOLOGICAL COMMUNITY†
inadequate prenatal care, poor self-efficacy, and inadequate family Northview, a public high school (grades 9 through 12), is located in CT
support systems. Why would these problems be expected? The nurse 1 in city X; it is 1 of 10 public high schools in that city. The Northview
can use research to identify potential problems associated with spe- school district encompasses all of CT 1. Most of the students who attend
cific situations. ChapterÂ€24 documents research findings that identify Northview walk to school or take the city bus.
the social and health-related impacts of pregnancy. The school is a two-story red brick building built in 1962. The building
• Social functioning: The level of social functioning can be measured by and its grounds, which consist of a parking lot, an athletic field, and a
calculating the dependency ratio: small area of grass, cover one city block. The school is situated between
B and C Streets and between Second and Third Avenues. The main
Number of persons 20 years * * + number of persons > 65 years entrance to the school is on B Street. When approaching the school, the
× 100
Number of persons ages 20 through 64 years observer is struck by the rather stark appearance of the complex—no
For this community the dependency ratio is: trees, little grass, mostly concrete—and a moderate amount of litter
(paper, broken glass, and beverage cans) around the schoolyard.
 548 + 743 + 1280 + 522 +  The interior of the building is traditional in appearance. The long halls,
5273  782 + 1323 + 33 + 21 + 80 + 4  lined with lockers on either side, are painted a pale yellow; the floors are
  = 2.1 × 100 = 210 tiled, and the windows have grates over them for security. The entrance
2554  401 + 293 + 89 + 930 + 701 + 140 
  area next to the administrative offices has a display of trophies won in
various sports events and a bulletin board that lists the football schedule
This community is very dependent on its adult members. and various notices for students, faculty, and visitors. The first floor con-
• Types of disabilities or impairments present or expected: congenital sists of the administrative offices, health room, counselors’ offices, audi-
anomalies are known to be the fourth leading cause of death for this torium, music room, gymnasium, cafeteria, kitchen, and faculty lounge
community. The nurse can expect that there may be a number of infants area, a few small classrooms, and a common area. Students describe
**The number of people under 18â•›years is not listed, so the calculations are based on the number of people 19 or younger (the information that was available).
†
From Trotter, J. (1985). Description of a phenomenological community: A case study. Baltimore, MD: University of Maryland School of Nursing,
Undergraduate Program.

the common area as their place and is located just outside of the gym- Because Northview is part of the public school system, it must adhere
nasium; thus it is also convenient to use when ballgames are being to certain guidelines set forth by state and local authorities. The follow-
played. The area resembles a small teen center. The second floor con- ing policies are included:
sists of classrooms and a large media center. Lockers and bathrooms 1. All children must attend school until age 16.
are on both floors. The bathrooms have a lot of graffiti on the walls 2. Students must have at least 20 credits to graduate (1 physical edu-
but are fairly clean. The classrooms have a traditional appearance, with cation, 3 social studies, 2 mathematics, 2 science, 4 English, and 8
green chalkboards, individual chairs with arm desks, a teacher's desk, elective credits).
and some visual materials such as posters and signs. In several rooms, 3. All students must pass mastery tests in reading and mathematics to
hanging maps and screens appear to be in disrepair. The classrooms graduate from high school.
were designed to hold 30 to 35 students. The basement consists of the 4. Each school year must consist of a minimum of 180 instructional days.
physical maintenance plant, the science laboratories, and the industrial 5. All high schools in city X are in session from 8:00â•›am to 3:00â•›pm, with
arts classrooms. The stairways are at both ends of the halls. 30 minutes for lunch.
The staff at Northview includes the principal, Mr. Johnson; 32 teach- The budget is determined by the City X Board of Education. Funds for the
ers; 3 full-time and 2 part-time counselors; a psychologist who visits public schools are tax supported (city and state) and are allocated to schools
weekly or when called; a community/public health nurse from the local based on a formula that considers full-time-equivalent students (FTEs). This
health department who spends one-half day per week at the school; a year, the budget was cut in the areas of capital equipment and sports.
truancy officer who covers three schools; secretaries; cooks; janitors; The school is organized by departments. Each department has a chair-
and volunteers who staff the health room. The teachers are members of person (who is a faculty member) and a team leader. Each team or
the teachers' union and are active in its activities. department makes decisions about how to present the material, but the
The mean age of the teachers is 28â•›years. Most of the teachers are material must be within the overall curriculum guidelines. All faculty
women and have been teaching fewer than 10â•›years. The student members report to the principal. Northview has 11 departments: art,
to teacher ratio is 1:26, but this ratio includes special education business, English, foreign languages, home economics, industrial arts,
and resource teachers. The average class size is 35. Each teacher mathematics, music, physical education, science, and social studies.
is involved as a homeroom advisor in addition to having a regu- The physical education teachers are responsible for teaching the health
lar teaching assignment. The homeroom is a 20-minute period at component of the curriculum. Occasionally, the community health nurse
the beginning of each day. Each teacher is assigned approximately will teach a class on a health-related topic.
25 students as advisees. The homeroom period serves as an atten- The community/public health nurse spends one-half day per week at
dance and announcement time, as well as a time for some small the school. Because the meeting is not always held the same day each
group activities. week, the school principal announces over the public address system
The enrollment at Northview is 834: Of these, 275 are ninth graders when the nurse is in the building. The nurse then sees students in the
(140 female and 135 male students), 240 tenth graders (122 female health room based on self-referrals or referrals from teachers or other
and 118 male students), 200 eleventh graders (102 female and 98 male school personnel. The health problems most commonly referred to the
students), and 119 twelfth graders (61 female and 58 male students). nurse include communicable diseases and rashes, first-aid problems,
The enrollment was 852 last year. The students range in age from 13 pregnancy, chronic illnesses, personal hygiene, dental problems, and
to 19â•›years; 817 of the students are black, and 17 are of Asian descent. eating disorders (obesity and anorexia); requests for birth control infor-
The religion is predominantly Protestant. mation and vision screening are also made.
Northview is an active school with many organizations, clubs, and activi- During a recent visit to the school, some of the following comments
ties. Joanne Riley, president of the Parent Teacher Association (PTA), and concerns were overheard:
states, “It is very difficult getting a lot of the parents involved.” The PTA
meets once a month, and the average attendance is 30. The Student Students:
Government Association (SGA) is composed of representatives elected • “I can't wait until I get out of here. I'm quitting school as soon as I can.”
from each of the four classes. The group meets weekly to determine stu- • “I sure hope we win the trophy again this year.”
dent policies and to plan and coordinate student activities. The president • “My period is 3â•›weeks late; I think I might be pregnant. Do you
of the SGA, Pat Smith, says that the biggest problem he sees is that a lot of know where I can get an abortion? My dad would kill me if he
kids drop out of school as soon as they can. “It's hard to get some of these knew about it!”
students involved in school activities. Take Harry over there [he points to a • “I heard that if you take the pill too long, it does something to your
boy standing in the hall with about five other students around him]—what- blood.”
ever he says goes with many of the problem kids. Yeah, we definitely have • “Did you hear what happened to Angie? She got some kind of ter-
two kinds of kids here—ones who want to better themselves and ones rible infection from wearing a tampon. I sure hope that doesn't
who are here because they have to be.” Smith also says that students are happen to me.”
proud of their football team, which has won the regional championship for • “I never use a condom because it doesn't feel good.”
the last 3â•›years. The school publishes a monthly newspaper, The Viewer,
and an annual yearbook. The school is active in sports (football, basketball, Teachers:
track, and baseball) and has other activities such as drama club, dance • “If we don't get our raise this year, I'm quitting teaching.”
club, chorus, band, and cheerleading. Many of the clubs and organizations • “We just can't handle all of these kids unless we get more help in the
have fund-raisers to help support their activities. School dances are held classroom.”
at intervals during the school year, usually associated with special events • “I'm really concerned about the increasing number of pregnancies
such as the homecoming game or Valentine's Day. Schoolwide assemblies among our girls. Last year, there were 38, and there are already 45
are held during the school day approximately three times per year. this year. It's such a shame—they don't have any way to continue
Continued

their schooling. They drop out of school before the baby is born; and Characteristics
even though they say they're planning to come back, there's no one to Physical Characteristics
take care of the baby.” 1. In existence since 1962
• “I really think we need to do something about the increasing number 2. Demographic data:
of substance abuse and sexually transmitted disease cases.” • Ages: students, 13 to 19â•›years; faculty mean age, 28â•›years
• “You know these students don't go for regular health and dental • Race: students: 817 black (98%); 17 Asian descent (2%); staff and
checkups; they only go when they're sick or have problems.” faculty: unknown
• Gender: students, 425 (51%) girls; 409 (49%) boys
Principal: • Ethnicity: unknown; predominantly black student body
• “I'm really pleased about how well our program is working to reduce • Housing: very little information is available about the housing
absenteeism.” (Last year the principal and the PTA worked together situation of community members; this is a city environment.
to identify components of the problem and then petitioned the school (However, the nurse might observe the housing and review cen-
board for additional funds for a truancy officer, who works with volun- sus tract data.)
teers to check on absent students.) • Density of population: teacher-to-student ratio 1:35; class-
Phenomenological Community Assessment of rooms slightly crowded because they were built to hold 30 to
Northview High School in CT 1 35 students
Boundaries 3. Physical features of the community: fairly young, fairly large student
• People: students (834) and staff, consisting of 1 principal, 32 teach- group; traditional school building
ers, 5 counselors, janitors, and cooks
• Place: one city block in city X, census tract 1, between B and C Streets Psychosocial Characteristics
and Second and Third Avenues 1. Religion: mostly Protestant
• Common interests or goals: students’ education; for staff, education, 2. Socioeconomic class: no data (The nurse could ask the principal and
and employment review census tract data.)
• Criteria for membership: students must have completed eighth grade; 3. Education: students, grades 9 through 12; faculty, presumably col-
teachers, counselors, and staff must meet the employment criteria lege education (the nurse should check this); staff, no information
set by the school system for their occupation, which are unknown available
• Suprasystem: city X school system and the board of education 4. Occupation: faculty, teachers and counselors; staff includes secretar-
ies, cooks, and janitors
Goals 5. Marital status: no information, but the nurse might expect that most
Education of students, grades 9 through 12. The nurse may find other of the students are single
goals described in the school's written philosophy.
External Influences from Suprasystem

Resources Demands
Money Taxes fund budget A smaller budget than previous year's budget
Fund-raisers from PTA
Facilities Facilities are available in the surrounding census tract, No information
but no information available in this description
Formal human services Community/public health nurse, half day per week Not full-time
Psychologist
Truancy officer
Informal human services Volunteers Probable lack of resources to assist pregnant adolescents to stay
in school
PTA
Health information Sex education courses in the curriculum not required by city
school district
Lack of information related to abstinence and birth control
Legislation Laws related to attendance, mastery examinations,
number of credits for graduation, curriculum, and
number of instructional days
Immunization requirements for students not described
Union laws for teachers
Values of suprasystem Information related to budget Budget adjustments that indicate that school board values
sports less than the community; with only half day per week of
funding for the nurse, it appears health is not a high priority

Internal Functions of the Community

Economy
Resources Demands
Formal human services Principal Fewer teachers than needed based on teacher
dissatisfaction and student to teacher ratio
Teachers
Counselors
Staff
Informal human services Volunteers in health room (Some people would place this resource No resources for single mothers
here, others in “External Influences from the Suprasystem.” )
No formal health education program
Money No information about amount of money generated within the
community
Fund-raising within certain clubs
No information on how money is spent
Facilities Adequate space, classrooms, common area for students, faculty Lack of audiovisual equipment
lounge, health room
Some equipment in classroom in disrepair
Education Mastery examinations, which are a criterion for productivity;
curriculum appears to provide educational opportunities for
students who wish to go on to college, as well as for students who
are interested in jobs immediately out of high school (business,
industrial arts); further assessment is necessary.
Analysis of Economy: The school has a mix of resources and demands. Communication
The community is struggling with budget and personnel problems that • Nonverbal: Teachers appear frustrated, and students cannot wait
affect the provision of services. Volunteers are available, and facilities to leave. SGA activity indicates that some students are engaged in
are, for the most part, adequate. Any new health programs would have school. The school seems to support sports activities, and many clubs
to be inexpensive or require additional fund-raising. and student organizations (i.e., drama club, dance club, chorus, band,
and cheerleading) are available. Several special events such as home-
Polity coming occur throughout the year.
Organizational structure: • Verbal: There is no mention of schoolwide announcements, but a bul-
Principal letin board is in use. The principal has established a task force with
other personnel to study the dropout rate. Some evidence is sugges-
Depts. Depts. Depts. Depts. Staff SCA
tive of democratic or horizontal communication, but most commu-
students nication appears to be vertical; this area needs further exploration.
Announcements are made during the homeroom period, a school
1. Leaders: The formal leaders are the principal, the department chair- newspaper is published monthly, and a school yearbook is published
persons, and the SGA president. Informal leaders include Harry, the annually. School assemblies are held three times a year.
leader of the problem students. Analysis of Communication: The school has a mix of resources and
2. Patterns of decision making: Decisions regarding the curriculum are made demands, but many more resources are identified, as well as a variety of
within the departments following school system guidelines. An example verbal and nonverbal communication patterns and a variety of planned
of a past decision is that made regarding absenteeism. In this decision, activities. Low morale would need to be considered when suggesting
some efforts at democratic decision making were probable because the new health activities. Time would need to be spent empowering faculty
principal enlisted the PTA and school board. No other data are available. and students.
3. Methods of social control: Rules regarding attendance come from the
suprasystem, with the SGA and PTA particularly mentioned in relation Values
to absenteeism. • Traditions: School dances are associated with special events (home-
Analysis of Polity: Although the data are sparse, a variety of formal leaders coming, Valentine's Day) and sports events.
and one informal leader are available. The formal leaders are resources, • Subgroups: There are student activities’ groups, sports groups, Harry's
but the informal leader is not considered a positive leader by the formal group, and the SGA.
leaders. Norms of conduct have been established, and no real information • Environment: There are window grates for security; trophy displays;
is available to suggest whether they are being largely ignored or violated, moderate litter on the school campus; common area for student use
with the exception of absenteeism and dropping out. When planning for and relaxation; the description does not indicate that the complex is
health care services, a variety of leaders and groups need to be involved. poorly maintained.
Continued

• Health: Facilities consist of a health room, but no description of sup- Presymptomatic illness or problems that might be expected in stu-
plies or environment is provided. With regard to attitudes about dents per the literature include substance abuse, sex education
health care, health priority, and health care professionals, students needs, access to birth control, depression and suicide, pregnancy,
generally seek crisis-oriented care. Students appear to consider the sexually transmitted diseases and HIV infection, trauma and vio-
nurse a valuable resource for health care and information. Some stu- lence, and communicable diseases such as mononucleosis, upper
dents do not appear to value preventive care (i.e., a need exists for respiratory tract illnesses, and, if the population is underimmunized,
sexual abstinence and birth control information; the unwanted preg- measles. Vulnerable or high-risk groups include pregnant adoles-
nancy rate is high). Interviews or surveys are necessary to get addi- cents (45 of 425 girls, or 11% [national rate in 2000 was 4.1% (U.S.
tional information. Department of Health and Human Services, 2011)]), teenage parents,
• Homogeneity versus heterogeneity: The description indicates that dropouts, substance abusers (including smokers), and sexually active
the students are racially homogeneous. Socioeconomic status is not adolescents.
known; the nurse would need additional information. Attitudes toward • Social functioning: School attendance is problematic but may be
school and education appear to be polarized (i.e., some students are improving, according to the principal.
active in school organizations and pursue education; others drop out). • Types of disabilities or impairments present or expected: Learning
No information is available to make an assessment about the staff. disabilities are likely to be present because the school has special
Analysis of Values: The school values traditions, safety, and sports. education classes. No additional information is available, but a likely
Students are very homogeneous and are, therefore, more likely to have source would be health room records and children with individualized
similar values than do those in another community with more widely education plans related to disabilities.
variant characteristics. The school appears to be moderately concerned
with cleanliness. The health care provider is valued, but preventive Environmental Factors
health care behavior is not a priority. If preventive health issues are • Physical environment: This appears adequate from the description,
linked to sports, some students may be interested. except some classes may be crowded.
• Social environment: Teachers appear dissatisfied, indicating a stress-
Outcomes (Health Behaviors and Health Status) ful environment.
People Factors
• Size: There are slightly fewer students than 2â•›years ago. No addi- Level of Health
tional information is available. • Actual needs: These include ways to deal with substance abuse;
• Mortality and morbidity: The number of students enrolled decreases sexually transmitted diseases; pregnancy; health information
with grade level. No information is available on how many students needs related to hygiene, birth control, sexual abstinence; teenage
have died in recent years or about the reason for leaving the school or parenting.
causes of death, if any have occurred. Major diseases and conditions • Potential needs: These include ways to deal with depression and high
are communicable diseases (specific diseases unknown) and rashes, accident rate.
accidents requiring first aid, pregnancy, and chronic illnesses (none • Community action: No information is supplied, but remarks about
specified), dental problems, and eating disorders. No information health-related needs seem to indicate little action addressing health
is available about the incidence and prevalence of these problems. issues has been taken.
1. Write a definition of community. Does the definition include 4. Use the responses in guideline 3 to begin to develop a survey
the three critical components? Does your definition relate you might use with more community members.
more to a geopolitical community or to a phenomenological 5. Use the community assessment tool presented in this chapter
community? to assess a community. Start by identifying whether the com-
2. Draw a diagram depicting the communities to which you munity is geopolitical or phenomenological.
belong. Do you work or attend school in the same geopolitical 6. Using the demographic characteristics of a community and
community in which you live? How many phenomenologi- epidemiological and nursing literature, predict what health
cal communities do you belong to? In which communities problems are likely to exist in the community.
do you receive health care? 7. Suppose that a state survey of public schools indicates
3. Interview at least two members from the same community increasing rates of alcohol and tobacco use among middle-
regarding their perceptions of the health of their community school students. The parents and school administrators deny
members and the community's competence. Compare and that a problem exists in the school in community A. As a
contrast their responses. What questions emerge for further school nurse, how might you begin to explore whether a
assessment? problem exists in this community school?
WEBSITE

and assessment materials: on the Evolve site:
• NCLEX Review Questions 15A: The Community Assessment Tool Applied to Geopolitical
• Critical Thinking Questions and Answers for Case Studies and Phenomenological Communities
• Care Plans 15B: Census 2000: Geographical Areas
• Glossary 15C: Windshield Survey
15D: Geographical Information Systems (GIS)
15E: Using Geographical Information Systems (GIS) in CommuÂ�
nity Health Nursing
15F: Example of a GIS map for Heart Disease Death Rates,
2000-2006, U.S. Adults Ages 35+, by County.
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CHAPTER
16
Community Diagnosis, Planning,
and Intervention
FOCUS QUESTIONS
What is the history of contemporary health planning in the What are examples of community diagnoses?
United States? How are priorities determined in health planning with
What are the responsibilities of community/public health nurses communities?
in planning health-related changes with communities? What is a target population?
How do models of community organization relate to health What are common types of interventions typically planned
planning? by community/public health nurses?
What principles and steps can assist the nurse and community What are strategies for implementing plans?
in developing an effective plan?
CHAPTER OUTLINE
Population-Focused Health Planning Identification of the Target Population
Population Targets and Intervention Levels Identification of the Planning Group
History of U.S. Health Planning Establishment of the Program Goal
Rationale for Nursing Involvement in the Health Identification of Possible Solutions
Planning Process Matching Solutions with At-Risk Aggregates
Nursing Role in Program Planning Identification of Resources
Planning for Community Change Selection of the Best Intervention Strategy
Community Organization Models Delineation of Expected Outcomes
Structures for Health Planning Delineation of the Intervention—Work Plan
Steps of Program Planning Planning for Program Evaluation
Assessment Tools Used to Present and Monitor Program
Analysis of Data Progress
Diagnosis Implementation
Validation Types of Interventions
Prioritization of Needs Strategies for Implementing Programs
KEY TERMS
Community empowerment Nursing Outcomes Classification Population-focused health
Community organization models (NOC) planning
Data gap Omaha System Process objectives
Gantt Chart Outcome objectives Program Evaluation and Review
Management objectives Planned Approach to Community Technique (PERT)
North American Nursing Diagnosis Health (PATCH) Social action
Association (NANDA) classification Planning, Programming, and Budgeting Social planning
system System (PPBS) Target population
427
428 CHAPTER 16â•… Community Diagnosis, Planning, and Intervention
ChapterÂ€15 provides community/public health nurses with the Â�

prevention); a program to screen preadolescent girls for scolio-
basics of community assessment, the first step in the nursing sis is geared toward early detection and treatment (secondary
process. The chapter illustrates the use of a systems-based com- prevention); and an exercise program for stroke victims to limit
munity assessment tool to assist nurses in gathering informa- or minimize their disability is an example of a tertiary level of
tion about a community. This chapter continues the nursing prevention.
process with communities (FigureÂ€16-1), introducing the pro- Population-focused health planning can range from plan-
cess of planning and implementing population-focused health ning health care for a small group of people to planning care
care in communities. The components of and steps used in pro- for a large aggregate or an entire city, state, or nation. The plan-
gram planning, the types of interventions appropriate for the ning process described in this chapter is applicable to all types
community level, and the responsibilities of the community/ of communities (phenomenological and geopolitical) and to
public nurse in planning and implementing care with popula- all levels of planning (local, state, national, and international).
tions are described. The nursing process is dynamic, not static, Health planning can be proactive or reactive. The goal is to use
as the arrows in the figure illustrate. Health intervention plans a more proactive approach and for nurses to be an integral part
may be modified as new information becomes available. It is of the planning process.
important to include community members in as many steps in
the process as possible. Input from the population(s) should be History of U.S. Health Planning
elicited regarding analyzing the assessment data to determine The history of health planning in the United States has alter-
population diagnoses and priorities, identifying desired out- nated between the federal and state governments. Before the
comes, planning, and evaluation (American Nurses Association 1960s, health planning occurred primarily at the state level.
[ANA], 2007). In the 1960s, health planning became a federal effort. In 1966,
the Comprehensive Health Planning and Public Health Service
POPULATION-FOCUSED HEALTH PLANNING Amendment was passed to enable states and local communi-
ties to plan for better health resources. Inadequate funding
Health planning is a continuous social process by which data allocation led to the National Health Planning and Resources
about clients are collected and analyzed for the purpose of Development Act of 1974. This legislation created a national
developing a plan to generate new ideas, meet identified client network of health system agencies and statewide coordinat-
needs, solve health problems, and guide changes in health care ing councils responsible for health planning. The intent was
delivery. To date, you have been responsible primarily for devel- to improve health status and care, while reducing cost. These
oping a plan of care for the individual client. How do you go goals were to be achieved by preventing unneeded or duplicate
about developing a plan of action to meet the health needs of a services, decreasing fragmentation of services, and coordinat-
community? How is the plan different from that for the health ing resources. New services were encouraged based on regional
of an individual or a family? What types of nursing actions and needs assessments.
interventions are appropriate for the community? In the 1980s, President Reagan aimed to reduce both the size
of the federal government and the influence the federal govern-
Population Targets and Intervention Levels ment had on states. His administration eliminated the federal
Population-focused health planning is the application of a budget and planning requirements while encouraging states to
problem-solving process to a particular population. In popula- make their own planning decisions. The federal health objec-
tion-focused health planning, communities are assessed, needs tives for the years 2000, 2010, and 2020 suggest targets for local
and problems are prioritized, desired outcomes are determined, communities and states to consider (U.S. Department of Health
and strategies to achieve the outcomes are delineated. and Human Services [USDHHS], 2010a).
Persons for whom you desire change to occur are referred Increasing costs have placed heavy demands on the health care
to as the target population. Planning care for groups or popula- system (see ChaptersÂ€3 and 4). As a result health planning has
tions results in programs, and hence the term program planning essentially become economically focused. The federal government
is often used when planning care at the community level. has attempted to control its share of health care costs by changing
Programs may be aimed at the primary, secondary, or ter- reimbursement methods, and shifting some of the budget respon-
tiary level of prevention. For example, a health education sibilities to the states. Because the federal government mandates
program about safer sex is aimed at preventing sexually trans- health care services in those specific programs, states are left with
mitted diseases through health-promotion measures (primary limited autonomy to plan and deliver health care services.
Assessment Diagnosis Planning Implementation Evaluation

and Analysis (Selected Intervention
Examples)
• Include • Identify • Involve • Health education • Includes both process
community health issues community • Screening and outcome evaluation
members in and problems leaders • Direct health • Community members
process services contribute to evaluation
process
FIGUREÂ€16-1â•‡ Illustration of the nursing process with communities.

CHAPTER 16â•… Community Diagnosis, Planning, and Intervention 429
In 1980, the Omnibus Budget Reconciliation Act encour- organizations identify program planning as a primary function
aged the use of noninstitutional services, such as home health of the community/public health nurse.
care, to fight escalating costs. In 1983 the Prospective Payment In addition to mandates from professional organizations,
System drastically changed hospital reimbursement, resulted in nurses should be involved in program planning for several rea-
shorter hospital stays for patients, shifted care into the commu- sons. Nurses make up more than one-third of all health care
nity, and placed greater responsibilities for care of relatives on workers in the United States and implement the majority of
family members (see ChaptersÂ€3, 4, and 28). health care programs. Our involvement in numerous and
The Gramm-Rudman-Hollings Budget and Deficit Control diverse health programs has given us experience in seeing what
Act of 1985 added additional budget controls and cutbacks to works and what does not. This experience helps identify diffi-
health care. Taken together, these and subsequent federal efforts culties that can be avoided in the future.
have presented a challenge to all health care professionals to Nurses spend a greater amount of time in direct contact with
plan and implement cost-effective health care programs that their clients than do any other health care professionals. We are
meet the needs of the people they serve. It is imperative that with the clients in the community, gaining first-hand informa-
nurses become more cognizant of the health care planning pro- tion about their health, their lifestyles, their needs, and what it
cess and their role within it. is like to be a member of that community. This exposure to the
The 1990s and early 2000s offered new opportunities for community places us in the unique position of possessing valu-
nurses to be involved in efforts to reform the nation's health able information that is useful to the planning and implementa-
care system (ANA, 1991). Debate continues about the degree tion of successful health programs.
to which government should be involved in health plan- Not only do nurses make up a large portion of health care
ning and whether federal or state planning is preferred (see providers, they also make up a large portion of health care con-
ChapterÂ€3). The federal Patient Protection and Affordable sumers in the United States. With the emphasis on consumer
Care Act (Affordable Care Act) of 2010 requires access to participation in health planning, nurses are in a unique posi-
health care for most Americans. Some states have already tion to make an impact in the planning of population-focused
passed their own health care legislation, ensuring access to health programs.
health care, identifying standard health benefit packages, and
budgeting or requiring finance mechanisms. A greater interest Nursing Role in Program Planning
has developed in ensuring that planning efforts also address Planning for change at the community level is more complex
the quality of health care. Furthermore, Healthy People 2020 than at the individual level. Components to the Â�client sys-
includes a goal that federal, state, and local public health infra- tem have been increased, and more people and more complex
structures should have the capacity to provide essential public organizations are involved. Baccalaureate-prepared commu-
health services (USDHHS, 2010a). nity/public nurses are expected to apply the nursing process
Health care planning for specific geopolitical communi- with subpopulations or aggregates with limited supervision
ties continues at the state and local levels. Community/public (American Association of Colleges of Nursing, 1986; ANA,
health nurses are involved with specific communities to assess 2007). If nurses practice in agencies with a broad public health
community needs. Nurses explore how the Healthy People mandate, they will find that the scope of their focus shifts to
2020 objectives apply to these geopolitical or phenomenologi- larger populations (APHA, 1996). Community/public health
cal communities. Based on the assessments, community/public nurses prepared at the baccalaureate level are expected to
health nurses participate with others to develop plans to meet collaborate with others to assess the entire population and
the health care needs of the people. multiple aggregates in a geopolitical community (ANA, 2007).
There are federal requirements for hospitals to report in Therefore community health planning often takes a multidis-
detail their community benefits activities (uncompensated ciplinary approach, which requires excellent teamwork and
care and other services) to the Secretary of the Treasury thorough communication. The roles of collaborator, coordi-
(Internal Revenue Service, 2011). In addition the 2010 Patient nator, and facilitator are important when working with the
Protection and Affordable Care Act requires tax-exempt hos- community as client.
pitals to do a community-needs assessment every three years. A necessary task is to collaborate with people from the
That assessment is intended to assist in planning how to best community to validate nursing diagnoses made from the
use hospital resources to the community's benefit (Public Law assessment; to plan with, not for, the community; and to
148, 2010). enlist community members' support and assistance in imple-
menting change. If the community is not involved from the
Rationale for Nursing Involvement in the Health beginning, the program may not be effective. Just as you will
Planning Process have better adherence and outcome from planning care with
Florence Nightingale and Lillian Wald pioneered health plan- an individual client, so, too, you will have a more successful
ning based on an assessment of the health needs of the commu- program if you involve the community in the assessment and
nities they served (see ChapterÂ€2). Additionally, nurses have long planning phases.
been involved in implementing programs planned by other dis- The coordinator role emerges when working with a vari-
ciplines. Both the American Nurses Association (ANA) (2007) ety of community members and organizations within and
and the American Public Health Association (APHA) (1996) outside of the community. The nurse is in a key position to
state that the primary responsibility of community/public health coordinate the activities and facilitate the community's abil-
nurses is to the community or population as a whole and that ity to achieve a higher level of health. However, to effect
nurses must acknowledge the need for comprehensive health change at the community level, community organization
planning to implement this responsibility. Both professional must be understood.
PLANNING FOR COMMUNITY CHANGE Urban example. In the inner city of Chicago, Illinois, a
team of nurses identified a community need to improve
To plan and implement programs at a community level effec- maternal and infant health outcomes because the commu-
tively, the community/public health nurse must understand how nity had higher rates of maternal and infant complications
the community works, how it is organized, who its key lead- than the national norm. Assessment indicated that women
ers are, how the community has approached similar problems, from minority groups (African American and Hispanic) in
and how other programs have been introduced in the past. The the community needed support to follow through with pre-
health care professional who is facilitating the community orga- natal and postpartum care, education to improve parenting
nization process with regard to a specific health need or prob- skills, and encouragement to use health prevention behav-
lem must work with the community members. To be an effective iors, such as immunizations, to improve the health status of
change agent in applying the nursing process, the nurse must be both the mothers and the infants. The nurses implemented
aware not only of the community and how it works, but also of the REACH-Futures program, which is a home-visiting
methods of community organization that facilitate change. program designed to monitor the health status of partici-
pants, provide appropriate health services as needed, and
Community Organization Models improve the health and welfare of both young mothers and
Rothman (1978, 2008) identifies three community organi- their infants. The project enrolled 588 African American
zation models designed to facilitate change in a community: and Hispanic pregnant women into an intervention pro-
community development (now called empowerment), social gram that used both health professionals (nurses) and
planning, and social action. The three models can be used sepa- community workers to deliver health services. Each team
rately or in combination. Although the models are presented consisted of one nurse and two community workers. Home
here in pure form, in reality, they are generally combined. visits were initiated in the last trimester of pregnancy and
Social planning was the model most used by community health continued at 1-month intervals, or more often as necessary,
nurses and other public health care practitioners between the for a planned 36â•›months. The community workers, who did
1970s and the early 1990s. However, community organization most of the home visits, were trained in child development
approaches used by Lillian Wald and others during the nine- milestones, appropriate parenting skills and techniques, the
teenth century, as well as during the 1960s, are reemerging as identification of home safety and health hazards, and strat-
models for community empowerment. egies to improve compliance with immunization schedules
Each model contains four components: goals, strategy, prac- and well-baby visits (Norr etÂ€al., 2003). Initial evaluation
titioner role, and medium of change. TableÂ€16-1 summarizes the of the program, after 1â•›year, indicated that the community
salient points from each of the three models. A thorough under- workers were effective in supporting young mothers and
standing of the components is necessary in planning for change improving parenting skills and compliance with immuni-
in a community. Each model involves community change. zation schedules and well-baby visits.
Rural example. Community health nurses enlisted the
Community Empowerment Models
use of “community guides and community leaders” to iden-
The community empowerment model is an approach designed tify health resources and solutions for older adult residents
to create conditions of economic and social progress for the and their caregivers in a Mexican American community
whole community and involves the community in active partici- in Arizona (Crist & Dominguez, 2003). The health inter-
pation. The community empowerment approach is also referred ventions were secondary and tertiary, aimed at increasing
to as the locality development approach because of its work within the knowledge and use of health care services by the older
the community. The community-locality development model is adults and their caregivers.
a grassroots approach that uses a democratic decision-making The nurses recruited nanas (grandmothers) as actors
process, encourages self-help, seeks voluntary cooperation from in a short play or telenovela designed to reduce resistance
the members, and develops leadership within the group (Milio, to use of health services. Additional community collab-
1971). In this approach, community members believe they have orative efforts included development of an Elders Use of
some control over their destiny and therefore become actively Services Community Advisory Council to assist and guide
involved. The change strategy is characterized by, “We know the nurses toward community-acceptable interventions.
we have a problem, let's get together and discuss it.” The theory
underlying this model is that if people are involved in determin- This approach, then, has the potential of having the longest
ing their own needs and desires, they will become more active in lasting effect of the three models to be discussed. However, the
solving their problems than if someone else comes in and solves task is also the most time-consuming to initiate because time is
the problems for them. If they are more active in working out required to discuss the problems, to make decisions democrati-
solutions to their own problems, they will be more satisfied with cally, and to develop leadership within the group that will be able
the solutions and will continue to expend energy to make them to sustain the program. Therefore even though the community-
work. That is, if they are vested in the solutions, they will have locality development approach to community organization is
more of a commitment to them. The solutions will be more sus- successful, it may not always be used in pure form because of the
tainable (Bent, 2003). This model seeks to build on community amount of time required to accomplish the action.
assets and strengthen community competence.
The community empowerment model is especially impor- Social Planning Model
tant for communities with vulnerable and underserved popula- The social planning approach emphasizes a process of rational,
tions. This model is being used successfully in both urban and deliberate problem solving to bring about controlled change for
rural communities. social problems. This method is an expert approach in which
TABLEÂ€16-1â•…â•‡THREE MODELS OF COMMUNITY ORGANIZATION PRACTICE â•›ACCORDING

TO SELECTED PRACTICE â•›VARIABLES
VARIABLES COMMUNITY EMPOWERMENT SOCIAL PLANNING SOCIAL ACTION
Goal categories Self-help; community capacity Problem solving with regard Shifting of power relationships
of community action andÂ€integration (process goals) toÂ€substantive community and resources; basic institutional
problemsÂ€(task goals) change (task or process goals)
Basic change strategy Broad cross-section of people Fact gathering about problems Crystallization of issues and
involvedÂ€inÂ€determining and andÂ€decisions on the most organization of people to take
solvingÂ€theirÂ€own problems logicalÂ€course of action action against obstructive targets
Salient practitioner role Enabler-catalyst; coordinator; teacher Fact gatherer and analyst; Activist or advocate; agitator; broker;
of problem-solving skillsÂ€and program and policy designer negotiator; partisan
ethical values andÂ€implementer; facilitator
Medium of change Guiding of small task-oriented Guiding of formal organizations Guiding ongoing action groups and
groups andÂ€ofÂ€data mobilizing of ad hoc mass action
groups
Adapted from Rothman, J. (1978). Three models of community organization practice. In F. Cox, J. Erlich, J. Rothman, etÂ€al. (Eds.), Strategies
ofÂ€community organization: A book of readings (pp. 25-45). Itasca, IL: Peacock Publications; and Rothman, J. (2008). Approaches to community
intervention. In J. Rothman, J. Erlich, & J. Tropman (Eds.), Strategies of community intervention (7th ed., p. 163). Peosta, IA: Eddie Bowers
Publishing Company.
knowledgeable people (experts) take responsibility for solving which is direct and often confrontational and radical, may be
problems. The degree of community involvement may be very Â�characterized as follows: “Let's organize to rectify an imbalance
small or very great. (The greater the involvement is, the more of power.” In the 1960s the social action approach was used
successful the outcome will be.) The social planning approach a great deal. The civil rights movements and protests against
is characterized by, “Let's get the facts and proceed logically in the Vietnam War are examples of the social action approach.
a systematic manner to solve the problem.” Pertinent data are Current examples include welfare rights organizations and
considered before decisions are made about a feasible course of advocacy groups for the environment or for the homeless, as
action to meet the need. well as some antiabortion groups.
Agencies and organizations frequently use this approach
as they attempt to effect desired change. The legislative and
Citizens in the Chattanooga Creek area of Tennessee became
regulatory process is one example of a social planning
concerned about the quality and safety of water in the
approach. Problems are identified, data are collected, and bills
Chattanooga Creek. A local environmental activist group,
are introduced into local, state, or national legislative bodies
Stop Toxic Pollution (STOP), organized. STOP contacted
to effect change. A social planning approach is also used when
local public health nurses, other health professionals, and the
a local health department institutes a program of directly
Agency for Toxic Substances and Disease Registry (ATSDR).
observed therapy for treating tuberculosis. Public health
ATSDR is a federal agency responsible for preventing and
nurses use facts gathered about the prevalence of tuberculosis
mitigating the health hazards of exposure to toxic wastes.
in the community, as well as public health and nursing litera-
An assessment conducted by local health personnel, area
ture about effective treatment programs, to plan a program
residents, and a nurse researcher from ATSDR revealed sev-
to directly observe persons with active tuberculosis take their
eral potential sources of pollution and 42 hazardous waste
antituberculosis medications.
sites. A nursing diagnosis was developed:
The social planning approach can be effective, but it
Potential for injury—residents who were exposed to creek
has one major pitfall: the potential for lack of commu-
water or ate fish from the creek were at risk of short-term
nity involvement. Much money has been spent and many
gastrointestinal and skin problems, and long-term skin or
health programs have failed because experts have planned
liver cancer.
programs for the community instead of with the commu-
The following three-pronged intervention strategy was
nity. The health planners, the nurse experts, must develop
devised:
a Â�partnership with the community for effective health care
1. Public education
planning (ANA, 2007).
2. Public protection
Social Action Model 3. Clean up hazardous waste sites (Phillips, 1995)
STOP, community nurses, and other local health Â�providers
The social action approach is a process in which a direct, often
were actively involved in developing and implementing
confrontational, action mode seeks redistribution of power,
the public education program aimed at both adults and
resources, or decision making in the community or a change
Â�children. The group also cooperated in ensuring that the
in the basic policies of formal organizations, or both. In this
problems with the creek remained in the news. Publicity
approach, one group of people or segment of an organization
about the Â�situation facilitated the public education aspect
or community is feeling oppressed, and the organization or
of the Â�intervention and also spurred public officials to take
community is viewed as needing basic changes in its institu-
remedial actions to isolate the hazards. Finally, the site was
tions or practices. Nonviolent civil disobedience or aggressive
placed on the National Priorities List for pollution cleanup.
actions may be taken to facilitate these changes. This approach,
Change Theory The World Health Organization adopted the Healthy Cities
Each of the community organization models involves change. program in the 1980s to promote the health of urban commu-
Change can be threatening and stressful or it can be exciting and nities (Kegler etÂ€al., 2009). Collaboration among multiple com-
rewarding. Understanding some theory about planned change munity sectors and community participation are hallmarks of
will provide a guide to use in the planning process. Lewin (cited this model, which focuses on the role of local government in
in Dever, 1991) describes change as being a three-stage process: creating physical, social and economic environments that pro-
unfreezing, moving, and refreezing. In the first stage, unfreez- mote health (Rabinowitz, 2001). Over 3000 projects exist world-
ing, a need for change is identified. The stimulus for the per- wide in both urban and rural areas.
ceived need may be within the client or come from an outside The Healthy People 2020 objectives are introduced in
force. Disequilibrium exists or is created, making a disruption ChapterÂ€2 and used as examples throughout the text. Many state
in the status quo (unfreezing), and change is initiated. Moving, and local jurisdictions have developed health improvement
the second stage of the change process, occurs when the pro- plans that link the national perspective of Healthy People 2020
posed change is tried out by the people involved, old actions with local needs.
are questioned, and attitude changes occur, creating move-
ment toward acceptance of the proposed change. This phase STEPS OF PROGRAM PLANNING
is a vulnerable time for the people involved, because change is
threatening and anxiety producing. Individuals will need help The planning process consists of a series of specific steps.
and support while trying out the proposed change. Refreezing, Although each of these steps is necessary, the steps do not
the third stage of the change process, occurs when the change have to occur in the exact sequence given here. Occasionally,
is established and accepted as a permanent part of the sys- several steps may be undertaken simultaneously, or they may
tem. Stabilization of the situation occurs. Lewin also describes occur in a slightly different order. Identification of the plan-
forces that facilitate (driving forces) or impede (restraining ning group may occur much earlier in the sequence. The steps
forces) change. Driving forces must exceed restraining forces are as follows:
for change to occur. 1. Assessment
2. Diagnosis
Structures for Health Planning 3. Validation
Several structures or schemes have been developed by national 4. Prioritization of needs
organizations to help communities plan for improving their 5. Identification of the target population
health. These structures encourage collaborative partnerships 6. Identification of the planning group
and comprehensive assessments as building blocks for commu- 7. Establishment of the program goal
nity health planning. 8. Identification of possible solutions
Planned Approach to Community Health (PATCH) is a 9. Matching solutions with at-risk aggregates
program initiated by the Centers for Disease Control and 10. Identification of resources
Prevention. PATCH attempts to engage entire geopolitical com- 11. Selection of the best intervention strategy
munities in a comprehensive assessment of their health needs 12. Delineation of expected outcomes
rather than focusing solely on high-risk groups or those served 13. Delineation of the intervention work plan
by a specific health institution. PATCH depends on the partici- 14. Planning for program evaluation
pation of citizens and the cooperation of several organizations Some researchers call steps 8 through 14 operations planning
within the community in partnership with local and state gov- (e.g., Hale etÂ€al., 1994).
ernment resources.
Assessment
Gage County, Nebraska has used PATCH strategy to plan A thorough, accurate assessment of the community is the
interventions to address health issues found as a result of a first essential step in program planning. ChapterÂ€15 provides
county-wide behavioral risk survey. The PATCH coalition a framework for community assessment and assessments of a
identified several priority risk areas and developed programs geopolitical and a phenomenological community.
to address them, including the following:
• Improve nutrition through school and work site education Analysis of Data
• Reduce injuries through increasing car seat and seat belt use A systematic analysis of the data collected is necessary to
• Improve physical fitness by increasing opportunities for identify the problems, needs, strengths, and trends in the
county residents to engage in physical activities (Gage community. Categorizing the data first is always helpful to
County PATCH, 2011). identify the inferences that are descriptive of actual or poten-
tial health problems. The community assessment described in
The National Association of County and City Health ChapterÂ€15 provides a framework in which to categorize the
Officials (NACCHO) developed a strategic planning tool, data about community functioning. Within each subsystem,
Mobilizing for Action through Planning and Partnerships nurses identify resources (assets, strengths) and demands
(MAPP) (NACCHO, 2008). MAPP is intended for use by local (deficits, weaknesses), looking not only at whether something
health departments in planning with geopolitical communi- is present, but also to what extent, how it is working, and how
ties to improve health status and public health system capaci- it relates to the past and future to provide an idea of trends
ties (see ChaptersÂ€15 and 29). The tool emphasizes community over time. Nurses also consider the health status of the pop-
ownership of the process. The action cycle of MAPP includes ulation. Typically, the nurse identifies high-risk aggregates
planning, implementation, and evaluation. among the population as well.
In addition to illustrating the community's strengths and weak- visual displays. Computer-based geographical information sys-
nesses, an analysis will provide information about demographic tems (GIS) that map data spatially are becoming more widely
and personal characteristics, which are important to consider when used (see ChapterÂ€15).
planning and implementing health programs. For example, if you Obtaining as much data as possible that are specific to the
are working with a group of senior citizens enrolled in a senior target population is important. TableÂ€16-2 includes the age and
center and your assessment indicates a potential risk for injury by sex of people living in census tract 1 and city X. Census tract
fire, what other factors should you consider in the assessment data 1 data are included in city X totals, but, as can be seen, census
before you plan a fire prevention program? One factor that comes tract 1 is quite different from city X. The population of the cen-
to mind is the educational level of the senior citizens. Knowing the sus tract is younger than the total city population, and data from
educational level provides information about the appropriate level the city cannot be used to describe the residents of the census
at which to plan the teaching interventions. The level of disability tract. Looking at city X data only and thinking that the data
and social functioning indicates the presence of visual or hearing would apply specifically to census tract 1 would not be accurate.
impairments that might affect the type of teaching strategy you
use. Additionally, if many seniors are in wheelchairs or need assis- Diagnosis
tive devices, you would focus the program on fire safety involving After analyzing the data, the next step is to make a definitive
limited mobility and would need to modify practice sessions to the statement (diagnosis) identifying what the problem is or the
participants' level of ability. In other words, analysis of community needs are. Nursing diagnoses for communities may be formu-
data provides information not only about what is needed, but also lated regarding the following issues:
about what will be appropriate in the intervention. • Inaccessible and unavailable services
• Mortality and morbidity rates
Data Gaps • Communicable disease rates
Assessment sometimes reveals areas in which all the informa- • Specific populations at risk for physical or emotional problems
tion is not available. This lack of information is called a data • Health-promotion needs for specific populations
gap. The nurse must identify areas of insufficient information • Community dysfunction
and devise a strategy to collect additional data if possible. Data • Environmental hazards (ANA, 1986)
gaps themselves may sometimes be informative. For example, if The format of the problem statement varies, depending on
you cannot find out the date of a town council meeting, it might the philosophy of the agency conducting the assessment. For
imply that the council is not open to citizen input. example, problems or needs may be stated simply in epidemi-
ological terms, such as a high rate of adolescent pregnancies,
Ways to Display Data for Analysis whereas in other instances you may be asked to state the prob-
As shown in ChapterÂ€7, displaying data that aid in the analysis lem or need as a nursing diagnostic statement.
process can be done in a variety of ways. Graphs, charts, histo- Nursing diagnosis has evolved since 1973 as a result of the
grams, and mapping techniques are some of the most common efforts of the North American Nursing Diagnosis Association
TABLEÂ€16-2â•…â•‡COMPARISON OF AGE BY SEX OF POPULATIONS IN CENSUS TRACT I AND CITY

X, 2000
CENSUS TRACT 1 CITY X
AGE (YEAR) NUMBER PERCENTAGE NUMBER PERCENTAGE
Male
Under 5 548 6.9 38,512 4.3
â•‡ 5-9 743 9.4 44,204 4.9
10-19 1280 16.2 84,037 9.3
20-34 401 5.1 85,373 9.4
35-54 293 3.7 95,793 10.6
55-64 89 1.1 41,788 4.6
65-74 33 0.4 25,938 2.9
75 and above 21 0.3 11,822 1.3
Total 3408 43.0 427,467 47.2
Female
Under 5 522 6.6 37,567 4.1
â•‡ 5-9 782 9.9 43,502 4.8
10-19 1323 16.7 86,668 9.6
20-34 930 11.7 95,611 10.6
35-54 701 8.8 108,122 11.9
55-64 140 1.8 48,920 5.4
65-74 80 1.0 36,165 4.0
75 and above 41 0.5 21,737 2.4
Total 4516 57.0 478,292 52.8
Total population 7924 100 905,759 100
(NANDA) (NANDA, 2009). The initial North American How does the nurse formulate a community-focused nursing
Nursing Diagnosis Association (NANDA) classification system diagnosis? A diagnosis is a statement that synthesizes assess-
of nursing diagnoses focused on the physical needs of individ- ment data; it is a label that describes a situation (state) and
ual clients but was not applicable to the family and community implies an etiological component (reason). A nursing diagno-
situations faced by community health nurses. Over the years, the sis limits the diagnostic process to the diagnoses that represent
NANDA classification system has expanded to include biologi- human responses to actual or potential health problems that are
cal, psychological, and social needs of individuals and families. within the legal scope of nursing practice.
Because of ongoing refinement, the taxonomy of nursing diag- A nursing diagnosis has three components: a descriptive
noses at present has 11 functional health patterns. Tools have statement of the problem, response, or state; identification of
been developed to assess the community using the functional factors etiologically related to the problem; and signs and symp-
health pattern typology (Gikow & Kucharski, 1987; Wright, toms that are characteristic of the problem (Carpenito, 2000).
1985). Newer NANDA diagnoses may also apply to commu- Using this information, let us take a moment to try to state
nities; examples include the diagnoses impaired home mainte- nursing diagnoses for some problems on the community level.
nance and impaired social interaction. Situation 1
Other classification systems have been developed in an Howard County is a suburban county with a rapidly increasing
attempt to address the community. One example is the number of older adults. The assessment data indicate the presence
Omaha System, written by community/public health nurses of only one taxicab company serving that area. No public bus sys-
for community/public health nursing practice (Martin, tem is available.
2005). The system was designed by the Omaha Visiting Nurse Obviously, the problem is lack of transportation; but how
Association and has been used in home care, public health, might this be worded in nursing diagnosis format?
and school health practice settings, among others. Client Suggestion:
problems/needs/concerns are organized into four domains: Altered health-seeking behaviors related to inadequate trans-
physiological, psychosocial, health-related behaviors, and portation services for senior citizens
environmental. Each domain may involve actual or potential However, inadequate transportation probably also affects
problems or opportunities for health promotion. The system other areas of seniors' lives, such as socialization and commu-
includes four categories of interventions: teaching, guid- nity participation. If this factor were validated through further
ance, and counseling; treatments and procedures; case man- assessment, an additional diagnosis might be as follows:
agement; and surveillance. Although originally developed Impaired social interactions related to inadequate transporta-
for application with individuals or families, users are now tion for senior citizens
applying the problem domains and interventions with com- Situation 2
munities (Martin, 2005).The Omaha System includes more Students in Johnson High test very low on an acquired immu-
environmental and community factors than are considered in nodeficiency syndrome (AIDS) awareness survey. Further investi-
the NANDA system. gation reveals that no information is provided to the students, and
Because of the multiple nursing diagnostic and classification the parents do not want information taught in the school. Ninety-
systems, the NNN Alliance has formed to develop a consistent eight percent of the students stated that they do not believe they are
classification system. The NNN Alliance is a collaboration of in any danger of getting human immunodeficiency virus (HIV).
NANDA and the Center for Nursing Classification and Clinical Suggestion:
Effectiveness (CNC). The taxonomy developed by the NNN Lack of knowledge about HIV/AIDS in high school students
Alliance has four domains (Dochterman & Jones, 2003). The related to:
one relevant to community health practice is the environmen- • Inadequate information provided in school curriculum
tal domain, with three subsets: health care system, populations, • Parental attitudes about the disease
and aggregates. All three subsets have diagnosis, outcome, and • Perception that they are not at risk for the disease
intervention arenas. Situation 3
Because community/public health nursing is concerned Assessment data indicate that a high number of children at
with health promotion, other nurses have developed ways to Little Joy Day Care Center have low hematocrit levels and median
add wellness diagnoses to the problem-focused diagnoses of household incomes less than $15,000 per year. Both parents and
NANDA. Neufield and Harrison (1990) recommend that well- children scored very low on a nutrition game.
ness nursing diagnoses for populations and groups include Suggestion:
three components: the name of the specific target population, Altered health maintenance among children at Little Joy Day
the healthful response desired, and related host and environ- Care Center related to lack of knowledge about foods high in iron
mental factors. For example, high school students with children and to low median household income.
(target population) have the potential for responsible parenting
(desired response); this potential is related to a desire to learn Validation
about child development (host factor) and the presence of a Validating data and nursing diagnoses with the community is
family life education curriculum and an availability of teachers important. Do community members really see this as a prob-
(environmental factor). lem? If so, do they desire a solution? Have they adjusted to the
During the late 1990s and early 2000s, NANDA added several problem and therefore may be resistant to change? For exam-
community-focused diagnoses: readiness for enhanced commu- ple, people living in a run-down housing area in a large city are
nity coping, ineffective community coping (NANDA, 2002) and offered better housing in a new project. However, many people
risk for contamination (NANDA, 2007). These diagnoses address choose to remain where they are rather than leave their friends
a community's ability to adapt and solve problems. and move to a strange environment. These people have adapted
to the problem and are, for a variety of reasons, resistant to pos- nurse planned a program to decrease gonorrhea among high
sible solutions. The restraining forces (friendships and fear of school students in census tract 1, the students enrolled in high
the unknown) are greater than the driving forces (desire for school in census tract 1 would be the target population, that is,
newer housing). Many programs have failed because the pro- the group in which the nurse wishes to effect change. Can you
fessionals planned care based on their own values and percep- identify the target populations in the following examples? What
tions of the problem and did not validate clients' perceptions of are the communities?
the problem and their desire for change. Perhaps if the residents • ExampleÂ€1: a program to decrease alcohol-related automo-
had been involved in the decisions to move together, the resis- bile accidents among students at Jackson High
tance would be lessened. • ExampleÂ€2: an exercise program for frail older adults at
How is validation with the community carried out? Hebron House Senior Center
Validation may be done in a variety of ways. You might • ExampleÂ€3: a health education program about first aid for 10-
use a questionnaire, conduct personal interviews, or make and 11-year-old girls enrolled in Girl Scout Troop No. 26
appointments with key community leaders or informants. Students, the frail older adults, and 10- and 11-year-old
Foremost, community members need to be included in plan- Girl Scouts are the target populations in the three respective
ning groups. Â�examples. Did you list Jackson High, Hebron House Senior
Center, and Girl Scout Troop No. 26 as the phenomenological
Prioritization of Needs communities? If so, you are correct.
The community assessment identifies needs and problems. Can the target population and the community ever be
However, not all needs can be addressed simultaneously; one and the same? Even though they are listed separately
priorities must be determined. Prioritization can be based in the previously mentioned examples, the community and
on many factors, such as the seriousness of the problem, the target population may be one and the same. Remember
the desires and concerns of the community, time, cost, and that ChapterÂ€15 stressed the importance of defining the com-
availability of resources. Obviously, a life-threatening situ- munity, because the parameters delineated in the definition
ation, such as a nuclear spill, will have priority over other determine what data to collect. Therefore the community
less life-threatening situations. A health problem may also might be defined as the students enrolled at Jackson High. If
be identified as serious when the community rate is higher this definition is accurate, the community and the target pop-
than the national rate for the same problem.Â€The APHA ulation would be one and the same. Similarly, the frail older
(1961) identified the first five of the following six factors to adults at Hebron House and the 10- and 11-year-old girls of
consider when determining priority of health needs at the Girl Scout Troop No. 26 might be designated as the commu-
community level: nity; again, the community and target population would be
1. Degree of community concern the same.
2. Extent of existing resources for dealing with the problem
(e.g., time, money, equipment, supplies, facilities, human Identification of the Planning Group
resources) The nature and extent of the community's needs will determine
3. Solubility of the problem who should be involved in developing the plan. Consideration
4. Need for special education or training measures should be given to (1) persons for whom the plan is designed,
5. Extent of additional resources and policies needed that is, the target population; (2) those who are concerned with
6. Degree to which community/public health nursing can con- the health problems; (3) those who appear best able to contrib-
tribute to the planning process ute resources to the plan; and (4) those who are most likely to
When attempting to prioritize the community's needs, follow through in carrying out the plan of action. The size of the
assessment data and the nursing literature must be used to planning group must also be considered. For logistical reasons,
answer questions such as the following: How concerned is obviously, everyone concerned with the problem cannot be per-
the community? How does the magnitude of the problem sonally involved as a member of the planning group. However,
compare with national rates? Are enough resources avail- the interests of persons who are concerned must be considered
able to deal with the problem? Can the problem be solved? and handled in a representative manner throughout the plan-
What additional education and training measures, if any, will ning process.
be needed to solve the problem? What additional resources An important task is to identify the opposition early in the
will be needed? Are existing policies in place that need to planning process and attempt to get these individuals involved.
be changed or modified for the problem to be solved? Are The opposition might help improve the plan by pointing out
community/public health nurses likely to be effective? After weaknesses. Participation also provides time to plan an appro-
answering these questions, priorities may change from those priate rebuttal to opposition arguments. Involving opponents
identified initially. in the planning process is much better than waiting until the
program is implemented and then facing resistance and pro-
Identification of the Target Population gram failure. Finally, the opposition may become involved and
The term target population is used to describe the identified convert to supporters.
group or aggregate in which change is desired as the result of Keep in mind the following general guidelines: community
a program or intervention. An assessment is sometimes con- members need to be included early in the assessment phase.
ducted on an entire community, as was done with “city X” and However, an expanded or a different group may be formed
“Northwood High” in ChapterÂ€15. However, intervention can before or after the target population is identified. Considerations
also target one segment of the population. For example, city about who should be involved in the planning group are sum-
X has a high rate of gonorrhea. If a community/public health marized in BoxÂ€16-1.
BOXÂ€16-1â•…â•‡GUIDELINES FOR â•›WHO many prevention-oriented programs aimed at people living in

SHOULD BE INVOLVED IN poverty have failed because the people responsible for the pro-
THEÂ€PLANNING GROUP grams did not consider motivational factors. Studies show that
poverty contributes to an orientation to the present rather
• Broad segments of the community, whenever possible, to provide than to the future so people living in poverty tend to be more
widespread base of support for the program crisis- or treatment-oriented (immediate need) rather than
• Leaders and others who control financial resources and have the prevention-oriented (future need).
legal authority to deal with the problem What motivates people to accept or oppose a strategy? A variety
• People in a position to promote acceptance of the program (e.g., of factors can influence acceptance or opposition. Cultural, eth-
media representatives, key community leaders, influential commu- nic, and religious values influence how people accept health care
nity members) plans. People will not accept programs that are incongruent with
• People who will implement the program their cultural, ethnic, and religious practices (see ChapterÂ€10). For
• People who will be affected by the program example, a program on birth control for adolescents may meet
• People who are most likely to offer resistance, the opposition with much opposition from parents, or some faith communities,
• Specialists in the area who can contribute to the group's Â�understanding
or both. As another example, opposition to HIV/AIDS education
of the problem and knowledge of possible Â�alternative solutions
may exist within a school because many parents do not want sex
education taught in the school. Understanding the community's
social values and beliefs enables the nurse to plan a program
Establishment of the Program Goal that will be more consistent with these beliefs. For example, a
The program goal is a comprehensive statement of intent or rural community with a long history of self-sufficiency may
purpose. A difference exists between the program goal and prefer to raise money internally to fund a new program rather
the desired outcomes (objectives). The goal is stated in general than apply for a grant from the state health department.
terms and gives no indication of possible means of achieving Perceived vulnerability is another source of emotional oppo-
the desirable outcome (McKenzie etÂ€al., 2009). Objectives, how- sition to programs. If people feel threatened, they may oppose
ever, are stated in terms of a specific outcome that contributes in the planned change. Although a small portion of the popula-
some way to the achievement of the goal. The following are two tion will always oppose any change, identifying who might feel
examples of program goals: threatened by or vulnerable to the proposed action is impor-
• To improve health knowledge regarding HIV/AIDS tant. Once these people are identified, the nurse can plan to
• To decrease infant mortality rate work with them to explain the plan and solicit their help and
These positions are broad statements of purpose, not specific cooperation rather than their opposition.
and measurable objectives. Economic factors are also a consideration. Is the strategy
After the program goal is established, health planners will cost-effective? If not, the nurse will probably have to plan a more
have to meet to discuss possible ways to achieve the goal and a cost-efficient alternative. Remember that cost-effectiveness refers
feasible time frame within which to accomplish the goal. to time and resources, as well as money. Generally, although the
least costly alternative will be the most popular, an alternative
Identification of Possible Solutions that is more costly in money but saves time or resources will
At this point in the process, the planning group has a brain- occasionally be favored.
storming session to examine various strategies and to identify What about political factors? You have heard people say,
the pros and cons of each strategy for this particular commu- “It will probably go through this year because this is an elec-
nity. What might work for one community may be inappropri- tion year.” This statement refers to the political climate and the
ate for another. Several factors influence the appropriateness of importance of knowing when to propose certain programs.
strategies. Physical, psychological, social, cultural, economic, In election years, programs and strategies that appeal to the
and political considerations affect the appropriateness of strate- greatest number of voters for a politician in a given area would
gies to solve a problem in any given community. be more powerful strategies than ones that appeal to a small
Physical factors include demographic characteristics such as minority of the voting population.
the age, race, gender, education, and income of the population. Power is closely associated with politics. Milio (1981) describes
For example, a health education program that uses a series of organizational effectiveness as the capacity of an organization to
speakers might be appropriate for an adult population, whereas bargain for scarce resources. Whoever has the most power gets
a group of children might need a more action-oriented, partici- the resources. Knowing what community leaders and elected offi-
patory program, such as a puppet show or a game. The level of cials favor and approaching them for their support early in the
education is crucial in knowing what type of interventions to planning process is important. Likewise communities who can
plan. The level of education influences whether the nurse will generate substantial citizen support for a proposed program and
plan a program that has a lot of reading or a visual, nonreading communicate that support to their elected leaders via letters, ral-
program. When printed materials of any kind are used in the lies, town hall meetings, and other strategies are most likely to suc-
intervention or to promote the program, the reading level must ceed in influencing their elected officials to support their position.
be considered (see ChapterÂ€20).
The major area of concern in relation to psychological factors Matching Solutions with At-Risk Aggregates
is motivation. Will members perceive a proposed plan as help- Within the population assessed, you may determine that dif-
ing or hindering the solution to the problem? People will accept ferent subpopulations have different needs based on their risks,
strategies or programs that are consistent with their value sys- problems, and concerns. Consequently, you may want to iden-
tem and that they perceive as helping the problem. For example, tify specific solutions for different at-risk aggregates.
Having decided on a course of action, the next step is to plan

For example, in the clinical example provided in ChapterÂ€15,
the details of the intervention. First, however, specific, expected
when nurses assessed the members (population) of a Korean
outcomes must be delineated.
immigrant community, they identified numerous at-risk
aggregates, each requiring a different health care service to Delineation of Expected Outcomes
address their needs (Kim etÂ€al., 2002). Hypertensive adults
Objectives for health programs include outcome objectives,
required prescription medication and exercise classes, and
process objectives, and management objectives (Hale etÂ€al., 1994).
women needed breast cancer screening and education. An 8%
Outcome objectives address the health status or health behav-
case rate of hepatitis B (above the national average) dictated
iors desired in the target population or competencies desired in
a two-pronged approach: health education for adults and
the community. Process objectives specify the implementation
young children and an immunization program for children.
activities and health care delivery that are necessary to achieve
the desired changes in the outcome objectives. Management
Identification of Resources objectives define the structures needed to carry out the pro-
Discussing the possible solutions in relation to the identified cess objectives. The Healthy People 2020 objectives (USDHHS,
resources is an important part of planning. The nurse should 2010a) are an important source of specific objectives.
identify the resources within the community, as well as out- For outcome objectives to be useful, they must meet a variety
side the community, that can be used to help solve the problem. of criteria or indicators. Some criteria for the outcomes commu-
These sources include both human and nonhuman resources. nity health status, community competence, community disaster
Human resources can provide expertise and people. Nonhuman readiness and response, and community risk control are published
resources include funding, facilities, supplies, and equipment. in Nursing Outcomes Classification (NOC) (Moorhead etÂ€al.,
Knowing ahead of time that personnel, funding, or needed sup- 2008, pp. 290-305). These criteria provide cues to measure the
plies are insufficient is better than aborting the mission for lack expected outcomes.
of resources after the intervention is begun. Outcome objectives (Ervin, 2002; Gronlund, 1970; Mager,
1962) should relate to the program goal or goals and the following:
For example, in the Korean community identified in ChapterÂ€15 • Identifying the program participants (who)
and previously discussed, bilingual health Â�professionals and • Describing specific behaviors that program participants will
social service personnel were identified as appropriate resources exhibit to demonstrate accomplishment of the objectives (what)
to assist with communication and Â�values clarification, and to • Describing the condition in which participants will demon-
serve as educators to assist the Â�non-Korean health professionals strate accomplishment (where and to what extent)
to deliver culturally competent care (Kim etÂ€al., 2002). • Describing the standard performance expected to indicate
accomplishment (how much)
Selection of the Best Intervention Strategy • Describing the time frame (when)
The nurse should select the best strategy for the population How does writing objectives for the community differ from
within the context of resources and time available. A problem writing objectives for an individual client? Although the same
can almost always be solved in more than one way. The key in criteria must be met, community-focused objectives are written
this step of the planning process is selecting the best strategy for for the group or population. When working with an individual
the population within the context of available resources. client, the nurse may state the following objective: After watch-
The best intervention strategies are culturally appropriate ing a film on diabetes, the client will state at least three signs of
and personalized to the preferences of the target population. hyperglycemia.
How would a similar objective be stated if the nurse was
ExampleÂ€1. Smith Battle (2003) found that teen mothers working with a group of diabetic clients? One example might
accepted health-related assistance best when they felt they be the following objective: After watching a film on diabetes, 90%
were in a reciprocal relationship, in which their views were of the participants enrolled in the diabetic education program will
considered important. Consequently, to be successful with state at least three signs of hyperglycemia.
teen mothers in this community and similar communities, What is the difference? When working with the community,
Smith Battle (2003) recommends that community health the nurse must consider the population and indicate whether all
nurses use a participatory rather than a nurse-focused strat- members of the population or a certain portion of the population
egy. Rather than be passive recipients of nursing care, the needs to demonstrate the action. Examples of specific community-
teens should be encouraged to contribute their knowledge to oriented behavioral objectives and differences between criterion
the community/public health nurse and community. and norm-referenced objectives are listed in TableÂ€16-3.
ExampleÂ€2. An assessment of health education needs for In criterion-referenced outcome objectives, the objectives
Arab American adolescent cigarette smokers in the Troy, specify the behaviors desired in the target population or com-
Michigan, area revealed that they were eager to share their munity. For example, the pregnancy rate of census tract 1 will
reasons for smoking and the efforts they had made to quit. be reduced to 40 pregnancies per 1000 female adolescents in
The adolescents reviewed an existing smoking cessation 3â•›years. In norm-referenced outcome objectives, the desired out-
program and offered suggestions to modify intervention come is compared with another population or an ideal. For
strategies to customize it to their target group. These teens example, the pregnancy rate of female adolescents in census
also advised the nurses that including family and peer partic- tract 1 will be no higher than the national rate of pregnancies
ipation in the health education project would be important per 1000 female adolescents in 3â•›years. The population might
(Kulwicki & Rice, 2003). also be compared with itself: the teenage pregnancy rate of
census tract 1 will be reduced 50% in 3â•›years.
TABLEÂ€16-3â•…â•‡BEHAVIORAL OBJECTIVES/ Management objectives are concerned with funding; person-

OUTCOMES nel; program support, such as equipment and record keeping;
and publicity. The following is a management objective: The
Sample Outcome Goal health department will hire three community/public health nurses
At least 40% of the smokers among mothers enrolled in the central for school health within 4â•›months.
city Mom and Tots Center will have modified their smoking habits
by June 2004. Delineation of the Intervention—Work Plan
Determine specific behavioral objectives: include who, behavior, In this step, the nurse plans the basics of the intervention and
condition, criteria, and when. takes into consideration the specific what, how, who, when, and
where (BoxÂ€16-2). A good plan will have the following questions
Sample Outcome Objective (Criterion-Referenced) answered before any intervention:
Given a smoking modification program, at least 80% of the • WHAT actions are to be done?
interested mothers will devise and implement a contract to modify • HOW are the actions to be accomplished?
their smoking habits by the fifth week of the program. • WHAT resources (equipment, space, money) are needed?
1. Who—description of group Interested mothers • WHO is responsible for the accomplishment of each action?
participants
• WHEN will each action occur?
2. Behavior—description Devise and implement a
• HOW MUCH TIME will be required to accomplish the action?
ofÂ€theÂ€behavior the participants contract to modify smoking
• WHERE will the actions take place? This question includes
will exhibit to demonstrate habit
accomplishment of the obtaining the place and determining how much space is
objectives needed.
3. Condition—description Given a smoking modification This work plan includes specific process and management
ofÂ€conditionÂ€in which program objectives discussed earlier in the chapter.
participants will demonstrate Taking the time to make a detailed work plan in the beginning
accomplishment will save time and will make for a much smoother working phase.
4. Criteria—standard of At least 80% will actively Nothing is more frustrating, or embarrassing, than coming to the
performance expected to participate intervention phase and realizing that a basic detail is missing.
indicateÂ€accomplishment
5. When—description of time By the fifth week of the Planning for Program Evaluation
frame program Although evaluation is the last step of the nursing process, eval-
uation planning should begin as soon as goals are established.
Sample Outcome Objective (Norm-Referenced) All too often, evaluation is not even considered until the end.
After the presentation by the nursing students, the target population However, plans must also be made for evaluation. Evaluation
will demonstrate a statistically significant increase in knowledge is needed throughout the program to measure progress, as well
as measured by a paper-and-pencil pretest and posttest.
as at the end to measure the overall value, adequacy, efficiency,
1. Who—description of group The target population
Â�outcomes, and effectiveness. Evaluation is a continuous feedback
participants
process that provides the stimulus for changes in the system.
2. Behavior—description Increase in knowledge, as
ofÂ€theÂ€behavior the measured by a paper-and-
participantsÂ€willÂ€exhibit to pencil pretest and posttest BOXÂ€16-2â•…â•‡STEPS IN ESTABLISHING â•›A
demonstrate accomplishment WORK PLAN
ofÂ€theÂ€objectives
3. Condition—description of After the presentation by the 1. Identify the specific target population to be served by the program.
condition in which participants nursing students 2. Specify the number of people to be served during various time peri-
willÂ€demonstrate ods (called utilization).
accomplishment 3. Sequence the interventions logically, and specify when they are to
4. Criteria—standard of Will demonstrate a be phased in and who is responsible to do so (perhaps using a Gantt
performance expected to indicate statistically significant Chart).
accomplishment increase in knowledge 4. Determine the personnel needed. Anticipate learning needs of the
personnel regarding implementing the program. (For example, if a
program's purpose is to screen pregnant women for risk of abuse,
nurses would need to know the factors indicating increased risk.)
Process objectives specify incremental activities or ser- 5. Identify space, equipment, educational materials, and disposable
vice delivery that will lead to attainment of outcome objec- supplies needed.
tives (Ervin, 2002). These objectives are monitored in short 6. Develop a budget, including revenue sources and costs of person-
intervals to ensure that the program is on course to meet nel, equipment and supplies, publicity, use of buildings, and admin-
outcome objectives and program goals. The following is an istrative services.
example of a process objective: 75% of Northview High stu- 7. Develop mechanisms for managing the entire program, including
supervising personnel, administering the budget, monitoring the
dents will participate during the spring semester in an educa-
planned sequence of activities (work plan), and conducting forma-
tion session on reducing risky sexual behavior. An objective
tive evaluation.
such as this one would contribute to attainment of the pro-
8. Develop mechanisms to communicate with interested parties and
gram goal: to reduce risky sexual behavior among high include the parties in program monitoring and decision making.
school students.
Program evaluation is the process of determining whether Program Evaluation and Review Technique
the program is achieving its purpose, whether it should be The Program Evaluation and Review Technique (PERT) is a
continued or terminated, and how it can be improved or bet- more complex tool. PERT is a network programming method
ter managed (Glick & Kulbok, 2002). Process and management developed during the 1950s through a joint effort between
objectives are evaluated throughout the program to ensure that the U.S. Navy and private industry (Lockheed Aircraft
planned activities are being accomplished. Outcome objectives Corporation and Booz Allen Hamilton, Inc.) for the Polaris
are measured primarily at the end of the program to determine Missile project. Similar to the Gantt Chart, PERT also looks at
whether the program goal was attained. the concepts of events and time but is particularly useful for
Many approaches can be used for program evaluation. large-scale projects.
ChapterÂ€17 is devoted to exploring different methods of Â�program The intent of PERT is to accomplish the following:
evaluation in detail. Sufficient to mention in this chapter is that • Focus attention on key developmental parts of the program
a plan for program evaluation must be seen as an essential • Identify potential program problems
step in the planning process so that systematic program evalu- • Evaluate program progress toward goal attainment
ation becomes a reality, not merely an afterthought. BoxÂ€16-3 • Provide a prompt, efficient reporting method
summarizes some keys to success and pitfalls in planning and • Facilitate decision making
implementing health care forÂ€communities. PERT involves the following three steps (Roman, 1969):
1. Identifying specific program activities
Tools Used to Present and Monitor Program Progress 2. Identifying resources to accomplish these activities
During implementation of the plan, evaluating progress is 3. Determining the sequence of activities for accomplishment
important. A visual guide to present and measure program PERT uses a flowchart designed to estimate the time
progress is often helpful. Several tools are used to chart activ- required to complete specific events necessary to complete
ity and anticipate management problems in the implementa- the entire project. Events are shown on a chart by shapes (cir-
tion phase. The three tools that are discussed here are the Gantt cles, ovals, squares, or triangles) with numbers. The number
Chart, the Program Evaluation and Review Technique, and is not necessarily a sequential number; that is, number 3 does
the Planning, Programming, and Budgeting System (Green & not have to occur after number 2. The numbers designate a
Kreuter, 2005; Rowland & Rowland, 1992). task, not a sequential order. The activities to complete the
events are the time-consuming element. Time is represented
Gantt Chart on the chart by lines and arrows. Unlike the Gantt Chart, each
Henry Gantt developed the Gantt Chart during World War I to line has three different numbers representing three time esti-
identify the process needed to accomplish a result. mates: optimistic, most likely, and pessimistic. Optimistic is
Starting with a final work result, major steps necessary the shortest amount of time possible to complete the activ-
to obtain the result are projected backward from results ity if everything goes perfectly; most likely is the most likely
to actions; their timing and sequence are then considered amount of time needed to complete the activity; and pessi-
(Drucker, 1974). The Gantt Chart considers the concepts of mistic is the longest amount of time the activity might take
events and time (FigureÂ€16-2). The events are listed down the (Ervin, 2002).
left side of the chart. Time is represented across the chart for
each event by lines showing when the event is to start and Planning, Programming, and Budgeting System
when it is to be completed. The Planning, Programming, and Budgeting System (PPBS)
is an economical method of expressing a program plan. PPBS is
an outcome-oriented accounting system designed to determine
the most efficient method of resource allocation to attain mea-
BOXÂ€16-3â•…â•‡PITFALLS AND KEYS TO
â•› surable objectives (LaPatra, 1975).
SUCCESS IN IMPLEMENTING The three components of the PPBS are as follows:
HEALTH PROGRAMS 1. Planning: formulation of objectives and identification of
Pitfalls to Success alternatives and methods for accomplishing the objectives
Inaccurate assessment 2. Programming: delineation of resources for each identified
Nonvalidation of data with community alternative
No community involvement 3. Budgeting: assignment of dollar values to the resources
Insufficient resources required for the program implementation
Lack of coordinated planning Although designed by the U.S. Department of Defense to
Lack of leadership plan broad-scale programs, the PPBS can be used as a frame-
Poor communication work to plan programs for smaller organizations and popula-
tion groups.
Keys to Success
Thorough, accurate assessment
Validation of assessment data with the community
Involvement of the community IMPLEMENTATION
Sufficient resources
Implementation is the action portion of the plan; in other
Well-developed plan, with coordination among team members
words, the plan states what will occur in the implementation.
Good leadership
Open communication Mobilizing people and resources to activate the plan of action is
a challenging task for the community/public health nurse.
EXAMPLE OF GANTT CHART
This chart specifies time frame, tasks, and persons assigned to work on each task. Time frames listed below are suggested task allotment
intervals; your group's progress may vary somewhat from these guidelines.
Begin task Complete task Duration of task

Time (in weeks)
Tasks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Person assigned
1. Review task chart and

delegate tasks
2. a. Selection of health
need/target population/
community and
suprasystem
b. Seek agency/
community approval
to work with them
3. Community assessment:
a. Identify data needed
b. Determine method(s)
of data collection
c. Collect data
d. Analyze data
e. Complete written
community assessment
and analysis
4. Health need of target

population:
a. Review literature
of community
health needs and
risk areas for
target population
b. Identify additional
data needed specific
to selected population
c. Determine method of
data collection
d. Identify or develop tool
e. Pilot tool and revise
f. Collect data
g. Analyze data
5. Propose nursing
intervention(s)
a. Select priorities
b. Identify goals/objectives
c. Identify possible
interventions
d. Select interventions
6. Develop evaluation
plan
a. Review literature
b. Selection of program
evaluation method
FIGUREÂ€16-2â•‡ Example of a Gantt Chart, which specifies time frame, tasks, and persons assigned
to work on each task. Time frames listed are suggested task allotment intervals; actual intervals
may vary. (Adapted from Community Health Nursing Faculty, Undergraduate Program. [1985]. Syllabus for
nursing [p. 325]. Baltimore: University of Maryland School of Nursing.)
The role of the nurse during implementation varies based on

For example, in the Chattanooga Creek case study introduced
the type of program, the community, and the community orga-
earlier in this chapter, different health education programs
nization methods used. Baccalaureate-prepared Â�community/
were planned for local health care providers, elementary
public health nurses may directly implement the plan in part-
school-age children, and adult residents to make them aware
nership with others, coordinate programs and services, pro-
of environmental health hazards (Phillips, 1995).
vide health education and health promotion, consult with
others, and implement public health laws, Â� regulations, and Another example of targeting education occurred in 170
policies (ANA, 2007). In many health programs, community/ public and Catholic elementary schools in Ontario, Canada
public health nurses perform the interventions and manage (Cicutto etÂ€al., 2006).
the program. Community/public health nurses often conduct
health education and screening programs and may provide pri- In Ontario, the schools had no school nurses and relied on
mary health care. Community/public health nurses manage public health nurses. A needs assessment conducted via ques-
programs by supervising personnel, administering the budget, tionnaire to teachers revealed that teachers did not know which
ordering equipment and supplies, maintaining program records, students had asthma and 80% of teachers did not feel confident
and ensuring that planned interventions areÂ€accomplished. in handling asthma. To provide asthma-friendly schools, pub-
Throughout the implementation phase, the nurse continues lic health nursing interventions were targeted to children with
to collaborate, coordinate, and consult with others. The role of asthma and to the broader school community. An asthma edu-
facilitator increases because the nurse must facilitate the com- cation program for children with asthma occurred once per
munity's sense of ownership of the program. Active participa- week for 6â•›weeks. Multiple posters, newsletter articles, teacher
tion of the community is essential to the success of the program; in-service education programs, and standardized asthma man-
the health program will be successful only if the community agement forms targeted schools, teachers, staff, and parents.
owns it. The nurse facilitates ownership by getting key peo-
ple involved from the beginning and by facilitating increased The teaching methodology must be appropriate to the com-
involvement in the program. Therefore the nurse's role may munity. Using different methods of presentation that appeal to
change during implementation as the community begins to many senses (not just the lecture method, which is the least effec-
assume more responsibility. tive method) is important. U.S. society has been described as a
Implementation results in change that can be stressful and media society. Use media that are well received by a given age
threatening. Resistance to change is natural and inevitable, group (e.g., for young children, use a puppet show or coloring
because every system attempts to maintain dynamic equilib- books to teach content). Be creative! One example of a creative
rium. Change brings an initial state of disequilibrium. However, health-promotion program is a music video designed for adoles-
if the people in the community have been involved from the cents in which the lyrics suggest birth control behaviors. This cre-
beginning in a plan that affects them, are informed about the ative effort was designed by the Johns Hopkins Population Center
benefits of the plan for them, and are convinced of the value of for reaching populations in other countries. This approach has
the plan, they are less apt to offer resistance. been popular in the Philippines and was released in Mexico.
Types of Interventions Screening Programs

Just as many different types of interventions can be made for Screening programs are designed to provide early detection
the individual, so, too, a variety of interventions can be con- and diagnosis of health problems (see ChapterÂ€19). An impor-
ducted for the community as client. All 17 public health nurs- tant point to remember is that screening does not prevent the
ing interventions discussed in ChapterÂ€1 can be carried out with disease but merely identifies risk factors or early signs so that
communities (Minnesota Department of Health, 2001). Several appropriate treatment intervention may be obtained.
major types of community/public health intervention pro-
grams exist, including the following: To improve access to tuberculosis (TB) treatment among
• Health education programs inner-city homeless, faculty and student nurses screened
• Screening programs 327 residents of an addictions recovery program duringÂ�
• Establishing services an 18-month period (Lashley, 2007). Nursing students
• Policy setting and implementation Â�administered Mantoux tuberculin skin tests and provided
• Increasing community self-help and competence assessments for TB symptoms. Those individuals with posi-
• Increasing power among disenfranchised individuals tive findings were referred to the city health department TB
clinic for appropriate treatment. Nursing students educated
Health Education Programs the residents about TB infection, transmission, and con-
Much intervention at the community level is aimed at educat- trol. The students also coached residents to keep clinical
ing people about their health (see ChapterÂ€20). Health educa- appointments and tracked those who missed appointments.
tion programs can be geared toward one or more of the three
levels of prevention. Programs provide information on how to Important to note here is that when planning a screening pro-
promote health, prevent illness, manage care for those with ill- gram, referral and treatment resources must be included as part
nesses, minimize the effects of illness or injury, and ensure a of the intervention. Saying, “You have a problem” is not enough.
healthful environment. The nurse must also provide information about how and where
Different health education programs may be targeted to spe- to go for help. Community participation in screening activities
cific at-risk aggregates within the larger population or commu- and health fairs can be increased by using bilingual volunteers and
nity that has been assessed. paid community workers, as well as translators, when appropriate.
Establishing Services Increasing Community Self-Help and Empowerment

Many community health programs focus on establishing the Locality development strategies focus on strengthening the pro-
services required to meet the health needs of a given popula- cesses that involve community members in solving their own
tion. Some examples of services are school health clinics, home problems (Rothman, 1978). These strategies do not result imme-
health care nursing services, grocery shopping services for diately in new educational programs on a specific health topic
home-bound older adults, and daycare centers for older adults. or in new services or policies. Instead, community competence
Bremer (1987) has described the establishment of a community is enhanced (Moorhead etÂ€al., 2008). Short-term results among
health nursing service to promote the health of older adults in community members include increased self-confidence, increased
their homes and to prevent disability. levels of problem-solving skills, and new or strengthened com-
With the advent of nurse practitioners in the 1970s, contem- munication and problem-solving networks and coalitions.
porary community nursing centers began to emerge. Although Milio's work (1971) with the Mom and Tots Center in Detroit is a
the number of health centers is difficult to document, there are classic example of this form of community development.
at least 129 of these centers in the United States (Institute for
Nursing Centers, 2007). More than half of these centers are affili- Nurses who were concerned about the plight of older adult
ated with another organization, often a school of nursing, and residents in rural Alabama found that older adults were often
the rest are freestanding. Community nursing centers provide unable to perform chores or to pay to have chores and other
direct access to nursing services, such as primary care, assess- activities done that would help maintain their independence
ment and screening, education, case management, and counsel- and improve their quality of life. The nurses developed the
ing. The centers tend to plan and provide care for traditionally Rural Elderly Enhancement Program to develop community
underserved populations, such as children and poor, older adults, volunteer coalitions; provide accessible and safe water, hous-
and homeless individuals. Approximately 40% of care in nursing ing, and transportation; and conduct needs assessments of
centers is provided to the uninsured, who receive free care or pay older adults (Farley, 1993). Community participation in the
on a sliding scale. Another 34% of those served are in Medicaid Alabama Rural Elderly Enhancement Program consisted of
and Medicare programs (Institute for Nursing Centers, 2008). the following activities and services:
Innovation is basic to public health nursing practice. Housing—Builds steps, ramps, porches; replaces roofs and
windows
Sloand and Gebrian (2006) describe village-based fathers' Fund raising—Helps older adults buy medications and
clubs in Haiti, which has the poorest health indicators in the obtain transportation and public water
western hemisphere. Public health nurses supervise village Education—After training by nurses, volunteers provide
health agents who are paraprofessionals. There are 40 active health education to older adults
fathers' clubs with 700 members; fathers meet regularly for Helping Hand—Trained volunteers provide friendly visits
health education, support, and community building. and homemaking, personal, and respite care
Policy Setting and Implementation The REACH-Futures program discussed earlier in this chap-
A community may have needs that must be met by policy ter is an example of the empowerment of a community through
changes (Williams, 1983). These changes might include leg- the involvement of lay health workers (Norr etÂ€al., 2003).
islation at the local or state level. Interventions that focus on Through locality development strategies, public health nurses
policy setting may include lobbying, building coalitions, and can assist communities in strengthening their capabilities to
participating in the political process. For example, a group of engage in the core public health functions: assessment, policy
nurses initiated mandatory seat belt legislation as a result of development, and assurance. Community/public health nurses
the deaths and injuries they witnessed in emergency depart- can facilitate partnerships among community groups and vari-
ments. In St. Louis, public health nurses were successful ous subpopulations through which community members can
in getting the jurisdiction for a lead poisoning control pro- become more active in identifying their health concerns, lobbying
gram returned to the health department (Kuehnert, 1991). for changes in health policy, and ensuring culturally appropriate
Previously, the responsibilities for lead screening and con- health promotion and disease or injury prevention. Thus self-help
trol had been transferred from the health department to the goes beyond empowerment of a specific population to strengthen
private sector, resulting in lower screening rates and a higher the structures and competency of the entire community.
prevalence of lead poisoning.
Process evaluation of specific programs or interventions may Changing Community Power Structures
result in recommendations for policy improvement. Strategies that shift the power balance within or among commu-
nities can empower disenfranchised individuals. The power bal-
Personnel from a local health department responded to ance can be shifted if the ability of community members to help
an outbreak of Norwalk-like virus at a church camp in the themselves is increased. However, the institutionalized structures
northwestern United States. Community/public health of the community often must also be changed if the population
nurses who attended the camp were concerned about the is to have more equal access to community power. One example
perceived absence of partnership between the local health is the attempt to restructure employment opportunities so that a
department personnel and the camp community (Sistrom & working adult is guaranteed a wage above the poverty level.
Hale, 2006). This led the nurses to recommend that commu-
nity participation be identified as an essential part of out- Strategies for Implementing Programs
break investigation guidelines. Several strategies can be used for implementing programs on
the community level.
Single Action
During their first visit, several students noticed two inci-
In the single-action approach, programs are implemented one
dents of bullying during playground activities. This obser-
time for a specific purpose. In some instances, this approach is
vation and subsequent collaborating data (interviews
all that is necessary or all that resources will allow.
with teachers, the school nurse, the principal, and some
Phasing third-grade students) identified a need to address bullying
behavior as a health need.
Phasing in programs over a period is sometimes necessary or
In developing the intervention plan, the nursing students
advantageous. Phasing in is often used in large programs and
collaborated with the county police department, the univer-
in programs in which a multitude of resources are needed. The
sity school of social work, and a high school student peer-
problem is sometimes so multifaceted that several different
counseling program. The ultimate intervention included
stages of interventions are required to solve it.
an educational component, several play-acting sessions,
Phasing has been used to implement the national injury pre-
and an ongoing peer-counseling program under the guid-
vention program. To reduce injuries and fatalities related to motor
ance of participants in the high school peer-counseling pro-
vehicle accidents, interventions have been added over time:
gram. All the groups profited from the collaborative effort.
1. Mandatory seat belt laws passed by states
The nursing students gained valuable experience working
2. Mandatory helmets for motorcyclists by states
with multiple disciplines and agencies. The third-grade stu-
3. Improved safety standards for children's car seats
dents gained an ongoing support program that continues
4. Federal funding eliminated or reduced if states did not pass
to help them cope with bullying behavior. The school of
mandatory seat belt laws
social work and police department gained additional expe-
5. Laws tightened to allow police to stop a vehicle solely for
rience working with young children in violence prevention
nonuse of seat belts
activities. The high school students learned how to modify
6. Upgrading of manufacturing standards for car structures
their approach to peer counseling by making it age appro-
Collaboration and Networks priate. The high school students also benefited because they
acquired volunteer or credit hours needed to graduate from
Collaborative efforts between disciplines and agencies can be
high school.
effective and efficient when planning care at the community
level. A partnership between agencies and personnel results
in better use of resources and often a much stronger pro- Coalitions
gram. A great deal more can be accomplished when resources A coalition is a temporary union for a common purpose.
areÂ€pooled. Coalitions are effective strategies at the local, state, and national
political levels and often are population oriented. For example,
A group of 10 nursing students enrolled in their senior coalitions for women's health issues have been formed.
community/public health course decided to do a commu- Ultimately, a program's success depends on many fac-
nity project in an elementary school. After consultation tors, including human resources, funding, political will, and
with the school principal, and because of time constraints community support. Community/public health nurses—
(10â•›weeks), the students limited their community to one with their unique knowledge of community resources
group, the third-grade students. The nursing students and assets, community problems or lack of resources, and
visited the school and classrooms to gather information. key players—are well situated to facilitate and empower
community action.
KEY IDEAS
1. Health planning is a social process that many disciplines use problems. No single classification system exists for nursing
to promote the health of populations and the competency of diagnoses for communities.
communities. 7. Program goals are broad statements of desired health
2. Health interventions planned for groups and populations outcomes. Outcome, process, and management objectives
are often called programs. Although programs may be contribute to goal attainment.
single actions, they are more often ongoing interventions 8. Community/public health nurses use Healthy People 2020
involving several different activities and phases. objectives as guides to develop goals and objectives for
3. Steps in health program planning are consistent with the health programs in specific communities.
nursing process and include assessment, analysis, planning, 9. Community/public health nurses often implement and
implementation, and evaluation. manage community and public health programs.
4. Community/public health nurses work in partnership with 10. Common health care interventions performed by
other professionals, community leaders, and community Â�community/public health nurses include health education,
members to plan and implement health care based on a screening, policy formation, establishing new nursing
community assessment. services, and community empowerment.
5. Community health planning based on community assess- 11. Planning health programs for communities includes plan-
ment is a basic element of community/public health nursing. ning for evaluation.
6. Community nursing diagnoses address the commu-
nity members' responses to actual and potential health
â•…â•‡THE NURSING PROCESS IN PRACTICE

Health Planning for a Phenomenological Community
In this case study, we use the community assessment of Northview • Individuals with resources (health department, board of education)
High School given in ChapterÂ€15 to plan and begin to implement health • Individuals who will implement the plan (community/public health
programs. Many of the steps of program planning discussed earlier in nurse, physical education teacher)
this chapter are evident. In this situation, Ms. Fields is charged by the principal to develop a plan
A community/public health nurse, Marian Fields, is assigned full time to and then bring it to him and the school board for consideration. Ms.
two high schools, Northview and South Central high schools. This assign- Fields is able to arrange several meetings with a group consisting of
ment is new for her. She is expected to spend 5â•›days each 2-week period some faculty (including the physical education teacher), health depart-
at each school. Previous to her appointment, the health department pro- ment personnel, and student representatives.
vided a nurse for one half day per week at each school. Her job description
includes staffing a health room to address the complaints of ill students, POSSIBLE SOLUTIONS
maintaining the health and immunization records of all students, adminis- During the meetings, participants brainstorm the following possible
tering medications and providing treatments as ordered for chronically ill solutions to the problem:
students (e.g., nebulizer treatments for asthmatic students), assisting with • Teen clinic on site
classroom instruction on health-related issues, and developing programs • Teen clinic near the school
to address the major health-related concerns of the high school students. • Educational program regarding sexually transmitted diseases and
Through the assessment of Northview High School in ChapterÂ€15, the containing contraceptive information
following health issues emerged: • Educational program without contraceptive information
• Substance abuse, including smoking • Simulation experience: caring for a child (to increase motivation to
• Communicable diseases and rashes avoid pregnancy)
• Injuries necessitating first aid • Peer counseling or partnership program
• Insufficient birth control information • Interviews with teenage parents to determine why they got pregnant
• Unprotected sexual activity • Inviting adolescents with sexually transmitted diseases or HIV to
• Teenage pregnancy speak (to increase perceived vulnerability to disease)
• Lack of daycare for infants of teenage parents • Participatory programs to strengthen identity and self-efficacy and
• High dropout rates for pregnant teens identify own goals or values
• Sexually transmitted diseases
• Vision screening PROGRAM GOALS
• Chronic illnesses After much discussion, the group incorporates a large number of solu-
• Personal hygiene tions into a two-phase program design. The first phase is to develop a
• Dental problems comprehensive sex education program aimed at changing risky health
• Obesity and anorexia behaviors. The second phase is to improve access to health services
Ms. Fields decides to concentrate her initial program efforts on a single for sexually active students. (Planning for evaluation is discussed in
health issue rather than to address all the health problems of the high ChapterÂ€17.)
school at one time.
PRIORITIZATION Phase 1: A Sex Education Program

In selecting a health need for intervention, the community/public health Ms. Fields is responsible for designing the educational program. She
nurse should consider how many students are affected by the prob- reviews the literature on teenage pregnancy, birth control, sexual activ-
lem, as well as the degree of risk associated with the problem. Risky ity, attitudes, and knowledge level. Because of the various opinions
sexual behavior is selected as the priority problem because it is of con- about the inclusion of sexually transmitted disease and contraceptive
cern to both parents and faculty; community/public health nurses can information in a sexual education program for adolescents, Ms. Fields
contribute to the solution, and risky sexual behavior can be changed. needs to identify the community's position on these topics. From con-
Addressing risky sexual behavior also has the potential to contribute versations with parents, she knows that many people would support
to other health status outcomes as well. The nurse's ultimate goal is inclusion of this information in the educational program. She meets
to change the health status of her community by lowering the rates of with the principal to determine his position, who informs Ms. Fields
teenage pregnancy and sexually transmitted disease through reducing that he will support inclusion of the topics and that the school superin-
the number of students engaging in unprotected sexual activity. When tendent has informed him that five of seven school board members will
comparing the teenage pregnancy rate for this school with national sta- support the position.
tistics, the nurse finds the school's pregnancy rate (18%) is well above To validate that Northview High School students' needs are similar
the national rate (4.3%) (USDHHS, 2010b). to those identified in the literature, the nurse designs a questionnaire
to distribute to a sample of students. The aim of the questionnaire
TARGET POPULATION is to assess the level of student knowledge about the selected top-
The target population is the students attending Northview High School. ics to tailor the educational program for the students at Northview
High School. Her survey reveals that students are knowledgeable
PLANNING GROUP about the mechanics of sexual intercourse, and most acknowledge
Ideally, the planning group at Northview should include the following: the importance of protection during sexual intercourse; nevertheless,
• The consumers (students in the high school) they continue to engage in risky behavior and show knowledge defi-
• Individuals who are concerned with the problem (faculty, administra- cits on a significant number of topic areas included in the following
tors, members of the parent-teacher association [PTA]) nursing diagnoses.

Nursing Diagnoses and Problems Implementation
1. Population at risk for health problems as evidenced by a high rate of Ms. Fields identifies a significant number of resources to assist with
sexual activity (more than 50% of students sampled report engaging the program she has designed. The physical education teacher is will-
in sexual intercourse) ing to assist with the lecture portion of the program but does not want
2. Knowledge deficit related to the risks of pregnancy during sexual to conduct seminar discussions. The health department is willing to
activity provide a social worker and a clinical psychologist to implement the
3. Inconsistent use of birth control first discussion groups and assist high school staff to become more
4. Knowledge deficit related to functioning of various birth control comfortable with the discussion process. In addition, the health depart-
mechanisms ment is willing to provide posters, brochures, and other visual aids for
5. Knowledge deficit related to signs, symptoms, and potential conse- classroom instruction.
quences of untreated sexually transmitted diseases Ms. Fields presents her plan to the principal, who agrees that the
plan is appropriate and sends it to the school superintendent for
Nursing Goals and Actions review. The superintendent, with the principal and Ms. Fields in atten-
The program goals are as follows: dance, presents the plan to the school board, and it is approved by one
• Provide students with the skills needed to explore the benefits and vote. The principal assigns a volunteer biology teacher to help with
risks of engaging in sexual activity during adolescence. classroom instruction. Ms. Fields intends to implement the program
• Increase the knowledge level of students about sexually related at the start of the second term, after the students return from winter
information so that students can make informed choices about vacation.
behavior. Process Objective. Seventy-five percent of students will partici-
ProblemÂ€1 Outcome Objective. Consistent with the Healthy People pate in the instructional program during the spring semester.
2020 objectives, reduce the number of students who begin sexual
activity and increase the number of students who postpone beginning Phase 2: Improve Student Access to Health Services,
sexual activity until they are older. Including Services to Address Risky Sexual Behavior
The nursing actions are as follows: To validate the need for additional adolescent health services,
1. Develop a seminar discussion program with student participation Ms.Â€Fields surveys the resources for teenage health services in the sur-
that explores the reasons students begin or continue to engage in rounding geopolitical communities. She finds that a community health
sexual activity. center is nearby. This site provides services to well children under the
2. Identify the benefits and risks of beginning sexual activity. age of 6â•›years, prenatal care to pregnant women, and family planning
3. Provide skill-developing exercises that help students practice the services. No services are aimed specifically at adolescent health prob-
declining of sexual advances. lems. Although teens can be served at the site for pregnancy and family
4. Develop a peer network that will support students who choose not to planning, the clinic has not had the resources to actively target teens.
engage in sexual activity. From the assessment of the high school community (see ChapterÂ€15),
ProblemÂ€2 Outcome Objective. Increase student knowledge about Ms. Fields knows that support services for teen parents are inade-
the process of conception. quate; many of the teens do not continue with school, and many drop
The nursing actions are as follows: out. The surrounding census tract consists of families with moderately
1. Explore the physiological process of conception. low income. Many are “gray area” families; that is, they have no health
2. Examine the myths associated with preventing pregnancy during insurance but do not qualify for state medical assistance because their
sexual intercourse and physical intimacy. income exceeds the eligibility criteria. Two general practitioners are
ProblemsÂ€3 and 4 Outcome Objective. Increase student knowl- in the community, both with heavy client loads. These practitioners do
edge about birth control methods. treat adolescent members of families in their practice, but restrict the
The nursing actions are as follows: number of families who are unable to pay for services. Care is acutely
1. Review various birth control methods, including abstinence. focused rather than preventive in nature. Both practitioners report that
2. Discuss the benefits and risks of each method. they do not have the time or resources to target teens or emphasize
3. Identify the risk of pregnancy for each method. preventive health practices. No other medical professionals are practic-
4. Hold a discussion seminar that explores with students common rea- ing within the community boundaries.
sons why some opt not to use birth control.
5. Link the myths associated with reduced risk of pregnancy, inconsis- Nursing Diagnoses
tent contraceptive use, and actual pregnancy risks. 1. Inadequate services to provide adolescent health care
ProblemÂ€5 Outcome Objective. Increase student knowledge of 2. Inadequate services to address primary prevention with respect to
sexually transmitted disease. pregnancy and sexually transmitted diseases
The nursing actions are as follows: 3. Inadequate support services for teenage mothers with respect to day-
1. Review common sexually transmitted disease signs and symptoms. care, parenting skills, and continuation of their educational program
2. Review treatment and potential complications of common sexually
transmitted diseases. Nursing Goals and Actions
3. Provide seminar discussion to explore with students the issues and The program goals are as follows:
concerns related to these health issues; correct misconceptions. • Improve health services for adolescents.
4. Relate the best ways to reduce the risk of sexually transmitted • Improve support services for teenage parents, especially teenage
disease. mothers.
Continued

ProblemsÂ€1 and 2 Outcome Objective. Provide adequate health 3. Convene a committee of professionals, students, and community
care services to students within 24â•›months. representatives and leaders. Report results with problems 1 and 2
The nursing actions are as follows: as previously stated, assist the committee in developing a proposal
1. Convene a committee of community and suprasystem represen- for support services, and have committee members present the pro-
tatives and health care providers to identify the types of health posal to the school board.
Â�services needed.
2. Have the committee brainstorm ways to provide these services, Implementation
including addressing the issues of cost and access. Ms. Fields met with both professionals and students in an effort to
3. Develop a proposal for providing health care services to the teenage identify the problems associated with continued schooling during
population. and after pregnancy. Some of the problems identified included the
4. Present the proposal to the school board for approval. following:
• No in-school child daycare
Implementation • Limited daycare options in the community and the cost of these options
The proposal to improve health care services for adolescents resulted • Student families who are unable to provide daycare because of their
in a recommendation for a school-based clinic. This proposal was taken employment responsibilities
to the school board, which held hearings. A vocal minority of census • Poor preparation for parenting, including information related to man-
tract residents opposed a school-based clinic because they were not in aging infant illness, hygiene, infant growth and development, and
favor of providing contraceptives in a school-based setting. The commit- discipline techniques
tee then altered its plan to improve services to adolescents through the • Lack of emotional support for continued schooling, especially among
community health center. Funding for a pilot project was approved as a peers
joint effort of the local school district and the health department, with Ms. Fields is in the process of meeting with the committee to explore
each contributing $25,000. In addition, the health department will pro- the information she has collected. Several parents of adolescent moth-
vide the space and the services of one community/public health nurse ers, two teachers from the high school, a nurse practitioner from the
to staff the program. The program can use any existing equipment at the community health center, and a minister active in adolescent counsel-
health center, but new equipment and other support personnel will have ing have agreed to serve on the committee, as well as two high school
to come out of the program budget. The adolescent program is projected students who are mothers of infants. Ms. Fields would like to get rep-
to start in approximately 3â•›months. Ms. Fields is in the process of devel- resentatives from the local school board or academic administrators (or
oping a referral mechanism for students seen through the school health both) to complete the committee. Her efforts to date have taken one
suite who require further medical attention or seek services not currently half of the academic year. She hopes to have the committee intact and
offered through student health services. Evaluation will be needed as the the work completed before the end of the school year.
project unfolds. Process Objectives. Several process objectives were developed for
ProblemÂ€3 Outcome Objective. Develop support services for teen- phase 2:
age parents that will facilitate their educational progress and the well- • Two years from inception of the adolescent health program, 75% of
being of their children within 18â•›months. Northview High School students referred to the program will receive
The nursing actions are as follows: services at the health center or be referred to other community-
1. Meet with representatives of the teachers and administrative staff based services to meet their needs.
to identify problem areas for continued education. • Within 2â•›years, all adolescent parents will have access to affordable,
2. Meet with a sampling of young mothers and fathers to help identify certified child care.
problem areas and the types of services they believe would be most • Within 2â•›years, all adolescent parents who remain in school will be
beneficial to their educational advancement. encouraged to attend a school-based parenting skills program.
1. Based on the assessment of census tract 1 in ChapterÂ€15, was involved; how long the process took; and what the sources
apply the steps for program planning. Be sure to identify of money, equipment, and space were. Ask the community/
who needs to be involved in the planning process to ensure public health nurse why the program was successful. Ask what
its success. Rewrite the health problems as nursing diagnoses. aspects were unsuccessful and what might have been done
Develop at least one program goal and related outcome and differently.
process objectives. Discuss the rationale for your selection of 4. Consider which model of community organization you
the priority problem. are more inclined to use: community empowerment, social
2. Attend a community meeting at which health concerns or health planning, or social action. What values and experiences con-
programs are discussed. Identify the key persons involved, and tribute to your preference?
discuss with several of them why they are interested in health 5. Read a major newspaper on the internet, watch the national
care. Identify differing points of view. Think about alternative news on television, or use other resources to identify examples
solutions that might provide common ground, in other words, of community empowerment, social planning, and social action.
that would include as many points of view as possible. What are the advantages and disadvantages of each model for
3. Interview a community/public health nurse who has been community change? How long-range were the outcomes? What
involved in establishing a new health program. Discuss who aspects of planning and implementing were especially difficult?
WEBSITE
STUDY AIDS
Visit the Evolve website for this book to find the following
study and assessment materials:
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of NANDA, NIC, and NOC. Washington, DC: advocate: Fostering the health of communities. Definition and classifications 2007-2008.
American Nurses Association. Clinical Nurse Specialist, 5(1), 5-10. Philadelphia: Author.
Drucker, P. (1974). Management: Tasks, Kulwicki, A., & Rice, V. H. (2003). Arab American North American Nursing Diagnosis Association
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nursing practice. Upper Saddle River, NJ: LaPatra, J. W. (1975). Health care delivery systems: Wiley-Blackwell.
PrenticeÂ€Hall. Evaluation criteria. Springfield, IL: Charles C. Phillips, L. (1995). Chattanooga Creek: Case
Farley, S. (1993). The community as partner in Thomas. study of the public health nursing role in
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14(5), 244-249. for tuberculosis control and prevention among 12(5), 335-340.
Public Law 148. (2010). Patient protection and U.S. Department of Health and Human Services. for practice, education, and research. CIN:
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2012 from http://www.gpo.gov/fdsys/pkg/PLAW- Williams, C. (1983). Making things happen: (1994). De Madres a Madres: Women
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In H. Schulberg, A. Sheldon, & F. Baker (Eds.), Miskelly, S. (1995). A parish nursing model:
Program evaluation in the health fields. New York: American Nurses Association. (2007). Public health Applying the community health nursing process
Behavioral Publications. nursing: Scope and standards of practice. Silver in a church community. Journal of Community
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Peacock Publishers. Anderson, E. T., & McFarlane, J. (2010). Community Author. Retrieved January 8, 2012 from
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intervention. In J. Rothman, J. Erlich, & ed.). Philadelphia: Lippincott Williams & Wilkins. framework/clearinghouse/upload/MAPP-factsheet-
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administration handbook (3â•›rd ed.). Gaithersburg, public health nursing: Methods and innovations. 12(5), 335-340.
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investigations: Community participation and Clark, H. M. (1986). A health planning simulation of Kansas Community Tool Box. Retrieved July 7,
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CHAPTER
17
Evaluation of Nursing Care
withÂ€Communities
Claudia M. Smith and Frances A. Maurer
FOCUS QUESTIONS
What are the responsibilities of a baccalaureate-prepared How does evaluation of nursing care with communities compare
community/public health nurse in evaluation of nursing with evaluation of care with families and individuals?
care with communities? How can evaluation of process be used to improve the
What are the steps in evaluation? operation of nursing programs?
What questions can be answered by evaluation? How is evaluation used to modify nursing care with
What outcomes are indicators of the effectiveness of nursing communities?
interventions with communities? What methods and tools are used in evaluation?
CHAPTER OUTLINE
Responsibilities in Evaluation of Nursing Care with Evaluation of Efficiency
Communities Evaluation of Process
Responsibilities of Baccalaureate-Prepared Community/ Uniqueness in Evaluation of Nursing Care with Communities
Public Health Nurses Criteria for Effectiveness
Formative and Summative Evaluations Sources of Evaluation Data
Community Involvement Documenting Evaluations
Standards for a Good Evaluation Analyzing Evaluation Data
Steps in Evaluation Modification of Nursing Care with Communities
Questions Answered by Evaluation Evaluation Methods and Tools
Evaluation of Outcome Attainment Designs for Evaluation of Effectiveness
Evaluation of Appropriateness Tools for Evaluation of Effectiveness
Evaluation of Adequacy Efficiency Analysis
KEY TERMS
Adequate Efficiency Result
Affective learning Evaluation Satisfaction
Appropriate Formative evaluation Summative evaluation
Effective Outcome measures
Evaluation of care with communities seeks to determine RESPONSIBILITIES IN EVALUATION OF NURSING

whether health has improved. Were the desired health goals CARE WITH COMMUNITIES
reached? How much progress was made toward the goals? What
themes, patterns, and results emerged? What side effects were Evaluation is the process by which a nurse judges the value of
evident? How have community competence and resilience been nursing care that has been provided. As with any type of nursing
enhanced? To what extent are the community changes sustain- care, the community/public health nurse seeks to determine the
able? Evaluation provides information to help community/pub- degree to which planned goals were achieved and to describe
lic health nurses improve the quality of their nursing practice. any unplanned results.
449
450 CHAPTER 17â•… Evaluation of Nursing Care withÂ€Communities
The purpose of the evaluation is to facilitate additional nursing care with geopolitical communities. Community/
Â�
decision making. An evaluation might conclude that what had public health nurses may also work with multidisciplinary
been done could not have been done better, that the goals were teams and nurses who engage in quality assurance and
reached, and that the goals were mutually desirable to the nurse accreditation reviews (ANA, 2007). Baccalaureate-prepared
and the community members. This conclusion would be cause community/Â�public health nurses will be more capable mem-
for celebration. As a result of another evaluation, the conclu- bers of evaluating teams if they have been introduced in their
sion might be that alterations are needed in the plan of care to education to ideas and skills in evaluating nursing care with
reach the desired outcomes more effectively; or possibly that, communities.
although goals were reached, the cost in money, time, or other In some instances, a baccalaureate-prepared community/
resources was too expensive for the nurse or the community public health nurse will work with a small phenomenological
members. community, such as a senior center or school; in this case, the
Evaluation is based on several assumptions: first, that nurs- nurse is likely to evaluate his or her own performance with min-
ing actions have results, both intended and unintended; second, imal assistance from a supervisor and peers. Either indepen-
that nurses are accountable for their own actions and care pro- dently or with help from supervisors, community/public health
vided; and third, that different sets of actions result in resources nurses are expected to evaluate the effectiveness of intervention
being used differently (i.e., some nursing interventions use programs that involve teaching, direct care, and screening and
more resources than others). referral.
Evaluation involves two parts: measurement and interpre- Regardless of the type or size of community, the members
tation. Many different schemes or models exist for organiz- themselves should, when possible, be involved in planning and
ing ideas about evaluation, which may result in confusion conducting the evaluation (ANA, 2007). The measurement of
among people who use different terminology for similar many health outcomes requires the judgment of the commu-
concepts. nity members themselves.
Basic to the nursing process, however, is the idea of measur-
ing whether planned goals were achieved. Synonyms for this Formative and Summative Evaluations
activity and its result are outcome attainment (Donabedian, When is nursing care with communities evaluated? Evaluation
1980), performance evaluation (Suchman, 1967), results of effort, of the effectiveness of care that takes place after the interven-
and evaluation of effectiveness (Deniston & Rosenstock, 1970). tions have been performed is known as summative evaluation
The question that the nurse attempts to answer is, “Were the because the nurse is evaluating the sum, the bottom line, the
planned goals achieved?” end results. Summative evaluation involves measurement of
Another basic idea addresses the quality of the results and community responses to nursing care and interpretation of the
the process that contributed to the results. Some terms used to degree to which planned goals were met. Summative evalua-
express this idea are as follows: tion usually consists of measurement of outcomes and goal
• Appropriate—suitable for a particular occasion or use; attainment.
fitting
• Adequate—able to fill a requirement; sufficient or satisfactory After assessing the members of a senior retirement
• Effective—producing an expected result; productive Â�community, Ridge Center Retirement Community, a com-
Each of these terms describes different aspects of measur- munity/public nurse designed a program with the goal of
ing quality. The following are some questions that may be asked increasing the walking regimen for obese and hyperten-
about quality. How and why did the interventions work? Were sive seniors living in Ridge Center. She developed an inter-
the nurses' actions ethical? Did the nurses address the most vention plan consisting of a health education program
important goals? Did the nurses involve community members and personal consultation with a sports fitness expert.
and recipients as participants (American Nurses Association All senior participants received a health clearance from
[ANA], 2007)? Were resources used wisely? How many needs their personal physician. A summative evaluation state-
and goals did the plan actually address? ment for the intervention was as follows: the target group
will increase their walking regimen from an average of
Responsibilities of Baccalaureate-Prepared 15Â€Â�minutes three times a week (data from the assessment)
Community/Public Health Nurses to 30 minutes three times per week.
According to the American Nurses Association (ANA) (2007),
community/public health nurses with bachelor's degrees in Summative evaluation may also take place several months
nursing are expected to work with advanced practice pub- or years after nursing care has been provided. This evalu-
lic health nurses (masters prepared) and community mem- ation seeks to determine whether a long-term impact was
bers in evaluating responses of the community to nursing made on the health status and the health responses of the
interventions. community.
The responsibilities of community/public health nurses Formative evaluation is evaluation that occurs through-
for evaluating nursing care with communities vary, depend- out the nursing process but before evaluation of the out-
ing on the size and complexity of the community and whether comes of care. This evaluation occurs during the formation
the community is geopolitical or phenomenological (see of the nursing care and during the process of its actual
ChapterÂ€15). delivery. In other words, formative evaluation considers the
Baccalaureate-prepared community/public health nurses day-to-day provision of programs of nursing care.
are expected to work with community members, advanced Formative evaluation allows ongoing modification of nurs-
public health nurses, and multidisciplinary teams to Â�evaluate ing practices.
CHAPTER 17â•… Evaluation of Nursing Care withÂ€Communities 451
In the intervention program discussed earlier, the program STEPS IN EVALUATION

goal remains the same. Several formative evaluation state-
Evaluation is a process that includes several steps: planning, col-
ments for the interactive portion of the health education
lecting the data, analyzing and interpreting the data, providing
program are as follows:
recommendations, reporting the results, and implementing the rec-
• The discussion portion of the program was longer because of
ommendations (McKenzie etÂ€al., 2009). BoxÂ€17-1 identifies evalu-
technical difficulties. Originally planned for half an hour,
ation activities in greater detail related to each of the major steps.
it was 30 minutes longer because the room was locked
and printed handouts were delivered late.
• Some senior participants were unable to hear the speaker. QUESTIONS ANSWERED BY EVALUATION
Planning did not account for hearing loss in some of the
Evaluation of nursing care with communities involves evalua-
participants. The room was large, and although the group
tion of programs of care for populations. Program evaluation
was small (n = 15), they were initially spread out over the
includes evaluation of outcomes (program goals and outcome
entire room.
In the formative example just mentioned, the nurse can take BOXÂ€17-1â•…â•‡STEPS IN EVALUATION
action to remediate some of the problems identified during the
Plan the Evaluation
intervention process. For example, the nurse might take the
1. Review goals and objectives.
names of participants and deliver the printed material to them 2. Meet with stakeholders to identify which evaluation questions
at some later date. The nurse had the seniors move into a small should be answered.
group in the room and found and used a microphone to help 3. Develop a budget for evaluation.
with the presentation. 4. Determine who will conduct the evaluation.
5. Develop the evaluation design: What will be done?
Community Involvement 6. Decide which evaluation instruments will be used to collect
Because the community members are involved in evaluation, at information.
least part of the evaluation must occur in the clients' commu- 7. Analyze how the evaluation questions relate to the goals and
nity. Mutuality is an important aspect of evaluation. Because objectives.
much of the impact of the community/public health nurse is 8. Analyze whether the questions of stakeholders are addressed.
indicated by self-care and lifestyle changes of community mem- 9. Determine when the evaluation will be conducted; develop a timeline.
bers, a nurse must document and validate outcomes directly
with community members. Additionally, although goals have Collect Evaluation Data
been achieved, some negative or unexpected results might also 10. Develop specific processes for collecting data through question-
have occurred. The nurse must explore the perceptions of com- naires, review of records or documents, personal interviews, tele-
munity members to discover and validate the meaning of the phone interviews, and observation.
11. Determine who will collect the data.
experience. Determining how satisfied community members
12. Pilot the data-collection instruments.
are with both the outcomes and the nursing interventions is
13. Refine the instruments based on data from the pilot.
important. 14. Identify the sample of persons from whom evaluation data will be
Stakeholders are individuals who have expectations about collected.
nursing care but who are not directly involved in its delivery. 15. Collect the data.
For example, there are individuals whose approval was neces-
sary, those who contributed money or supplies, those who vol- Analyze the Data
unteered to assist, and those (such as competitors) for whom 16. Determine how the data will be analyzed.
the presence of nursing services had an impact. Stakeholders 17. Determine who will analyze the data.
in a community immunization campaign might be the county 18. Analyze the data, generate several interpretations, and make
health officer, a retail pharmacist who donates syringes, a local recommendations.
pediatrician who is concerned about financial competition, and
parents of persons who were immunized. Community health/ Report the Evaluation
public nurses need to identify the stakeholders and invite them 19. Determine who will receive results.
20. Determine who will report the findings.
to participate in evaluation.
21. Determine format for the report, including an executive summary.
Standards for a Good Evaluation 22. Discuss how the findings will affect the program.
23. Determine which findings will be included in the report.
Standards for evaluation of nursing care with communities have 24. Distribute the report.
been formulated by the Quad Council of Public Health Nursing
Organizations and published by the ANA (2007): Implement the Results
• The employing agency is to provide supervision, consul- 25. Plan how the results will be implemented.
tation, and general evaluation plans for the baccalaureate- 26. Identify who will implement the results.
prepared community/public health nurse. 27. Determine when the results will be implemented; develop a time line.
• The community members are to participate in the evaluation. From McKenzie, J. F., & Smeltzer, J. L. (1997). Planning, implementing,
• The nursing care is to be revised based on the evaluation. and evaluating health promotion programs: A primer (2nd ed.; pp.
• Evaluation is to be documented and disseminated so that the 276–277). Boston: Allyn and Bacon. Copyright 1997 by Allyn and
record can strengthen nursing practice and knowledge. Bacon. Adapted by permission.
objectives), as well as evaluation of the structures and pro- evaluate the nursing care program in relation to the community
cesses used to achieve the outcomes (Ervin, 2002). The ANA health needs. Efficiency addresses the relationship of outcomes
Â�considers outcomes, structures, and processes as the primary to structures and processes. Each of these sets of evaluation
Â�categories of criteria to be used to measure the quality of nurs- questions is discussed in more detail.
ing care. Outcomes are the end results; structures are the social
and physical resources; and processes are the “sequence of events Evaluation of Outcome Attainment
and activities” (ANA, 1986, p. 18) used by the nurse during the Evaluation of outcome attainment, also called effectiveness,
delivery of care. For example, evaluation of a health program addresses the results of nursing interventions. Change toward
designed to identify adults with high cholesterol levels would predetermined goals, as well as unplanned effects, may have
include the following: occurred (see TableÂ€17-1). Frequently, large health programs
• Structure standard: Cholesterol screening will be available to are evaluated as a total intervention, without distinguishing
all adults, regardless of whether they can pay for testing. the effects of nursing interventions from the effects of other
• Process standard: Cholesterol screening will be performed health disciplines and program components. Therefore nurs-
on all adults who come to the health screening event. ing care may be lumped into a single evaluation for the whole
• Outcome standards: program rather than being evaluated as a separate intervention.
(a) One hundred percent of the adults screened will be given Devising evaluation strategies and criteria for each component
their test results. of a program is more useful because evaluators are given a bet-
(b) Eighty percent of adults with cholesterol levels above the ter idea of which strategies are effective and which might need to
recommended norm will follow up with a physician's be revised or eliminated. Evaluators can then determine nurse-
visit for evaluation. sensitive outcomes. This is also true for multifaceted community/
TableÂ€17-1 describes the following five categories of ques- public health nursing programs; knowing which nursing inter-
tions that can be answered by evaluation: (1) outcome attain- vention is contributing to which outcome is more helpful.
ment, also called effectiveness; (2) appropriateness of care; Evaluation of outcome attainment evaluates changes in the
(3)Â€adequacy of care in relation to the scope of the problem; population, the health care system within the community, or
(4)Â€relationship of resources to results, also called efficiency; and the environment. BoxÂ€17-2 identifies several variables that can
(5) process. This set of questions includes the criteria of out- be used as outcome measures of community health. Changes
come, structure, and process evaluation and adds appropriate- can occur in the population's knowledge, behavior and skills,
ness and adequacy. Questions of appropriateness and adequacy attitudes, emotional well-being, and health status.
TABLEÂ€17-1â•…â•‡QUESTIONS ANSWERED BY EVALUATION

VARIABLE QUESTIONS EXAMPLES OF MEASUREMENT
1. Outcome attainment Did change occur? Numbers and rates of children immunized
To what degree was progress made toward the goal? Numbers of cases of cancer found on Papanicolaou smears
What are actual effects on clients? Changes in attitudes regarding people with acquired
immunodeficiency syndrome (AIDS)
What unintended outcomes occurred? Reduction in teenage pregnancy rate
2. Appropriateness Did the goals fit the need? Plan of care compared with clinical nursing knowledge
Are the goals and plans acceptable to the community? Community preferences
Are the plans likely to achieve the goals? Plan of care is evidence-based
Does the plan duplicate existing efforts?
3. Adequacy To what degree does the intervention meet the total Rate of effectiveness multiplied by number of people
amount of need? exposed to service
Were some people not served? Outcomes relative to total needs in population
Degree to which need was a priority
4. Efficiency What resources were used? Relation of effort to outcome
Cost-effectiveness Can a better way be found to attain the same results? Output and input:
What resources were necessary to attain results? Money
Time
Personnel
Client convenience
Benefit-cost analysis Do the benefits justify the use of resources?
5. Process What did nurses do? When? Where? Number of clinics/or encounters/week or month
How many people were reached? Number of home visits
What were the reasons for the successes or failures? Amount of money spent
What contributed to the results? Education content taught and strategies used
What methods were used? Numbers of people attending screening sessions
Data from Deniston, O., & Rosenstock, I. (1970). Evaluating health programs. Public Health Reports, 85(9), 835–840; Donabedian, A. (1980).
The definition of quality and approaches to its assessment (Vol. 1). Ann Arbor, MI: Health Administration Press; Freeman, R. (1963). Public health
nursing practice (3â•›rd ed.). Philadelphia: W. B. Saunders; and Suchman, E. (1967). Evaluative research: Principles and practice in public service and
social action programs. New York: Russell Sage Foundation.
BOXÂ€17-2â•…â•‡POSSIBLE OUTCOME the proportion of the population that the teaching reached
MEASURES and the proportion that retained the information presented.
Having information is not sufficient for healthy living; the
1. Knowledge information must be put to use.
2. Behaviors, skills
3. Attitudes, commitment to action Behaviors and Skills
4. Emotional well-being Integrating health-related behaviors and skills into daily liv-
5. Health status (epidemiological measures) ing affects health status—raising children, caring for an older
6. Presence of health care system services and components bed-bound family member, seeking a prostate examination,
â•›7. Satisfaction or acceptance regarding the program interventions and preparing nutritious foods require action. These actions are
8. Presence of policy that allows, mandates, or funds labeled competent or skilled if they are consistent with existing
9. Altered relationship with physical environment
knowledge and if they are performed in an effective and effi-
cient manner.
When evaluating the health of a community, more than the Health behaviors may change as a result of interventions per-
outcomes of the population must be considered. Because the formed by community/public health nurses (see ChaptersÂ€18
interaction of people in their environment facilitates or hin- and 20 for more details regarding health promotion and health
ders health, variables such as the presence of health services, the teaching).
satisfaction and acceptance of such programs, the presence of When evaluating health behaviors of populations, the nurse's
policies, and a harmonious balance with the environment must interest is in the proportion of the population who engage in
also be considered. Each of these variables, which are used as an such behaviors. The usual way to collect information about
outcome measure of the health of populations or communities, health behaviors is to ask people what they do. However, people
is discussed in more detail. Each of these variables can be used do not always provide accurate reports because they may have
as a measure of the effectiveness of specific community/public forgotten information or want to look good to the surveyor.
health nursing interventions. Some data on health behaviors, such as use of a specific
health service, can also be collected from client health records
Knowledge and health care information systems. For example, immuniza-
A great deal of client teaching and health education is evaluated tion rates can be determined for populations of preschool chil-
by measuring the health-related information that the individ- dren receiving Medicaid or enrolled in a specific managed care
ual, group, or population has obtained. Although information organization by monitoring whether immunizations have been
alone does not result in behavior changes, having information received.
will often increase the possibility of behavior changes. For
example, just because a father knows how to prepare infant for- Adherence to drug treatment for latent tuberculosis infec-
mula in the proper concentration and with adequate asepsis tion (LTBI) was one of the behavioral outcomes evaluated
does not ensure that he will actually do so. However, if he does in a tuberculosis control and prevention program among a
not have that information, the only way he can prepare the for- homeless population in Baltimore (Lashley, 2007). Nursing
mula would be by trial and error or by chance. Having the infor- students and faculty partnered with a faith-based, inner-
mation increases the probability that the formula will be city mission and the local health department. Interventions
prepared properly. included education, tracking persons who missed appoint-
ments, monthly appointment reminders, and incentives. The
In response to an increased incidence of syphilis in an urban, desired outcome was that 65% of those in treatment for LTBI
Hispanic population, public health nurses and other pro- would complete a 9-month course of therapy. Although only
fessionals provided a 10-week outreach project to more 33% completed at least 6â•›months of medication therapy,
than 2800 individuals through street and business outreach this far surpassed the city's 11% completion rate among the
(Endyke-Doran etÂ€al., 2007). The project evaluation mea- homeless.
sured knowledge changes in the population. Health educa-
tion addressed knowledge and prevention of syphilis, and Time and money often limit the degree to which behavior
location of testing sites. Before-and-after levels of knowledge change can be measured. Observing the behavior of popula-
were based on interviews with different individuals. At the tions helps confirm the accuracy of what is reported; how-
beginning of the project, only 4% could identify prevention ever, this process takes much more time and money. Asking
measures or locations for testing. Near the end of the proj- people to make a contract with themselves to make a com-
ect 50% of those encountered had knowledge of prevention mitment to specific actions has been shown to increase
and transmission and 64% knew of available testing services. the Â�likelihood that the actions will be performed (Sloan &
Additional surveillance data from the local health depart- Schommer, 1991). Therefore when measuring actual behav-
ment showed that the number of Hispanics who sought test- ioral changes of populations is not possible, community/
ing for syphilis also increased. public health nurses can measure the degree to which people
commit to specific actions.
When evaluating populations, surveys may be used to deter-
mine knowledge about specific health-related topics. These Attitudes
surveys may be conducted as interviews or through written Attitudes include opinions and preferences about ideas, people,
questionnaires (Polit & Beck, 2010). When working with pop- and things. Persons have attitudes about the concept of health and
ulations, the community/public health nurse is interested in the ways in which health may be attained and maintained.
Because attitudes predispose the selection of some actions over Criteria for emotional well-being of a community also
others, attitudes are a health-related measure. For example, if include the degree of acceptance and cohesion among Â�members
a population generally views health as the ability to perform and patterns of support, socialization, and decision making.
work, people may take cold medication to allow them to feel When community members participate in the decision making
well enough to go to work. However, a group may not alter their that leads to goal achievement, perceptions of self-efficacy are
high-cholesterol diets because their current diets do not inter- enhanced. Self-efficacy is the belief that an individual can influ-
fere with their immediate ability to work. ence his or her environment and circumstances. Self-efficacy
Community attitudes also predispose the population to sup- contributes to self-concept and is necessary if community
port or work against various policies and services. For example, members are to have an impact on their health.
if the dominant community attitude toward criminals is that
they should be punished and live stark lives, there may be little Health Status
support for prison health services. If the predominant commu- An ultimate measure of the effectiveness of health services and
nity attitude is that health prevention can reduce human suf- programs is the health status of the population. Community/
fering and dollars spent for care of the ill, there may be more public health programs seek to reduce premature deaths, dis-
support for prison health services. abilities, and injuries. Health status is measured using epidemi-
Attitudes toward health and health behavior can be changed ological statistics about morbidity and mortality (see ChapterÂ€7).
through planned or spontaneous experiences. Attitudinal Epidemiological statistics that are collected for geopolitical
change is also called emotional learning or affective learning. communities do not distinguish the effects of nursing interven-
Attitudes of populations can be measured before and after tions from the effects of other health disciplines and programs.
an intervention to determine whether affective learning has However, epidemiological statistics can be used to evaluate
occurred. Changes in attitude may predispose people to change changes in health status that result from nursing interventions.
their behaviors. For example, as more members of a population
adopt the attitude that smoking is undesirable, smoking rates Community/public health nurses in Lincoln-Lancaster
decrease. In some neighborhoods, volunteer or paid members of County Health Department were concerned about the inci-
the community are trained by community/public health nurses dence of low-birth-weight babies born to high-risk mothers.
to address attitudes of community members about obtaining The intervention plan they developed consisted of an inten-
health care services such as mammography screening, prenatal sive home visitation schedule to educate and support the
care, and treatment for substance abuse. high-risk women.
To measure outcomes, a care pathway tool was used to
Emotional Well-Being and Empowerment track the 55 clients' progress during and after pregnancy. The
Emotional well-being in a population can be measured by the evaluation outcome revealed that five to nine home visits by
proportion of members who experience self-esteem and satisfac- a community/public nurse improved health outcomes for
tion with their lives. Emotional well-being of a community can mothers and babies. Mothers had higher hemoglobin levels
be measured also by assessing the existing structures and pro- during pregnancy. No low-birth-weight babies were born to
cesses to strengthen human development and connectedness. the mothers in the home-visit group. Program evaluation of
outcome measures demonstrated the effectiveness of nursing
A group of nursing students initiated a reminiscence interventions (Fetrick etÂ€al., 2003).
group in which residents of a nursing home were able to
reflect on and share their life experiences. The students' Epidemiological measures can also be used to measure
initial assessment indicated that the residents rarely changes in health disparities.
communicated with each other (even when in the same
room), had few visitors, and reported that they did not The Omaha Healthy Start program in Nebraska was
“feel at home.” After several weekly meetings, the nursing “designed to reduce local racial disparities in birth outcomes”
students observed that the participants initiated conver- (Cramer etÂ€al., 2007, p. 329). Birth and death certificate data
sation more with each other, and several of the residents provided by the state health department were used to track
reported “feeling at home.” low birth weights and infant mortality rates among infants
of three groups of mothers during 2002 and 2003. Birth out-
Improved quality of life is another outcome related to human comes improved during the second year among minority
well-being. women and the evaluation is being extended to document
long-term trends.
In an evaluation of a community-based outreach worker
program for children with asthma, one of the outcomes More recently, attempts have been made to measure increases
was quality of life of the children's caregivers (Primomo in positive health (an outcome measure) that occur after nurs-
etÂ€al., 2006). Using an existing questionnaire, postinterven- ing interventions. To measure positive health, the community/
tion phone interviews were conducted 1â•›month after ser- public health nurse focuses on what is desirable rather than on
vices were completed. Compared with before the program, the reduction of health problems. Two examples of these mea-
caregivers reported an improvement in their quality of life, surements are the percentage of the population with normal
especially because they did not have to change their plans blood pressure and the percentage of the population engaging
as frequently because of their child's asthma. They felt less in safer sex. In the previous clinical example of the Lincoln-
helpless and frightened, and they got more sleep. Lancaster group, a positive health outcome measure was identi-
fied. Mothers with the more intense home-visit schedules chose
breast-feeding as their feeding option more often than did Satisfaction with services can be measured through interviews
comparable mothers without the nursing intervention (Fetrick and questionnaires. Interviews may be conducted via phone or in
etÂ€al., 2003). person—one-on-one or in focus groups. Questionnaires have the
advantage of being anonymous. Questions may be as simple as
Presence of Health-Related Services the following: “What do you like about this health service?
Â� What
Community/public health nursing interventions may be would you change?”
directed toward establishing new services and programs or
strengthening the continuity of care among existing services. Nurses in Nebraska used 13 focus groups to evaluate the
These interventions may be measured by the presence of new satisfaction of 113 newly arrived immigrants with a public
health services and by the increased numbers of people receiv- health nursing program designed for the Medicaid managed
ing care. For example, in one senior center, the community/ care population (Kaiser etÂ€al., 2002). Results revealed that the
public health nursing students noted that the population was diverse language groups did not understand the health system
not engaging in physical exercise. Knowing that nursing stu- well, there were inadequate translation services, and cultural
dents were unable to be assigned permanently at that site, the beliefs affected health-seeking behaviors and participation in
students developed a videotape of exercises for older adults. the focus groups themselves. Results were used to strengthen
Copies were made for all of the senior centers in the suburban population-focused public health nursing interventions.
county. This action resulted in multiple senior centers having
access to professionally led, appropriate exercises. As a result Policies
of the nursing interventions, a new service was available for Policies are expressions of goals and rules that exist within a com-
senior citizens. munity; they are expressions of values (Diers, 1985). Policies may
The purpose of establishing new services is to fill gaps in be decided by persons within governments, formal organizations
health care that exist within the community, not to duplicate (e.g., ANA, the American Heart Association, nonprofit volunteer
existing services. Therefore new services should result in an clinics), businesses, and informal groups. Interpersonal and polit-
increased number of people receiving care. Establishing nurse- ical power influences the creation and maintenance of policies.
managed health centers targeted to underserved and vulner- Community/public health nurses, often in collaboration with
able populations is one way to improve access to health care others, can use the existence of health and social policy as one
(Institute for Nursing Centers, 2011). measure of the effectiveness of interpersonal and political power.
Not all new services are maintained. Evaluation can identify A new policy may be created, or an existing policy may be
activities that may help sustain new services. defended or changed. Policy may mandate, allow, or initiate
actions that affect a community's health. For example, a New
Phone interviews were conducted 6â•›months after Â�instructor- Jersey state law required the development of a school policy for
training workshops to determine whether trainees had delegation of epinephrine administration in nonpublic schools
actually adopted and maintained exercise programs for by unlicensed assistive personnel (Truglio-Londrigan etÂ€al.,
people with arthritis (Gyurcsik & Brittain, 2006). The spe- 2002). Public health nurses from the local health department
cific Â�program is offered by the Arthritis Foundation in the used site visits, discussions, and focus groups to evaluate the
United States. Results showed that 8 out of 11 trainees development and implementation of the policy.
initiated a program in their community; however, within
6â•›months only 3 programs continued. Reported barriers In state X, a budget crisis threatened reduction and
were recruitment of participants and finding a common Â�discontinuation of health care services to poor and dis-
time for the exercise sessions. These barriers would need abled persons served by state-funded programs. The nurses'
to be addressed in order to establish and maintain effective Â�association convention for state X debated the issue during its
physical activity programs. annual meeting. The association membership voted to pass
a resolution opposing budget cuts in health care Â�programs
Satisfaction and Acceptance serving poor and vulnerable populations. The goal was to
maintain services for at-risk populations.
Health-related services may exist in a community but be inef-
This organizational policy acted as a guide for all nurses,
fective because the people within the community do not accept
both convention attendees and nonattendees. Many nurses
the service. The perceived quality of interpersonal relationships
and nurse specialty organizations in the state used this pol-
is an important factor in strengthening client satisfaction. For
icy direction to take action. Individually and in groups, the
example, if the members of the community do not believe that
nurses lobbied their state legislators to disallow funding cuts
they are treated with dignity when they attend a clinic, they are
to medical assistance and primary health care programs for
likely to stop attending; they will transfer to another service if
low-income and disabled persons. The nurses advocated
one exists, or they may even forgo care to avoid the negative
maintaining all school nurse positions. Some of the nurses
experiences. Even when the care provided through a nursing
used the opportunity to lobby for universal health care for
program is effective, more people may be reached if the pro-
state residents. In addition to lobbying efforts, nurses took
gram is also tailored to strive for the satisfaction of participants.
the initiative to attract media attention to the problem.
Geographic accessibility, waiting time, and cost are other
Evaluation of the newly adopted policy of the nurses' asso-
factors that contribute to a population's satisfaction with
ciation for state X showed success. Some funding reductions
nursing programs. When nurses are aware of the culture of the
did occur, but they were small in comparison to the pro-
population, clients are likely to be more satisfied (Dreher &
posed cuts. No programs were eliminated.
Skemp, 2011).
Altered Relationships with the Environment nursing care is more likely to be appropriate. Occasionally, the
Elimination or reduction of environmental hazards is one mea- community/public health nurse must wait until after the inter-
sure of the effectiveness of programs directed toward provid- vention has been accomplished to evaluate whether the specific
ing a safer environment. For example, the removal of trash in goals and objectives were realistic for a given community. Just as
a vacant lot reduces breeding grounds for rats and other wild each individual is unique, so is each community.
animals while also removing physical and chemical hazards. Interventions are usually more appropriate when they are
Additionally, the effectiveness of a community educational evidence-based and the community health nurse researches lit-
program about environmental hazards may result in reduced erature that describes what has worked well with similar pop-
dumping. Reductions in environmental hazards result in fewer ulations. Nursing case studies and experimental research are
accidents and injuries. helpful in suggesting ideas for interventions within a specific
The reduction of environmental hazards can also reduce community. For example, strengthening the decision-Â�making
Â�illness. For example, public health nursing interventions can skills of adolescents is helpful in preventing drug use and
control asthma triggers, thereby improving asthma manage- unprotected sex. Exercise has been shown to slow the progres-
ment and reducing hospitalizations. sion of osteoporosis in postmenopausal women. Consequently,
each of these interventions would be evaluated as appropriate
Perceived ability to control asthma triggers was one outcome with their respective populations.
used to evaluate the effectiveness of a home-based educa-
tion program by outreach workers (Primomo etÂ€al., 2006). Evaluation of Adequacy
Preintervention and postintervention interview surveys were The community/public health nurse also evaluates the adequacy
conducted in person or by phone with caregivers of children of both the goals and the interventions. Adequacy addresses the
with asthma. All families reported making changes to reduce degree to which goals and interventions are sufficient to achieve
household asthma triggers. There was a significant reduction the desired change. TableÂ€17-1 includes some questions related
in hospitalization at follow-up, compared with the baseline. to adequacy.
Even when care is appropriate, it may be inadequate. Nursing
When hazards cannot be removed immediately or com- care is inadequate when not enough of the care is available to
pletely, the desired outcome may be avoidance or reduction of meet the total population need. For example, community/pub-
the hazard. For example, socio-culturally appropriate health lic health nurses who provide outreach to identify pregnant
education lessons were developed for adult, subsistence anglers women, refer them for prenatal care and nutrition programs,
to teach them to reduce mercury exposure from fish caught and teach them about the importance of nutrition are engaged
near a Superfund site in Georgia (Derrick etÂ€al., 2008). in appropriate nursing care. Prenatal care and improved nutri-
Reductions in product consumption and waste are other mea- tion are ways to increase the birth weights of infants. However,
sures of environmental health. More efficient use of resources this care may be inadequate if the number of pregnant women
is the goal. For example, increasing the number of people who is greater than those who can be reached by the number of com-
weatherize their homes or participate in recycling demonstrates munity/public health nurses. This care may also be inadequate
the effectiveness of conservation programs. Community/public if the women are found, but the prenatal and nutrition services
health nurses may be instrumental in collaborating to establish have long waiting lists. When nursing services are appropriate
programs or in referring people to existing programs. but inadequate to meet the need, nurses should consider other
Because the basic standard of living is associated with health interventions, such as creating community awareness that addi-
behaviors and health status, the level of poverty in a commu- tional services are needed.
nity can be used as one measure of the community's health.
The level of poverty directly relates to both the physical and the Evaluation of Efficiency
social environments (Haan etÂ€al., 1987). Therefore changes in Efficiency is related to evaluation of structure because it is a
the level of poverty can be used as a measure of the effectiveness measure of the relationship of resources to outcomes. Resources
of public health activities to improve the basic standard of living may include the nurses themselves, equipment, supplies, facil-
within the community. ities, policies or legal authority, organizational features, and
environmental features (ANA, 1986). Money, time, and emo-
Evaluation of Appropriateness tional energy are other resources.
Appropriateness may be defined as how well the nursing plan- TableÂ€17-1 also includes some questions to ask when con-
ning and interventions fit the assessed health need and culture sidering efficiency. For example, when evaluating the efficiency
of the community. The community/public health nurse consid- of an immunization clinic, the community/public health nurse
ers the appropriateness of both the goals and the interventions. might ask whether equipment exists that is not used, how many
TableÂ€17-1 includes some questions used in the evaluation of doses of immunizations were wasted, whether the layout of the
the appropriateness of nursing care. clinic prevents privacy, or whether heat escapes out the door
Goals are usually more appropriate when the community/ each time it is opened.
public health nurse has accurately assessed health needs of the The money, time, and other resources of the population must
population, readiness to change, and resources available. The also be considered. Interventions may be efficient for nurses but
Healthy People 2020 objectives (U.S. Department of Health inefficient for individuals and their families. Are parents tired
and Human Services [USDHHS], 2010) are targets that guide when they reach the clinic because they were unable to afford
local communities in selecting specific goals and objectives for a sitter for the other children? Are parents dissatisfied with the
health programs. When the assessment and planning have been information they receive because the language of the nurses and
conducted in partnership with the community members, the pamphlets is “over their heads”?
Evaluation of Process the same procedures, which increases interobserver reliability

Process evaluation focuses on how well the health-related pro- (Polit & Beck, 2010).
gram is operating and is linked to the original plan (Ervin, 2002). For care provided to individuals and families, the evaluation
The questions included in BoxÂ€17-3 help analyze how well the is documented on the legal record of the respective client. When
planned program is actually being implemented. Answering evaluating care provided to populations, the results are usually
the questions helps the community/public health nurse refine reported as statistics for the aggregate or as a case study (with-
and manage the program. Process evaluation is concerned with out identifying the specific participants).
clinical nursing care, but it also focuses on administrative and Because populations include many individuals or fami-
fiscal issues. Evaluation of the process of implementing the pro- lies, the criteria for measuring goal achievement may com-
gram is formative because it occurs throughout the life of the pare the population with another population; measurements
program. must be available for both populations to make the compari-
son. This process is called normative referencing. The popula-
tion may be compared with itself before and after the
UNIQUENESS IN EVALUATION OF NURSING CARE implementation. If change occurred, the nurse would expect
WITH COMMUNITIES to see an increase or decrease in one or more outcome mea-
sures. The population also may be compared with an entirely
Criteria for Effectiveness different population, such as the average for the United
In goal-based evaluation of populations, criteria for success are States. For example, if the incidence of prostate cancer in a
written in terms of percentage of population, not an individual population was higher than the average rate in the United
or a family. Because more than one individual is being evalu- States, the goal might be to reduce the incidence of prostate
ated, the population must often be sampled. In large popula- cancer to the national rate.
tions, a random sample of at least 10% to 20% of persons will
be useful. With small populations, the nurse can obtain infor- Maryland has a tuberculosis case rate that has remained his-
mation from all members, or as many as possible. One hundred torically above the national average case rate. One of their
percent participation is rare, however. program goals in the tuberculosis program is to decrease
More time and personnel may be needed to evaluate the care the case rate to the national norm. In 2002 the national
provided to populations or communities. Because of the num- case rate was 5.2 cases of tuberculosis per 100,000 people.
bers of people in the population, more than one person may For that same year, Maryland reported a case rate of 5.7 per
be needed to collect the information for evaluation. More time 100,000. Progress has been made; in 2006 the Maryland case
may also be required to ensure that the evaluators are following rate for tuberculosis was slightly below the national rate. In
2006 the national case rate was 4.6 cases of tuberculosis per
100,000 people compared with Maryland's case rate of 4.5
BOXÂ€17-3â•…â•‡QUESTIONS TO
â•› ASK IN per 100,000 people.
PROCESS EVALUATION
OFÂ€HEALTH PROGRAMS Criterion-referenced evaluation measures the extent to which
specific objectives are reached at the level desired by the plan-
• Is the target population being reached? If not, what outreach or
publicity may be needed? What evidence exists that the program is
ner. Many of the Healthy People 2020 objectives are criterion-
acceptable to the target population? referenced objectives. The following is a criterion-referenced
• How many people have been served? How does this compare objective targeted toward mothers of infants and preschool
with projections of desired utilization? What should be done if the children: in a smoking-modification program, at least 30% of
demand for services exceeds the current capacity? the mothers will devise and implement a contract to modify
• Are the program activities being phased in on time? If not, what their smoking habits by the fifth week of the program. If 30%
modifications in the time line are needed? of the mothers do so, the objective will have been achieved. The
• What are the staff development needs of the nurses and other per- mothers are not compared with other populations. (ChapterÂ€16
sonnel? What aspects of the intervention are difficult to implement provides more examples of normative-referenced and criterion-
and require further education? referenced objectives.)
• Are the planned resources being received? Have the budget rev- Determining what the criteria should be is not easy. If the
enues continued as planned? Are the program expenditures desired behavior is essential for safety, the criteria are high.
within the proposed budget? Have equipment and materials been For example, 100% of participants will hold the infant with
received? Have interested persons volunteered as they said they the head higher than the stomach and burp the infant during
would? feeding to prevent choking. If a nurse believes that all of the
• Have the planned interventions been carried out? If so, to what participants should know how to demonstrate a skill, then the
degree do they meet professional standards? behaviors should be as clear as possible. The criteria for proper
• Have any of the planned interventions not been implemented? If so, holding need to be explicit in this objective.
what are the barriers? Can these interventions be omitted because However, expecting 100% of the participants to reach the
the objectives are being achieved without the interventions, or objectives is usually unrealistic. In group-education sessions, a
should the interventions still be initiated?
few people are not interested, not feeling well, or distracted so
• What concerns have emerged regarding communication, decision
that they do not participate fully. Even when the participants
making, and participation? Are all interested parties still involved
are interested in learning, the teaching may not be sufficient
and informed about the program's progress? How do they perceive
the program? for them to learn; they may need different learning strategies
or more time. If the desired learning is complex or requires a
BOXÂ€17-4â•…â•‡SAMPLE â•›TOOL â•›TO ASSESS time, money, and physical and emotional energy. To evaluate
CLIENTS' INTERESTS efficiency, both effort and outcomes must be measured and
considered together.
Put a check mark (√) by the three things about which you want to Dissatisfaction occurs most frequently when expecta-
learn most. tions are not met. Nurses should expect dissatisfaction to be
What is the difference between medicine and street drugs? expressed by persons who perceive that care is inappropriate,
What can street drugs do to my body? inadequate, inefficient, or ineffective. Occasionally, the care pro-
How can I say no to drugs? vided by community/public health nurses may be both effective
What can I do to feel good without using drugs? and relatively efficient yet contribute to the dissatisfaction of
Why do people use drugs? some. Many stakeholders have expectations about nursing care
Other: yet are not directly involved in its delivery. The more the com-
munity/public health nurse is aware of stakeholders' expecta-
tions during the planning phase, the fewer surprises there will
change in lifestyle, a lower percentage of the population should be. Intermittent contact with all interested parties throughout
be expected to achieve the objective. For example, between 14% the process will allow early identification of misunderstandings,
and 45% of smokers who quit are able to abstain from smok- negotiation, and revision of the process to balance the interests
ing for 12â•›months. Smoking cessation is a difficult process. Only of many. Satisfying everyone is impossible.
approximately 2.5% of current smokers stop permanently each
year (USDHHS, 2000). Documenting Evaluations
Criteria for desirable outcomes can be selected because they BoxÂ€17-5 identifies data that are to be included in a written
reflect the clients' interests. For example, elementary school chil- record of the evaluation of nursing care with communities. This
dren were given an interest inventory to determine what they documentation describes what actually occurred, provides a
most wanted to learn related to drugs (BoxÂ€17-4). The answers historic record from which to study trends, and provides a basis
helped nursing students establish both the objectives of and the for deciding whether programs should be continued and how
content for the teaching sessions. they might be modified.
Criteria for desirable outcomes also can be selected because Evaluation reports may need to be written in different
they constitute the next logical step. For example, after parents formats for different audiences. For example, an evaluation
have learned to take the temperature of their infant, they should report written to gain funding might have different content
know which temperatures to report to the pediatrician, clinic, and focus than a report to be shared with the service par-
or nurse practitioner. ticipants. Evaluation reports to be delivered orally in small
groups or public meetings should be written in a more con-
Sources of Evaluation Data versational style.
The nursing process is to be mutual with the entire population When writing an evaluation report, the community/pub-
or its representatives. Consequently, evaluation of community/ lic health nurse should be politically and culturally sensitive.
public health nursing practice involves participants from the Negative realities can be addressed using positive words. Always
community (ANA, 2007). As part of the planning for evalua- imagine that the most powerful and influential persons in the
tion, decisions must be made regarding who will be involved in community will read the report and word it in a way that they
the evaluation. can accept. Similarly, consider the perspectives of the service
Some evaluation questions can be answered by the nurse
alone, and some questions can be answered best when others'
perspectives are solicited. When measuring effectiveness, the BOXÂ€17-5â•…â•‡DATA IN A â•›WRITTEN
community/public health nurse ensures that the relevant out- EVALUATION REPORT
come measures are collected from the target population. In 1. Indicate baseline health status or behaviors of client population.
some instances, collecting information from others who are 2. Indicate baseline resources and methods currently being used to
close to the target population will also be helpful. For example, address the health problem.
in a smoking-cessation program, the community/public health 3. List the health-related goals and desired outcomes.
nurse may also collect information about smoking habits from 4. Describe the nursing interventions (effort). Enumerate what actions
other members of the participants' households (with the par- were completed. If an educational strategy is being evaluated,
ticipants' permission). include both the actions completed and the content taught.
Epidemiological mortality and morbidity data are often 5. Indicate tasks that were planned but not done or completed.
obtained from other health care team members who collected 6. Specify other changes in the environment that might have
the information. If the goal is a health system change, such as affected the health outcomes, such as changes in funding, a tele-
establishing a clinic, a visit to the new clinic and interviews with vision health education campaign, or the closing of a clinic.
both the health providers and the population receiving care will 7. Describe what behaviors indicate goal achievement and the
be useful. degree to which the need is resolved.
The community/public health nurse can evaluate effi- 8. Describe the level of satisfaction of persons involved, and iden-
tify actual and potential resistance.
ciency with information from both the nurses implementing
9. Indicate any modifications that were made in the goals.
the health care program and the population who received care.
10. Discuss the relationship of effort to outcomes—efficiency.
Nurses can best describe the effort that they contributed: Who
11. Include interpretations and judgments.
did what? How many times? With how many people? The par- 12. Make recommendations.
ticipants themselves can best describe their efforts in terms of
participants and write in a way that does not reinforce cultural summative evaluations. With a case description, the community/
stereotypes or blaming. public health nurses cannot prove that the nursing intervention
When written reports are long, writing an executive sum- led to the specific health outcomes. However, ways to evaluate
mary is helpful for the persons or groups who will not be the likelihood that the outcomes were the result of the nursing
able to read the whole document. An executive summary is a interventions include the following: (1) the Â�implementation can
brief summary of the report that includes major findings and occur shortly after assessment so that developmental maturation
recommendations. does not account for the change; (2) the population members
can be asked whether they participated in other activities from
ANALYZING EVALUATION DATA the time of assessment until the time of evaluation; and (3) the
nurse can be alert to other community changes that might have
Distinctions should be made among facts, interpretations, contributed simultaneously to the health outcomes (Kosecoff &
judgments, and recommendations when discussing and pre- Fink, 1982).
senting the results of an evaluation (Patton, 1982). Results The time-series design is a quasiexperimental method in
are both factual and interpretive. Factual findings include which information is collected about the same population more
data (e.g., the program has served 50 clients during the than once (Kosecoff & Fink, 1982). The steps of the nursing
first 2â•›months). Interpretations are statements about inter- process include assessment, pretest, implementation, evalua-
relationships, reasons, and meanings (e.g., the clients have tion (posttest), and later evaluation. This design allows pretest
shown up because of the public service announcements and posttest results to be compared to demonstrate that change
on the radio). Judgments are evaluations made in the con- did occur. Additionally, the later evaluation indicates whether
text of values and include statements about the desirabil- the change was lasting; this evaluation considers permanency
ity or undesirability or goodness or badness of the data of results, also called impact. A time-series design was used to
and interpretations (e.g., “I'm really disappointed that we evaluate the effectiveness of the home-visit health-promotion
haven't reached 100 clients already”). Recommendations are and risk-reduction program previously discussed in this chap-
suggested actions based on the facts, interpretations, and ter (Fetrick etÂ€al., 2003).
judgments. A recommendation in this situation might be Evaluation research attempts to discover links between
to increase the publicity to double the numbers of clients implementations and health results, including the meaning
served in the next 3â•›months. of the experience to the participants. The goal of Â�empirical-
evaluation research is to establish that interventions are causally
MODIFICATION OF NURSING CARE WITH linked to desired outcomes. The knowledge can be generalized
COMMUNITIES to similar situations and can assist community/public health
nurses in selecting which intervention strategies are likely
Communities are dynamic and complex. Each human being to work best. This information also helps persuade funding
exists within a community and is an agent of his or her own sources that their money will be well spent. Beneficial out-
needs, desires, and self-expression. Social interaction among comes of home-based community/public health nursing
multiple human beings is even more complex. Consequently, interventions have been demonstrated; a major focus of future
because nursing care is created through the processes of human research efforts should be “rigorous outcome evaluation of
interaction, it must be continuously evaluated and revised. As community-level nursing strategies” (Deal, 1997, p. 125).
the membership of the population changes, so do health status, Because human beings are diverse, evaluation research also
health risks, health needs, assets, and interests. seeks to find what works best with different populations. How
Community/public health nursing practice occurs within are the results different with women and men or with young
physical, political, economic, cultural, and social contexts. and old? For example, empirical research indicates that young
AÂ€change in any one of these contexts results in changes in all children learn best through participation. Interpretive evalua-
other aspects of the community system. While nurses imple- tion research seeks to describe the meaning of the experience to
ment the planned care, a multitude of changes occur simulta- the participants. When nurses understand the perceptual and
neously in their environments. Therefore formative evaluation cultural meanings that the nursing care has for the participants,
helps community/public health nurses modify all steps of the nurses are better able to modify care. The care can become more
nursing process. beneficial and satisfying for the recipients.
EVALUATION METHODS AND TOOLS Tools for Evaluation of Effectiveness

The category of health outcome that is being measured will help
Designs for Evaluation of Effectiveness determine the tools that will be used. The tools are often the
Case descriptions and quasiexperimental designs may be used to same ones that are used to measure change with individuals;
evaluate the effectiveness of community/public health nursing however, the community/public health nurse is now collecting
interventions with communities. A case description examines the information from a large number of people.
the community, health goals, community/public health nurs- Behavior change is best measured through observation.
ing interventions, and outcomes. The evaluation described in Some parenting programs, for example, have used videotapes of
this chapter can be used to develop a case description. The case- parent-child interactions to collect information about aspects
evaluation design allows a thorough description of the situation of parenting; the tapes are then given to the parents as a reward
and is especially helpful in creating a history of the process, com- for participation. Criteria used to interpret parenting skills can
municating information about a new program or a demonstra- take several forms. BoxÂ€17-6 includes a sample checklist that can
tion program to others, and documenting both formative and be used to record the presence or absence of specific Â�parenting
BOXÂ€17-6â•…â•‡SAMPLE CHECKLIST TOOL

â•› BOXÂ€17-7â•…â•‡EXAMPLES OF QUESTIONS
FOR EVALUATING BEHAVIORS MODIFIED TO MEASURE
RELATED TO
â•› â•›INFANT FORMULA KNOWLEDGE AND ATTITUDE
FEEDING Knowledge
This tool can be used to observe parent or caregiver behavior related For each item, circle either True or False.
to infant formula feeding. An item is checked when the behavior is 1. True or False: Using condoms during sexual intercourse can help
observed during a feeding session. prevent HIV infection.
Responds to hunger cues almost always 2. True or False: Environmental tobacco smoke can reach a fetus dur-
Uses clean bottle, nipple, formula ing the mother's pregnancy.
Changes or washes nipple if contaminated
Holds infant Attitude
Holds bottle so that air is not allowed in nipple or uses col- For each item, circle Yes if you agree with the statement and circle No
lapsible bag bottles if you disagree with the statement.
Burps infant 1. Yes or No: Condoms should be used by sexually active individuals
Stops at ounces or sooner if infant is full to prevent HIV infections.
2. Yes or No: Pregnant women should be encouraged to avoid environ-
mental tobacco smoke.
actions. TableÂ€17-2 addresses similar actions and rates the Alternative Attitude Format
Â�quality of the parenting based on grouped behaviors. Circle the response that indicates the intensity with which you agree
Oral or written questions are usually used to collect informa- or disagree with each item.
tion on factual knowledge and attitudinal learning. The same 1. Condoms should be used by sexually active individuals to prevent
questions can be used to measure both aspects, but the scor- HIV infections.
Strongly Agree Agree Uncertain Disagree Strongly Disagree
ing is different. BoxÂ€17-7 provides examples of questions that
2. Pregnant women should be encouraged to avoid environmental
are modified to measure factual knowledge or attitudes. When
tobacco smoke.
developing questions to measure factual knowledge, the nurse
Strongly Agree Agree Uncertain Disagree Strongly Disagree
needs to develop a key of right and wrong answers to use in
scoring the tool. Note that when measuring attitudes, no right
or wrong answers exist.
An excellent randomized study has demonstrated the cost-
Efficiency Analysis effectiveness of home-visit follow-up by expert neonatal
nurses for infants with very low birth weights compared with
The efficiency of programs can be evaluated using cost-
continued hospital care (Brooten etÂ€al., 1986). Even though
effectiveness and benefit-cost analyses. Both methods con-
costs were incurred for the home-based nursing care, the
sider the resources used in relation to outcomes.
hospital and physician costs were much less for those cared
In cost-effectiveness, the cost per unit of outcome is deter-
for at home. For persons who are cared for at home, better
mined. For example, in a home health agency, the average cost
health outcomes were achieved at a net savings of $18,560
per home visit can be determined if costs and number of
per infant.
home visits are recorded. Similarly, the average cost per
maternity clinic visit or the average cost of providing prenatal
nursing care can also be computed. The costs must be com- Benefit-cost analysis also considers the resources used in
puted, and the value of the outcomes must be estimated relation to the resulting outcomes. However, benefit-cost anal-
(Ervin, 2002). To compare the cost-effectiveness of programs ysis asks, “Are the outcomes achieved worth the cost incurred?”
accurately, the acuity of client problems must be similar for AÂ€significant number of difficulties are encountered in
the two programs. Cost-effectiveness analysis is often used to completing a benefit-cost analysis (Ervin, 2002). First, the anal-
address the question, “Can similar outcomes be achieved with ysis is difficult to do because it requires that a dollar value be
less cost?” placed on the benefits (outcomes), and health programs often
TABLEÂ€17-2â•…â•‡SAMPLE RATING TOOL FOR EVALUATING BEHAVIORS RELATED TO INFANT

FORMULA FEEDING
Client demonstrates proper infant feeding by responding to infant hunger cues, preparing clean bottle/nipple/formula, holding infant, preventing
sucking of air, and feeding no more than ounces.
SCORE 1 SCORE 3 SCORE 5
Sometimes responds to cry Usually responds to hunger cues Always responds to hunger cues
Often uses contaminated nipples and dirty Occasionally uses contaminated nipples Uses clean equipment; changes nipple if
bottles and dirty bottles contaminated
Usually props infant Usually holds infant Never props bottle; holds infant
Allows sucking of air Usually does not allow air in nipple Prevents air in nipple
Feeds continuously Stops at oz to burp infant Stops at oz to burp infant
produce some intangible effects. Not all outcomes can be quan- Costs of programs include the direct costs of services, admin-
tified in terms of dollars. For example, what is the dollar value istrative costs, and the costs of increased demand on related ser-
of improved self-esteem? Second, to provide justice (i.e., to vices. For example, costs of an immunization program include
correct unequal access to health care), the provision of care direct costs of nursing services, supplies, educational material,
may be more important than whether it is efficient. Third, the and biological agents; indirect costs include record keeping,
value of benefits must be considered from several perspectives. utilities and building maintenance, salaries of administrative
For example, the provision of home visits to families with personnel, and publicity. Health care costs related to identifi-
infants can benefit the infant, the parent, and society. If only cation, referral, and treatment of health problems among the
the cost of care versus the immediate health outcomes is con- children who come for immunizations may also be increased.
sidered (e.g., having up-to-date childhood immunizations), The costs that clients incur in terms of time, energy, and
the benefits may not seem worth the cost. However, if the long- money should be considered in benefit-cost analyses. However,
term benefit of preventing hospitalization and disability from current methods of benefit-cost analysis often ignore this
measles and the benefit of high immunization levels in the human impact, especially for families with ill members. For
community are considered, the benefits are greater. example, care of ill persons in the home costs the health care
system less than care in a hospital or nursing home. However,
for some families, the cost of caring for their family member
Olds and colleagues (1993) asked whether the outcomes of a
at home is expensive in terms of lost wages or emotional stress
prenatal and infancy nurse home-visit program were worth
or both.
the financial cost of the program. Although there were posi-
Evaluation of efficiency helps community/public health
tive outcomes for both the mothers and the infants, the dollar
nurses refine programs so that more services are provided with
value of these benefits was not known. The researchers esti-
the same dollars, or the same services are provided at a lower
mated that costs were saved by outcomes such as fewer hos-
cost. Dollars saved can be channeled to serve more people or to
pital days at birth, fewer infant emergency department visits
fund other health programs. Because community/public health
for accidents, lower incidence of child abuse and neglect, and
nurses directly provide the care in many health programs, they
reduced maternal dependence on public assistance. When
are likely to have evidence of the less tangible benefits of the ser-
government cost savings for medical and social services were
vices. Nurses should contribute this information to any benefit-
calculated, the savings were greater than the cost of the nurs-
cost analysis. Because no precise estimation of the benefits can
ing interventions. The benefits (outcomes) were worth more
be made, community/public health nurses can help expand the
than the costs.
discussion to include quality-of-life issues.
KEY IDEAS
1. The responsibilities of community/public health nurses 6. Community members are to be involved in evaluation.
include the evaluation of nursing care provided to commu- Stakeholders are individuals who may be affected by the
nities. Evaluation enables the improvement of the quality of nursing interventions, including those who contribute
nursing care with communities. resources and those who receive the care.
2. Evaluation involves several steps, including planning the 7. An essential part of evaluation is determining effectiveness:
evaluation, collecting the data, analyzing and interpret- whether the goals and desired outcomes have been achieved.
ing the data, reporting the evaluation, and implementing Indicators of the effectiveness of nursing care include knowl-
suggestions. edge, behavior and skills, attitudes, emotional well-being
3. Evaluations are conducted to demonstrate that goals and and empowerment, morbidity and mortality rates, the pres-
desired outcomes are being achieved; to make decisions ence of services or health policies, community competence,
about continuing, expanding, or ending specific pro- client satisfaction, and human-environment relationships.
grams of nursing interventions; to improve nursing care 8. Programs of nursing care should be appropriate to the
so that goals and outcomes are achieved efficiently; and assessed community needs and culture, and should be
to improve nursing care so that it is acceptable to the efficient; the resources need to be used wisely to achieve the
community. desired outcomes.
4. Health-related programs have goals, outcome objectives, 9. Community/public health nurses seek to develop programs
process objectives, and management objectives. of nursing care that are adequate to the scope of commu-
5. Formative evaluation is conducted during the process of nity needs.
nursing care delivery to modify and improve the program. 10. Evaluation of process objectives helps monitor and
Summative evaluation occurs at the end of the program improve programs of nursing care. Process evaluation
to determine whether goals and desired outcomes were addresses the degree to which the program of interven-
achieved. tions is being carried out as planned.
â•…â•‡NURSING PROCESS IN PRACTICE

Evaluation at Northview High School
The following evaluation is based on the program of nursing care for the signs, symptoms, and potential consequences of untreated sexu-
Northview High School described in the Nursing Process in Practice fea- ally transmitted disease.
ture in ChapterÂ€16. 3. A random sampling survey was conducted of the student population
who received the intervention program and measured sexual behav-
Phase I: A Sex Education Program ior 3â•›months after the program.
Nursing Diagnoses or Problems 4. Summary evaluation of the program included evaluation steps 1, 2, and
1. Population at risk for health problems as evidenced by a high rate of 3 as mentioned, as well as interviews with the principal, teaching staff,
sexual activity and counselors; an assessment of the number of students affected; and
2. Knowledge deficit related to the risks of pregnancy during sexual the time and materials necessary to accomplish the program.
activity
3. Inconsistent use of birth control Analysis of the Data
4. Knowledge deficit related to functioning of various birth-control 1. Evaluation of the seminar discussion group indicated that approxi-
mechanisms mately 70% of the students in attendance were actively engaged in the
5. Knowledge deficit related to signs, symptoms, and potential conse- guided discussion. Students asked and answered questions and raised
quences of untreated sexually transmitted diseases issues during the discussion. The student evaluation of the seminars
indicated that 80% believed the seminars were informative, and 65%
Program Goals said the discussions were helpful in aiding their decision-making pro-
• Provide students with the skills needed to explore the pros and cons cess related to initiating or continuing sexual activity, in analyzing the
of engaging in sexual activity during adolescence. role of peer pressure in the decision-making process, and in clarifying
• Increase the knowledge level of students about sexually related their position on the issues. Approximately 10% of students thought
information so that students can make informed choices about the discussions were useless, and 12% reported that they did not feel
behavior. comfortable engaging in the discussion process. The peer-support pro-
ProblemÂ€1 Outcome Objective. Consistent with the Healthy People gram was intended to support students in their decision to remain celi-
2020 objectives, reduce the number of students who begin sexual activ- bate or to postpone sexual activity. Students were happy with the peer
ity or increase the number of students who postpone beginning sexual program; they reported a variety of responses from other students,
activity until they are older. including inquiry and ridicule. The members believed that the program
ProblemÂ€2 Outcome Objective. Increase student knowledge about helped them to be comfortable with their decisions. The peer group
the process of conception. continues to meet, and the number of new members increased by 5%.
ProblemsÂ€3 and 4 Outcome Objective. Increase student knowledge 2. The posttest results indicated that students were able to differentiate
about birth-control methods. between pregnancy-risk situations and situations that had less risk of
ProblemÂ€5 Outcome Objective. Increase student knowledge of sex- pregnancy, and they were able to identify birth-control methods, pros
ually transmitted disease. and cons of various methods, and failure rates. Students improved in
Process Objective. Seventy-five percent of students will participate the area of knowledge about sexually transmitted disease but were
in the instructional program during spring semester. unable to link specific health complications with selected diseases.
3. The survey of a random sample of students administered 3â•›months after
Evaluation Plan the program revealed that students were using condoms with greater
Ms. Fields is responsible for formulating an evaluation plan. In con- frequency during sexual activity and that the use of a concurrent birth-
sultation with other individuals who are involved in implementing the control method had increased approximately 10%. Essentially, no
program (teachers, psychologist, social worker), an evaluation plan is change was found in the numbers of students reporting sexual activity.
developed. A student representative is also included on the committee. 4. Summary evaluation indicated that the peer program was working
A series of four evaluation methods are decided on to measure the out- well for students who had joined. The seminar discussion and teach-
comes (effectiveness) of the program: ing intervention reached all intended students (sophomores, juniors,
1. Observations and interviews with participants in the seminar discus- and seniors), or 75% of the high school enrollment. Teachers reported
sion and peer network programs to evaluate problem 1 that they were pleased with the instructional portion of the program
2. A posttest to measure knowledge levels to evaluate problems 2, 3, 4, and 5 but thought that adding audiovisual materials, including a film, would
3. A survey to measure sexual activity and practices to evaluate Â�problemÂ€1 be useful to the learning process. Students were still uncomfortable
4. A summary evaluation of the effectiveness of the entire sex Â�education leading the seminar discussions. Overall, the planned interventions
program had worked well. Recommendations: (1) Continue the program for all
grades, with an emphasis on the incoming freshman class and the
Collection of Evaluation Data new sophomores who had missed the intervention during this school
1. Ms. Fields attended two of the seminar discussions led by the social year; (2) add to audiovisual budget to upgrade available instruc-
worker to observe student-leader interactions and student responses. tional media; (3) continue the peer-support program and encourage
Additionally, the students were asked to evaluate the seminars using expanded enrollment in the program; and (4) provide a summer in-
a five-question evaluation survey to measure satisfaction, with room service program to increase teacher expertise with seminar discus-
provided for additional comments. Ms. Fields and the psychologist sion of sexual issues.
devised an interview tool to guide the evaluation process of the peer-
support program. Report Evaluation Results
2. Ms. Fields and the other 2 teachers in the sex education program Ms. Fields prepared a written report of the evaluation results, includ-
developed a 20-question posttest. The posttest measured knowledge ing an executive summary, which she presented to the principal in a
in the area of pregnancy risks, appropriate use of birth control, and personal meeting. The principal reviewed the report, concurred with
â•…â•‡NURSING PROCESS IN PRACTICE—CONT'D

Evaluation at Northview High School
the results, and presented the report and recommendations to meet- Evaluation Plan
ings of the parent-teacher association (PTA) and the school board. To address problems 1 and 2, Ms. Fields and the committee proposed
Ms. Fields was asked to attend both meetings and participated in the and received funding to improve adolescent health services situated
discussion. within the local health center and to develop a community referral
mechanism for students seen in the school health suite who need fur-
Implement Recommendations ther medical care. To address problem 3, Ms. Fields received input from
The PTA was satisfied with progress in the sex education program and interested parties (teachers, school staff, teenage parents) and intends
voted to provide funding support to improve audiovisual materials and to convene a committee to develop a proposal for support services.
contribute to a teacher in-service program. The school board has taken The formative evaluation plan consists of reviewing the progress on
the report under advisement and is expected to decide on a course of these two efforts with individuals involved in the process.
action by the end of the summer, which will be too late to provide a sum-
mer in-service for interested teachers. Collection of Evaluation Data
Ms. Fields met with the staff of adolescent services to review progress.
Phase II: Improve Student Access to Health Services, She, health department personnel, and the principal reviewed her writ-
Including Services to Address Risky Sexual Behavior ten plan for implementing referrals from the health suite. Ms. Fields and
Nursing Diagnoses or Problems the vice-principal reviewed her progress on convening the committee to
1. Inadequate services to provide adolescent health care address support services for teenage parents.
2. Inadequate services to address primary prevention with respect to
pregnancy and sexually transmitted diseases Analysis of the Data
3. Inadequate support services for teenage mothers with respect Adolescent health services will be operational in 2â•›weeks. The staff is
to daycare, parenting skills, and continuation of their educational in place, and all the requested supplies have been ordered. The existing
program equipment provided by the health department is in place and is operational.
The service center originally planned to begin providing care in March, but
Program Goal implementation was delayed because of late-arriving equipment and the
Improve health services for adolescents and improve support services health department's delay in designating a nurse to staff the service. Ms.
for teenage parents, especially teenage mothers. Fields does have an adequate plan for community referrals, which includes
ProblemsÂ€1 and 2 Outcome Objective. Provide adequate health all agencies and professional personnel who are willing to provide care for
care services to students within 24â•›months. free or at a reduced rate. Unfortunately, the two general practitioners in the
ProblemÂ€3 Outcome Objective. Develop support services for teen- community are unwilling to assume care for any more clients at reduced
age parents that will facilitate their educational progress and the well- fees at this time. Ms. Fields has enlisted the help of other professionals in
being of their children within 18â•›months. an effort to identify other physicians who might be willing to assist with
Process Objectives. Several process objectives were developed for the project. Ms. Fields has been only partially successful in gathering her
phase II: committee to look at teenage parent support services. She has consulted
1. By 2â•›years from inception of the adolescent health program, 75% of with local community leaders (an alderman, three church pastors, and two
Northview High School students who are referred to the program will local business owners) and enlisted their help in recruiting volunteers. She
receive services at the health center or be referred to other commu- is hoping to have a complete committee in place in 1â•›month.
nity-based services to meet their needs.
2. Within 2â•›years, all adolescent parents will have access to affordable Report Evaluation Results
certified child care. At this point, the individuals who need to know the results of the efforts
3. Within 2â•›years, all adolescent parents who remain in school will be are involved in the review of progress and are informed about the status
encouraged to attend a school-based parenting-skills program. of the efforts.
1. Based on the plan of nursing care that you developed the distribution of condoms to high school students who
for census tract 1 using the first guidelines for learning in request them. The school board has voted for the policy, and
ChapterÂ€15, design an evaluation plan. Who are the stake- its meetings were open to the public. A vocal minority of par-
holders who need to be involved in the evaluation process? ents is upset by the policy because they believe sexual absti-
How will you evaluate program effectiveness? What will you nence should be the school's policy; they also believe that the
include in your formative process evaluation? home (family) is the place for sex education. What point of
2. Reflect on your own experience with a health program (e.g., view do you hold on this ethical question? What alternative
health education, screening, clinical care). Why did you seek courses of action would be possible if you were the school
care from that program? What were your goals? What was health nurse? What would you choose to do, and why?
helpful to achievement of your goals? What contributed to 4. Interview a community/public health nurse to determine
your satisfaction or dissatisfaction? How would you modify how immunization or other clinic programs are evaluated.
the program if you were the nurse involved? What data are routinely collected, and what questions are
3. Based on the incidence of teenage pregnancy and sexually answered? To what degree does the nurse participate in col-
transmitted diseases, including human immunodeficiency lecting and interpreting the evaluation data? How are the
virus (HIV) infection, a school system has decided to Â�permit data used to modify the program?
WEBSITE
STUDY AIDS
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U N I T 5
Tools for Practice
18 Health Promotion and Risk Reduction
in the Community
19 Screening and Referral
20 Health Teaching
465
CHAPTER
18
Health Promotion and Risk Reduction
in the Community
Gail L. Heiss*
FOCUS QUESTIONS
What does being healthy mean? What are the major national policies for health promotion?
What is the difference between promoting health and What are the responsibilities of the community/public health
preventing illness? nurse in promoting health and preventing illness in the
What models help explain health-related behaviors? community?
What influences the health of a society?
CHAPTER OUTLINE
Meaning of Health Health-Promotion and Health-Protection Programs
Determinants of Health Programs for Individuals
Biological Influences Programs for Families
Environmental Influences Programs for Populations in Communities
National Policy Health Promotion and Nursing Practice
Focus on Health Promotion Appraisal and Assessment
National Health Care Surveys Developing a Health-Promotion Plan of Care
Health Models Intervention Strategies
Health-Belief Model Evaluation
Health-Promotion Model
Primary Health Care Model
KEY TERMS
Clinical practice guidelines Health-protecting behaviors Risk reduction
Environmental restructuring Health-risk appraisal Self-efficacy
Faith community nursing Information dissemination Social support
Health-belief model Lifestyle assessments Transtheoretical model of behavioral
Health-promoting behaviors Lifestyle modification change
Health promotion Parish nursing Wellness
Health-promotion model Primary health care model
Health information assaults our senses daily. Advertisements perspective on three decades of benchmarks and monitored
and articles about healthy living, healthy diets, health clubs, new progress related to the nation's health, the impact of prevention
vitamins, new medications, and new exercise programs are on activities, and the movement toward health for all. Healthy People
the television, the radio, the Internet, magazine racks, and social 2020 is an interactive website that replaces the previously pub-
media sources such as Facebook and Twitter. Americans are trying lished print version as the main vehicle for dissemination of this
and buying and moving toward health—or are they? A review of important information (U.S. Department of Health and Human
the recently launched Healthy People 2020 objectives will Â�provide Services [USDHHS], 2010, http://www.healthypeople.gov/2020).
*This chapter incorporates material written for the first edition by Mary Ellen Lashley.
466
CHAPTER 18â•… Health Promotion and Risk Reduction in the Community 467
Healthy People 2020 is the most current plan to improve national baseline
Â� values. Other objectives are developmental—
the nation's health and is designed to achieve four overarching meaning they currently do not have national baseline data but
goals: (1) Achieve high quality, longer lives free of preventable will ultimately have data and tracking points. Detailed instruc-
disease, disability, injury, and premature death, (2) Achieve tions on accessing the data are available on the website.
health equity, eliminate disparities, and improve the health of Two specific examples of focus areas with detailed data that
all groups, (3) Create social and physical environments that have continued to be part of the Healthy People publications
promote good health for all, and (4) Promote quality of life, over the three decades of data collection include (1) physical
health development, and health behaviors across all life stages. activity and fitness and (2) nutrition and overweight.
The Healthy People 2020 plan includes 42 topic areas that con- In the focus area of physical activity, baseline data and
tribute to the achievement of these four overarching goals. (See improvements with references to the 2010 data can be found
ChapterÂ€2 Healthy People box.) When accessed via the inter- for objectives targeting the numbers of adults who engage in
active site, each of the 42 topic areas includes goals, objec- aerobic physical activity. A 10% improvement over the base-
tives, interventions and resources as well as links to screening line from the National Health Interview Survey is the target for
recommendations by the U.S. Preventive Services Task Force this measure. Detailed data for various age groups is available.
(USPSTF, 2011, http://www.uspreventiveservicestaskforce.org) Related to nutrition and overweight, detailed analysis reveals
when indicated. Each topic area is assigned to one or more lead that Americans are moving away from the target of achieving
agencies within the federal government that is responsible for a healthy weight. Links to community interventions and clini-
developing, tracking, monitoring and reporting on objectives. cal recommendations and consumer resources are provided and
Leading Health Indicators have been selected to monitor prog- are a useful tool for practicing community/public health nurses.
ress for 12 priority topic areas. (See ChapterÂ€2 Healthy People Funding for prevention efforts such as those to promote
box.) Also, four foundation health measures that accompany physical activity and achieve a healthy weight are meant to help
the overarching goals will be used to monitor progress toward decrease the cost of chronic disease such as cardiovascular dis-
promoting health, preventing disease and disability, elimi- ease, which is directly related to obesity and lack of physical
nating disparities, and improving the quality of life. (See the activity. Estimated costs for cardiovascular disease and stroke in
Healthy People 2020 box below.) 2005 were $394 billion. The estimated health costs related to the
Using the interactive Healthy People website, users can track 1 in 3 adults who were obese in 2008 was $147 billion. Notable
the progress of objectives in each of the 42 topic areas. Data also is data indicating that from 1980 to 2008, obesity tripled
to monitor progress are obtained from national surveys such for children—nearly 17% of U.S. children are obese (Centers
as the National Health Interview Survey or the National Vital for Disease Control and Prevention [CDC], 2011a). The impor-
Statistics System. If national data are not available, state or tance of health-promotion programs and the need for individ-
area data are used to monitor the objective. Some of the objec- ual and community commitment to health-promoting lifestyle
tives are measurable—meaning they contain data sources and changes cannot be overstated.
HEALTHY PEOPLE 2020

Foundation Health Measures
Overarching Goal of Healthy
People 2020 Foundation Health Measures Category Measures of Progress
Achieve high quality, longer lives free of General Health Status • Life expectancy
preventable disease, disability, injury, • Healthy life expectancy
and premature death • Years of potential life lost
• Physically and mentally unhealthy days
• Self-assessed health status
• Limitation of activity
• Chronic disease prevalence
Achieve health equity, eliminate disparities, Disparities and Inequity • Race/ethnicity
and improve the health of all groups • Gender
• Physical and mental ability
• Geography
Create social and physical environments that Social Determinants of Health • Social and economic factors such as living
promote good health for all environment
• Access to health services
• Physical environmental hazards
• Biology, genetics, and individual behaviors
Promote quality of life, health development, Health-Related Quality of Life and Well-Being • Physical, mental, and social health-related
and health behaviors across all life stages quality of life
• Well-being/satisfaction
• Participation in common activities
Adapted from U.S. Department of Health and Human Services. (2010). Healthy People 2020. Washington, DC: Author. Retrieved from http://www.
healthypeople.gov/.
468 CHAPTER 18â•… Health Promotion and Risk Reduction in the Community
BOXÂ€18-1â•…â•‡NURSING'S ROLE IN and Human Services (USDHHS) known as Steps to a Healthier

PREVENTION US Initiative (2007), to improve the lives of Americans
through community-based chronic disease-prevention pro-
The American Nurses Association supports efforts to do the following: grams. (This program is now called the Healthy Communities
• Increase nurses' knowledge and skill in providing preventive services. Program within the CDC.) Further progress has been made to
• Encourage partnerships with consumers and other disciplines to weave health and preventive practices in all aspects of our lives
identify needs, set priorities, develop strategies, and evaluate prog- including how we live, where we work, our ability to access
ress in promoting health. clean water and safe food, and how we spend leisure time. In
• Support health care legislation that holds health insurance plans June 2011, the National Prevention, Health Promotion and
accountable for preventive care. Public Health Council announced the release of the National
• Become involved in research to evaluate the extent to which spe- Prevention Strategy as America's plan for better health and
cific preventive interventions at the individual, family, group, and wellness. Using the goals set forth in Healthy People 2020, this
community levels improve health; affect access, use, cost, and
National Prevention Strategy (2011) establishes a cohesive fed-
desired outcomes; and prevent disease, injury, or disability.
eral response that focuses on prevention and prioritizes inter-
• Encourage using multidisciplinary efforts to call consumers' atten-
ventions that will prevent the leading causes of death such as
tion to health-promoting behaviors and environments and develop-
ing community-focused primary prevention models for care. obesity and tobacco use. The Strategy's seven priorities are the
• Influence local and national economic and political options toward following:
reconceptualizing health care in preventive and health-promoting • Tobacco free living
models. • Preventing drug abuse and excessive alcohol use
• Continue to advance nursing's concern that prevention and health • Healthy eating
promotion be central to reformed health care. • Active living
• Educate the public to promote the health of the population through • Injury and violence free living
a broader definition of health and its relationship to behavior. • Reproductive and sexual health
• Mental and emotional well-being
Reprinted with permission from American Nurses Association.
The strategy is also designed to strengthen collaborative
American Nurses Association position statement on health promotion
and disease prevention. Copyright 1995 by American Nurses efforts between the public and private sectors including busi-
Association, Silver Springs, MD. nesses, community groups, and health care organizations.
More contemporary definitions of health have emphasized
Health promotion is a major goal of community/public the relationship between health and wellness and health pro-
health nursing practice (American Nurses Association [ANA], motion. Although health may be viewed as a static state of being
2007). Community/public health nurses facilitate health in the at any given point in time, wellness is the process of moving
population through direct nursing interventions for health toward integrating human functioning and maximizing human
promotion and disease prevention with individuals, families, potential. Health promotion is the process of helping people
groups, and populations. The American Nurses Association enhance their well-being and maximize their human poten-
(ANA) (1995) position statement on health promotion and dis- tial. The focus of health promotion is on changing patterns of
ease prevention suggests specific nursing activities to influence behavior or environmental structures to promote health rather
comprehensive health-promotion services (BoxÂ€18-1). than simply to avoid illness. The goal of health promotion is
In this chapter, the concept of health is explored in depth, to enable people to exercise control over their well-being and
and major influences on health are examined. Theoretical ultimately improve their health, focusing on persons and popu-
models are presented that attempt to explain health-related lations as a whole and not solely on people who are at risk for
behaviors. National policies related to health promotion and specific diseases. Health promotion combines education, orga-
risk reduction are reviewed, and types of health-promotion nizational involvement, economics, and political influences to
and risk-reduction/health-protection programs are examined. bring about changes in behaviors of individuals and groups or
Finally, the responsibilities of the community/public health changes in environmental structures related to improved health
nurse in facilitating health promotion are explored using the and well-being (Cohen etÂ€al., 2000; O'Donnell, 1986). This clas-
nursing process. sic definition of health promotion remains pertinent and today
the terms wellness and health promotion are frequently used
MEANING OF HEALTH interchangeably, with both terms having elements of physical,
mental, and social well-being for both the individual and the
The concept of health has been defined in a variety of ways. community.
Historically, health and illness were viewed as extremes on a
continuum, with the absence of clinically recognizable disease DETERMINANTS OF HEALTH
being equated with the presence of health. In 1947 the World
Health Organization (WHO) defined health in terms of total Many factors, including lifestyle, genetics, and the environment,
well-being and discouraged the conceptualization of health as influence health. Lifestyle refers to the way people live their lives
simply the absence of disease. In 1995 the WHO launched a and involves patterns of working, playing, eating, sleeping, and
process known as “Health for All,” which is aimed at preparing communicating. A healthy lifestyle is easier to maintain when
countries to meet the challenges of the twenty-first century healthful patterns of behavior are learned early in life. Therefore
and emphasizes the need to see health as central to human the family plays a critical role in developing health beliefs
development and societal growth. In 2003, the United States andÂ€behaviors, such as exercise patterns, sound Â�nutritional prac-
launched an initiative from the U.S. Department of Health tices, regular use of seat belts, avoidance of harmful Â�substances
(e.g., tobacco, alcohol, drugs), stress management, and routine for clinical preventive services. In March 2010, the Patient
medical and dental evaluations. Protection and Affordable Care Act became law and provided
structure for efforts to provide accessible and affordable care for
Biological Influences all, including helping more children get health coverage, end-
Genetic endowment influences susceptibility to illness. Familial ing lifetime and annual insurance limits, giving patients access
tendencies toward diseases such as diabetes and heart disease are to recommended preventive services, and discounting prescrip-
well established. However, illnesses related to genetics may also tion mediÂ�cations for seniors and programs to reduce health
be influenced by cultural and environmental factors. Similarly, disparities. More information about the Affordable Care Act is
genetic features such as height and weight may be environmen- available at the new interactive website http://www.healthcare.
tally influenced. Thus, because many of these factors exist or gov. (See ChaptersÂ€3 and 6.) A lack of health care and primary
operate simultaneously, determining the relative influence of preventive services has a tremendous impact on the health of
genetics and the environment on the risk of developing disease a society (see ChapterÂ€21). For this reason, current emphasis is
is often difficult. on creating public and private partnerships to bridge the gap in
service availability.
Environmental Influences Health services may be directed toward primary, secondary,
Environmental influences also contribute to or detract from the or tertiary levels of prevention. Primary prevention is aimed at
ability of people to develop to their optimal potential. When preventing the onset of disease or disability by reducing risks to
examining environmental influences on health, the physical and health, decreasing vulnerability to illness, and promoting health
sociocultural environments must be considered. Factors in the and well-being. Secondary prevention is aimed at diagnosis and
physical environment that influence health include weather and treatment of illness at an early stage, thereby halting further
climatic conditions, noise, light, air, food, water, and exposure progression of disease and assisting persons to return to nor-
to toxic substances. According to Healthy People 2020, an esti- mal functioning. Secondary prevention includes case finding
mated 25% of preventable illnesses worldwide can be attributed for individuals and screening of high-risk groups for the pres-
to poor environmental quality (see ChapterÂ€9). ence of disease. Tertiary prevention focuses on the restoration of
Factors in the sociocultural environment that influence optimal functioning once a condition becomes irreversible by
health include the historic era in which one lives, values of fam- limiting the extent of disability that may occur and by assisting
ily and significant others, social institutions (e.g., governments, clients to function at an optimal level within the constraints of
schools, faith communities), socioeconomic class, occupation, their existing disabilities. The focus of this chapter is on primary
and social roles that encourage or diminish the importance of prevention to promote health and prevent illness in an individ-
preventive health practices. For example, an industrial worker ual, family, or community. ChapterÂ€7 provides additional detail
may be exposed to toxic or carcinogenic substances that render on levels of prevention.
him susceptible to different types of illness. In addition, health
resources may be available only in more affluent communities, NATIONAL POLICY
which diminish access to services by persons of lower socioeco-
nomic status. In the United States, higher education and higher Health promotion is a social project, not solely a medical enter-
socioeconomic class are associated with greater participation prise. Societies have a political responsibility to strengthen the
in health-promotion activities (see ChapterÂ€10). All who live link between health and social well-being. An integration of
in America “should have the opportunity to make the choices government, major interest groups (environmental, business,
that allow them to live a long, healthy life. . . .” (Robert Wood industrial, medical, labor, educational), and community forces
Johnson Foundation, 2010, p. 8). is needed to establish and maintain public policy and commu-
The health care system is another important aspect of the nity action that promotes the health of individuals, families, and
environment that must be considered when determining the communities in society. The ability of the health care system to
health potential of a society. Health care systems focus (in vary- engage in health promotion is often determined by national leg-
ing degrees) on prevention, cure, and rehabilitation in an effort islation such as the previously mentioned Affordable Care Act
to improve the health of society. The ability to access health care of 2010 and policies that provide economic and political sup-
impacts the overall health of individuals and groups. Access to port for health-promotion services in the community.
care also impacts the prevention of disease and the early detec-
tion of health conditions leading to a better quality of life and Focus on Health Promotion
improves life expectancy. Access to Health Services is one of the Healthy People, the first U.S. Surgeon General's report on health
topic areas in Healthy People 2020. Barriers to accessing health promotion and disease prevention, was instrumental in iden-
care include high cost, lack of accessibility, and lack of insur- tifying major health problems of the nation and in setting
ance coverage. People with health insurance are more likely national goals for reducing death and disability. The central
to have appropriate preventive health care screenings, such as message of this report is a message that has not changed over
a Papanicolaou (Pap) test, immunizations, or early prenatal the decades: the health of the nation can be improved by indi-
care. The uninsured are more likely to have poor health status. vidual and collective action in public and private sectors and by
The target for Healthy People 2020 is for 100% of the popula- promoting a safe, healthy environment for all Americans (U.S.
tion to have health insurance (83.2% had medical insurance Department of Health, Education, and Welfare, 1979).
in 2008) and to increase the percent of people having a spe- In 1980, the USDHHS published a second document enti-
cific primary care provider. There are numerous developmen- tled Promoting Health/Preventing Disease: Objectives for the
tal goals in the Access to Health Services topic area including Nation. This document set forth specific objectives for meet-
increasing the number of persons having insurance Â�coverage ing the national health care priorities established in the Surgeon
General's report. Subsequent reports leading up to the most The NHCS is the nation's primary health Â�statistics website,
current publication, Healthy People 2020, included priorities which includes data from a group of surveys, including infor-
such as reduction in hypertension, decrease in chronic dis- mation about health care services and characteristics of the
ease including cardiovascular disease and diabetes, increase clients served and other national vital statistics, including
in immunizations, reduction in sexually transmitted diseases, morbidity and mortality data (see ChapterÂ€7). Additionally,
improved access to preventive health services, accident preven- the CDC provides statistical data on chronic health prob-
tion, and reduction in smoking and alcohol and drug abuse. The lems (e.g., cardiovascular health) and preventable problems
Healthy People reports and objectives are designed to improve (e.g., tobacco-related disease). Most notable in the chronic
the health of the nation through a management-by-objective disease overview on the CDC website is information related
planning process. to the costs of chronic disease and the cost-Â�effectiveness of
Healthy People 2020 builds on the accomplishments of prevention. The U.S. Public Health Service Office of Disease
previous decades and includes new and pertinent topic areas Prevention and Health Promotion (ODPHP) coordinates the
such as Dementias including Alzheimer Disease, Healthcare- efforts of public and private sectors to reduce the risks of dis-
Associated Infections, Preparedness, Global Health and oth- ease and promote the nation's health. Accessing the ODPHP
ers. Healthy People 2020 is a compilation of years of data website (http://www.odphp.osophs.dhhs.gov) provides the user
collection and input from a diverse group of individuals and with links to Healthfinder.gov, Healthy People 2020, Health.
organizations. Healthy People 2020 topic areas include objec- gov and Dietary Guidelines for Americans. It is almost a
tives for identified target populations and links to activities one-stop-shop for accessing health information for consum-
and interventions for health promotion, health protection, ers and professionals including communication tools, infor-
and clinical preventive services. Additionally, the 2020 objec- mation on health literacy, and links to federal information
tives are data driven and are supported by scientific evidence. centers and clearinghouses. (See Community Resources for
Healthy People 2020 also involves some non–health sectors Practice at the end of this chapter for access to these websites.)
that also are determinants of health, such as agriculture,
education, housing, and transportation. The Healthy People HEALTH MODELS
2020 box below presents objectives targeting selected health-Â�
promotion activities. Biological, environmental, and sociocultural factors can influ-
ence health status. These multiple influences on health ulti-
National Health Care Surveys mately determine the type and extent of personal health
Numerous federal resources are available to obtain information behaviors. A variety of conceptual models have been proposed
on health care statistics and health surveys. Comprehensive in an attempt to describe, explain, or predict preventive health
historical and current data supporting the objectives and behaviors.
interventions relating to Healthy People 2020 are incorporated
into each topic area. The site is linked directly to data sources Health-Belief Model
such as the Centers for Disease Control and Prevention (CDC), The health-belief model, which has been widely used to
the National Health and Nutrition Examination Survey explain wellness and illness behaviors, was created in the 1950s
(NHANES), and the National Health Care Survey (NHCS). and has since been revised and tested extensively (Becker, 1974;
HEALTHY PEOPLE 2020

Sample Objectives for Selected Health-Promotion Activities
Physical Activities and Fitness Nutrition
1. Reduce to 32.6% the proportion of adults who engage in no leisure 1. Increase to 33.9% the proportion of adults who are at a healthy
time physical activity (baseline: 40% in 2000; 36% in 2008 repre- weight (baseline: 30.8% of persons 20â•›years old and over were at a
senting 10% improvement.) healthy weight 2005 to 2008.)
2. Increase to 47.9% the proportion of adults who engage in aero- 2. Reduce to 30.6% the proportion of adults who are obese (baseline:
bic physical activity of at least moderate intensity for at least 34% of persons 20â•›years old and over were obese in 2005 to 2008.)
150 minutes/week, or 75 minutes/week of vigorous intensity, 3. Reduce to 14.5% iron deficiency among pregnant females (baseline:
or an equivalent combination (baseline: 43.5% in 2008. This 16.1% of pregnant females were iron deficient in 2003 to 2006.)
objective has been modified from previous Healthy People
publications and updated based on current guidelines. Data is Tobacco
not comparable with previous 2010 objectives, but progress is 1. Reduce to 12% tobacco use by adults (baseline: 24% in 1998; 20.6%
noted.) of adults aged 18â•›years and older were current cigarette smokers in
3. Increase to 20.2% the proportion of adolescents who meet current 2008; progress is noted.)
federal physical activity guidelines for aerobic physical activity and 2. Increase to 80% smoking cessation attempts by adult smokers (base-
for muscle-strengthening activity (baseline: 18.4% in 2009. Data is line: 47% in 1998; baseline: 48.3% of adult smokers aged 18â•›years
not comparable with previous 2010 objectives.) and older attempted to stop smoking in the past 12â•›months in 2008;
4. Increase the proportion of employed adults who have access to no progress toward target.)
and participate in employer-based exercise facilities and exercise 3. Increase recent smoking cessation success using evidence-based
Â�programs (developmental: no baseline). strategies by adult smokers (developmental goal: no baseline.)
Data from U.S. Department of Health and Human Services. (2010). Healthy People 2020. Washington, DC: Author. Retrieved from http://www.
healthypeople.gov.
Becker etÂ€al., 1977; Hochbaum, 1956; Rosenstock, 1974).

A study of older adults (Easom, 2003) supports the con-
Proponents of the health-belief model contend that individuals
cept that limited self-efficacy can be seen as a barrier to par-
will take action to avoid disease states. Actions are motivated
ticipating in health-promotion activities. The goal of the
by (1) the sense of personal susceptibility to a disease, (2) the
project was to increase older adult participation in health-
perceived severity of a disease, (3) the perceived benefits of
promotion activities, such as following an exercise program
preventive health behaviors, and (4) the perceived barriers
and eliminating unhealthy behaviors. The older adults who
to taking actions to prevent a disease. Potential barriers
perceived themselves as unable or incapable of participating
include fear, pain, cost, inconvenience, and embarrassment
in physical activities because of various disabilities related to
(Rosenstock, 1974).
aging may have the barrier of a lowered sense of self-efficacy.
The client's perception of health status and the value placed
Another barrier identified was the loss of satisfaction when
on taking preventive action may also be affected by demographic
giving up an unhealthy habit, such as smoking. Additional
variables (e.g., age, gender, race, ethnicity), sociopsychological
barriers related to self-efficacy for these older adults include
variables (e.g., social class, peer pressure, attitude toward
lack of spousal or family support, lack of willpower, Â�powerless
Â�medical authorities), and structural variables (e.g., personal
attitude about disease progression, and fear of Â�overexertion.
experience with disease, knowledge of disease). Internal cues
Another recent study of long-term married couples identi-
(e.g., detecting a breast lump) or external cues (e.g., advice from
fied the importance of spousal support and self-efficacy as
significant others, exposure to a media campaign) can also serve
a predictor of participation in health-Â�promotion behaviors
to motivate healthful behaviors (FigureÂ€18-1).
(Padula & Sullivan, 2006). Implications for nursing prac-
Empirical research demonstrates that the attitude and
tice include the importance of providing additional verbal
belief dimensions of the health-belief model do predict indi-
encouragement to decrease fear and anxiety about per-
viduals' health-related behavior. When an illness or injury is
forming certain tasks and including the spouse in planning
perceived to be serious and barriers are low, individuals are
and implementation of the health-promotion interven-
more likely to seek medical care and follow the suggested
tion. Other interventions to eliminate barriers include edu-
treatment. In addition, individuals are more likely to engage
cation, exposure to role models and others who have been
in preventive health behavior when barriers to care are low
successful in accomplishing health behaviors, and decreas-
and when people perceive that they are susceptible to an illness
ing unpleasant situations, such as pain from chronic disease.
or injury (Janz & Becker, 1984). These two components of the
model, perceived barriers and perceived susceptibility, appear to
be the most important variables for health-promotion inter- In addition to helping clients decrease barriers to health pro-
vention. Additional study of the model led to a proposal to motion, nurses can also use the health-belief model to identify
include self-efficacy in the health-belief model as a way to help the need for specific programs for at-risk groups. Two studies
explain health-protective behaviors (Rosenstock etÂ€al., 1988). related to nursing interventions to reduce the risk of osteopo-
Self-efficacy is the belief of an individual that he or she can rosis included the importance of health beliefs as a component
perform, or learn to perform, a specific activity or behavior of the nursing intervention (Sadler & Huff, 2007; Sedlak etÂ€al.,
(see ChapterÂ€20). 2005). In both studies, the intervention to reduce perceived
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
Demographic variables (age, sex,

race, ethnicity, etc.) Perceived benefits of
Sociopsychological variables (personality, preventive action
social class, peer and reference group
pressure, etc.) minus
Structural variables (knowledge about Perceived barriers to
the disease, prior contact with preventive action
the disease, etc.)
Perceived susceptibility to
Likelihood of taking
disease ‘‘X’’ Perceived threat
recommended preventive
Perceived seriousness of disease ‘‘X’’
health action
(severity) of disease ‘‘X’’
Cues to action
Mass media campaigns
Advice from others
Reminder postcard from physician
or dentist
Illness of family member or friend
Newspaper or magazine article
FIGUREÂ€18-1â•‡ Health-belief model. (From Becker, M. [1974]. The health belief model and personal health
behavior. Thorofare, NJ: Charles B. Slack.)
Â�barriers to calcium intake and exercise was an educational inter- for health-promoting behaviors that improve well-being and
vention that incorporated cultural differences and health beliefs develop human potential. Pender and associates (2006) con-
as a method to change behavior to reduce osteoporosis risk. tended that health-promotion behaviors are determined by the
The importance of the nursing responsibility to address health following factors:
beliefs is emphasized as a health-protecting behavior. • Individual characteristics and experiences (including prior
The health-belief model is driven more by health-Â� related behavior and personal factors characterized as bio-
protecting behaviors than it is health-promoting behaviors. logical, psychological, and sociocultural)
Health-protecting behaviors are those that protect people • Behavior-specific cognitions and affect (including perceived
from problems that jeopardize their health and well-being benefits and barriers to action, perceived self-efficacy,
such as in the osteoporosis examples previously provided. activity-related affect, interpersonal influences, and situa-
Immunizing the population against infectious diseases and tional influences)
reducing exposure to environmental health hazards are • Behavioral outcomes (including the commitment to a plan
examples of health-protecting behaviors. Health-promoting of action and immediate competing demands such as family
behaviors are those that improve health by fostering personal or work commitments)
development or self-actualization. Many health behaviors, Pender's model represents a multitude of factors affecting
such as managing dietary intake, exercise, and stress manage- health-promotion behavior, which is the end point, or outcome,
ment, serve a dual function by being both health-promoting of the health-promotion model (FigureÂ€18-2).
and health-protecting. A clinical example of the importance of eliminating barri-
ers is examined in a study of healthy eating behaviors in women
Health-Promotion Model underserved by the health care system (Timmerman, 2007). In
Whereas the health-belief model may account for actions taken this population, the barriers to healthy eating included indi-
to prevent disease, Pender and colleagues (2006) proposed a vidual characteristics, experience, and culture. The barriers
revised health-promotion model that attempts to account were internal, interpersonal, and environmental and were seen
INDIVIDUAL CHARACTERISTICS BEHAVIOR-SPECIFIC BEHAVIORAL

AND EXPERIENCES COGNITIONS AND AFFECT OUTCOME
Perceived benefits
of action
Perceived barriers
to action Immediate competing demands
(low control)
Prior related behavior
and preferences
(high control)
Perceived
self-efficacy
Activity-related
affect
Personal factors; Commitment to a Health promoting

biological plan of action behavior
psychological
sociocultural
Interpersonal influences
(family, peers, providers);
norms, support, models
Situational influences;
options, demand
characteristics, aesthetics
FIGUREÂ€18-2â•‡ Pender's revised health-promotion model. (From Pender, N. J., Murdaugh, C., & Parsons,
M. A. [2006]. Health promotion in nursing practice [5th ed.]. Upper Saddle River, NJ: Prentice-Hall Health, Inc.)
to overlap to impede healthy eating. Interventions to improve

A woman believes that she is personally susceptible to devel-
health-promoting behaviors included individualizing the inter-
oping breast cancer, owing to risk factors such as age and
ventions (removal of internal barriers) while working with the
family history. She may realize that the disease is serious and
community (removal of environmental barriers) to develop a
appreciate the benefit of routine mammography and breast
plan of action that was broad enough to be applicable to the
self-examination. In response to a media campaign in her
larger population. Additional interventions included facilitating
community (external cue) or to palpating a breast lump
changes in public policy to eliminate barriers faced by under-
(internal cue), she acts by seeking mammography screen-
served women (Timmerman, 2007).
ing. As a result of this behavior, the disease may be detected
Primary Health Care Model early and treated, and hopefully the woman will go on to live
an active and healthy life. In this case, the theoretical model
Another way to view health and its relationship to individu-
would need to take into account the possible health out-
als is the primary health care model proposed by Shoultz
comes as a result of adopting preventive health behaviors.
and Hatcher (1997) (FigureÂ€18-3). The focus of the model is
health care for all members of the community, with a multi-
sectoral approach. The model should not be confused with Continuing work on theoretical models and their applica-
primary care or with personal health services, which address tion to research is needed to better understand the relationship
health care for individuals. Primary care services may be deliv- between changes in behavior and the actual effects of behavior
ered in a community setting (e.g., clinic, school) but do not modification on health status.
necessarily influence the health of the community. The pri-
mary health care model embodies the principles of community HEALTH-PROMOTION AND HEALTH-PROTECTION
participation and a multisectoral approach with an emphasis on PROGRAMS
prevention. The six key elements of environment, health ser-
vices, education and communication, politics, economics, Many different types of programs have been implemented to
and agriculture and nutrition surrounding the health of the reduce the risk of disease for individuals and groups in commu-
community are interlinked, and each element has an impact nities. Health-promotion programs attempt to increase the level
on health. Important to note is that the delivery of personal of well-being and self-actualization of individuals and groups
health care to individuals is a component of health services. by promoting behaviors that expand the potential for health
The model for primary health care provides a format for and personal development. The goal of health-promotion pro-
Â�community/public health nurses to promote health and health gramming is to enable people to act positively in their environ-
education related to community influences and the environment by creating conditions that encourage and nurture health.
ment. The model may also be adapted if necessary to add other Health-protection, also known as risk reduction, programs are
sectors to the influences on health, such as the impact of spiri- aimed toward facilitating behaviors that enable people to react
tuality on community health. to threats to health through early identification and avoidance
The models used to explain preventive health behaviors tend of risks (Pender etÂ€al., 2006). Thus health-protection programs
to be action oriented. People evaluate and respond to their per- are more reactive in their intent and are directed toward pre-
ceived needs and subsequently act by taking protective action venting illness by identifying, avoiding, and reducing risks to
or adopting health-promoting behaviors. Even so, because the health or by detecting illness early, before the onset of symp-
models have as their end point a change in behavior, actual toms. (See ChaptersÂ€19 and 9 for in-depth discussions on health
health outcomes or documented improvements in health are protection and environmental influences.) The benefits of com-
not directly addressed in the models presented. munity approaches to prevention are summarized in BoxÂ€18-2.
BOXÂ€18-2â•…â•‡BENEFITS OF COMMUNITY
PREVENTION PROGRAMS
Environment 1. Opportunity to reach the masses and effect widespread changes in
social norms
2. Increased public awareness of and commitment to health-promotion
UNI programming
Agriculture MM T Economics
3. Increased cost efficiency of group intervention compared with
Nutrition
CO
one-to-one contacts
Y
Health 4. Ability of the program to serve as an environmental cue, triggering

for all healthful behaviors
CO
5. Ability of the program to promote the development of an environ-

M
Y
Health
services
M U NIT Politics ment of social support for health promotion
6. Opportunity to evaluate the effectiveness of health-promotion programs
and to generalize findings to a wide range of demographic characteristics
Education 7. Enhanced approach toward promoting health in large populations
Communication 8. Additional resources for information exchange and social support
for members of the target population
FIGUREÂ€18-3â•‡ Primary health care model. (Copyright 1997 Hatcher, Data from Pender, N. J., etÂ€al. (2006). Health promotion in nursing
P. A., Shoultz, J., & Patrick, W. K. Used with permission.) practice (5th ed.). Upper Saddle River, NJ: Prentice-Hall Health.
The community/public health nurse develops, implements,

and evaluates health-promotion and health-protection pro-
grams for individuals, families, and groups in schools, work sites,
hospitals, faith communities, prisons, and community settings.
When planning programs for wellness in the community, an
important task is to develop partnerships with people who are
most likely to be affected by the program and to promote a sense
of cooperation, collaboration, and teamwork among groups.
The development of partnerships is especially important in the
design of culturally sensitive and effective prevention materi-
als, as well as problem-prevention campaigns or educational
programs.
The newly developed National Prevention Strategy previously
discussed provides both the consumer and the health care pro-
fessional opportunities to access health insurance information
and health-promotion programs that are both health protecting
and health promoting. This site demonstrates the principles set
forth by Pender (see BoxÂ€18-2), which highlight the benefits of
community prevention programs and the advantages of group FIGUREÂ€18-4â•‡Health-promotion programs for families include
and community interventions. teaching parents how to properly store medications and Â�harmful
chemicals so that they are not within the reach of young Â�children.
Programs for Individuals (From Hockenberry, M. J., & Wilson, D. [2011]. Wong's Â�nursing care of
infants and children [9th ed.]. St. Louis: Mosby.)
Health-promotion and health-protection programs may be
successfully implemented for individuals in many settings.
Individual health-promotion programs depend on an accu- practice guidelines are incorporated into resources readily
rate assessment of individual needs and risks to health, based Â�available to parents and families such as those accessible though
on genetic, biological, psychological, social, cultural, environ- healthfinder.gov. This site includes counseling topics for parents,
mental, developmental, and situational variables. Clinical many of which are geared toward parents to help them pro-
practice guidelines are a useful blueprint for providing health- mote health and safety in the home. To use the site, the Â�parent
promotion and disease-prevention services for care provid- may select the age and gender of the child and health-related
ers in primary care and public health settings. The National Â�guidelines are displayed. The health-related information is also
Guideline Clearinghouse (NGC) (2011) is a publicly available available in Spanish.
database of evidence-based clinical practice guidelines (http://
www.guideline.gov). NGC is updated weekly and is sponsored Programs for Populations in Communities
by the Agency for Healthcare Research and Quality (AHRQ) The community/public health nurse may also develop and
in partnership with the American Medical Association and the implement programs that reach larger groups in the commu-
American Association of Health Plans (AAHP) Foundation. The nity. Major types of community health-promotion programs
site provides the opportunity to search for clinical guidelines by include school, workplace, faith community, hospital, senior
disease condition, treatments, and interventions or measures. center, and community-wide programs. These populations may
The site includes links to patient education and resources but be viewed as phenomenological communities or aggregates or
is geared toward the health professional for purposes of locat- target groups.
ing evidence-based practice resources for adaptation to their
clinical situation. The clinical practice guidelines can also be School-Based Health Promotion
accessed through the AHRQ website, which provides numerous School-based health-promotion programs can facilitate health-
links to consumer resources, patient safety information, infor- promotion behaviors by encouraging the development of
mation targeted for specific populations, and research findings. health-promoting habits early in life that, in turn, foster long-
It is likely that the practicing community health nurse will find term healthy lifestyle behaviors (FigureÂ€18-5). Successful school
these guidelines embedded in clinical practice, physical exami- health-promotion programs are based on an understanding of
nations, and screenings provided through health care organiza- human behavior and developing partnerships with people who
tions. Some organizations use the guidelines as benchmarks of will be most affected by the program (e.g., students, families,
excellence and measures of care provided. peers, faculty and staff, affiliating agencies). These programs
contribute to overall community health-promotion efforts by
Programs for Families developing a sense of individual and social responsibility for
The community/public health nurse works with families to health, promoting an understanding of health and disease,
promote health and prevent disease. Families are often the basis reinforcing positive attitudes toward wellness, encouraging
for developing positive lifestyles because parents can encour- informed decision making in matters of health, and structur-
age their children to practice healthy personal habits. Educating ing the environment and social influences to support health-
parents on home safety hazards, use of child safety seats, immu- promotion behaviors (Pender etÂ€al., 2006).
nizations, and injury prevention can ensure a safer environment Traditionally, school health programs included health edu-
for children through parental intervention in hazard reduction cation curricula, health-promotion strategies, and the delivery
and reinforcing lifelong health practices (FigureÂ€18-4). Clinical of health services, including immunizations, physical health
by Chapman (2005). Factors that influence employee partici-

pation in work site health-promotion programs return to the
concepts previously discussed in the health-promotion model
(Kaewthummanukul & Brown, 2006). This review cites self-
efficacy and perceived benefits as the strongest predictors of
employee participation. A clinical example of a worksite health
promotion program that positively affected a company's finan-
cial bottom line is described by Redmond and Kalina (2009).
This nurse-driven blood pressure screening program promoted
a culture of health and wellness to adopt a healthy lifestyle for
the prevention of cardiac disease and disability.
Health-Promotion Programs in Faith Communities

Faith communities are ideal locations for reaching groups with
health-promotion programs. Faith communities emphasize the
spiritual dimension of health. When combined with programs
that promote physical and mental health, faith communities
truly serve to promote the total spectrum of health and well-
being. According to the standards of faith community nurs-
ing practice (American Nurses Association & Health Ministries
Association, 2005), faith community nursing (formerly called
parish nursing) intentionally focuses on the care of the spirit as
part of the process of promoting holistic health and preventing
illness in a faith community.
FIGUREÂ€18-5â•‡ A school health-promotion program teaching about
tobacco products and the harmful results of using them.
In a review of the literature, Peterson and colleagues (2002)
identified seven key elements for successful church-based health-
promotion programs: partnerships, positive health values,
requirements, screening, and first aid. Currently, these dimen- availability of services, access to facilities, community-focused
sions have been expanded to include food services and nutri- intervention, health-behavior change, and supportive relation-
tion, physical education, and guidance and counseling, as well as ships. Faith community nurses are also seen as health advocates
school psychology services. Also notable are the new Adolescent performing roles such as helping to access care, assisting as a navi-
Health objectives in Healthy People 2020. ChapterÂ€30 provides gator in the health care system, and working with the faith group
an in-depth discussion of school health nursing. to acquire needed health services in the community (Peterson,
2007). Activities common to faith community nurses include
Workplace Health Promotion organizing health fairs, making home visits, conducting blood
The workplace has become a major channel for health-Â� pressure screening clinics, and providing counseling and refer-
promotion activities and, as such, has received national ral services. Links to recent clinical examples of faith community
Â�attention. In Healthy People 2010, one of the nation's objectives programs are embedded in Healthy People 2020 topics areas.
for the year 2010 was to provide employee health-promotion
activities in at least 75% of workplaces with 50 or more employ- Hospital-Based Health-Promotion Programs
ees. Work site health promotion goals and programs were in a Hospital-based health-promotion programs are now focused on
separate category. New in the Healthy People 2020 format, the a variety of populations. Health-promotion and risk-reduction
goals and objective for worksite health promotion programs are programs are offered not only to hospital employees and cli-
embedded in each topic area. For example, there are links to ents, but also to various groups in the community. Partnerships
guides and programs designed to reduce the number of smok- between hospitals and businesses, schools, faith communities,
ers in the worksite, or guides for business to promote exercise senior centers, and community organizations not only have
and weight management. facilitated a large increase in providing health-promotion ser-
Numerous positive outcomes act as incentives for employer vices to the community, but also have served as a financial
and employee participation in health-promotion activities. incentive for hospitals as they improve their ability to attract
Incentives for employers include reduced rates of employee new physicians, clients, and the media.
absenteeism because of improved health status, increased Non-profit hospitals are required to provide community
employee productivity, decreased use of medical insurance benefits in order to maintain their tax-exempt status. Under the
benefits and workers' compensation for illness and accidents, Affordable Care Act non-profit hospitals are required to con-
decreased employee turnover, decreased accidents, and decreased duct a community health needs assessment every three years
premature morbidity and mortality. Incentives for employee and adopt implementation strategies to meet the needs.
participation include promoting a safe work environment,
improving access to services, providing a convenient service Health Promotion in Military Communities
location, receiving company payment for services, and provid- Pertinent to the culture of the United States today is the health
ing availability of services on company time. A review of litera- of the large number of military families. Physical and mental
ture related to the cost effectiveness and return on investment health of both the military service member and family cannot be
in health promotion programs is presented in a Â�meta-analysis overlooked. Children and parents must cope with the stresses of
deployment, frequent moves, changing schools, changing health Â�

geopolitical communities include decreasing morbidity and
care providers, finding new social support systems, and possible mortality in the community, achieving widespread community
financial hardships. The families of service members do not wear health protection, promoting cost-effective community-wide
uniforms, so they may not be readily seen in the community. health promotion, and promoting and sustaining health-Â�
Gabany and Shellenbarger (2010) outline the role of the com- promotion efforts in the organizational network of the com-
munity health nurse in assessing the needs of the military family munity. Interventions in these large-scale health-promotion
and also provide a list of potential resources. In addition, First projects may include using mass media and community health
Lady Michelle Obama developed “Joining Forces (2011)”, an education programs to increase public awareness of health risks
Â�initiative to assist military that calls on communities to identify and prevention practices, counseling, lifestyle assessments, faith
and assist military families (http://joiningforces.uso.org/). community and social group involvement, training of health
professionals, and reorganization of public services to target
Health Promotion in Geopolitical Communities high-risk populations. One such example of a community-wide
Community-wide health-promotion and disease-prevention project is presented as an interactive Internet guide to quitting
programs use health care, educational, recreational, social, smoking by the American Cancer Society (2011) titled Guide
and governmental resources to develop and implement pro- to Quitting Smoking. Tools to help plan a quit date, telephone
grams that enhance the well-being of large population groups. numbers and ideas for support, quizzes, and general informa-
Community-centered programs have been credited with tion and statistics on smoking and cancer are available. This
enhancing opportunities for social support and informa- information is presented in the steps of the nursing process for
tion exchange in the community and for exerting a signifi- planning a community-wide intervention in BoxÂ€18-3. Similar
cant impact on social policy. Goals for health promotion in smoking cessation information and interactive materials have
BOXÂ€18-3â•…â•‡COMMUNITY-WIDE SMOKING CESSATION: USING THE NURSING PROCESS

TO PLAN A COMMUNITY-WIDE INTERVENTION
ASSESSMENT OF THE PROBLEM 3. Deal with withdrawal.
• An estimated 46 million people in the United States continue to • Use alternatives such as gum or hard candy, vegetables, or
smoke. Tobacco use is a serious risk for health problems and early Â�sunflower seeds.
death caused by lung disease, heart disease, and cancers, including • Relax and perform deep-breathing exercises.
cancer of the mouth, bladder, kidney, cervix, and others. • Delay the urge to light up.
• Smoking in the home is hazardous to children and is related to otitis 4. Maintain or stay smoke free.
media, allergies, and asthma. • Renew and review your reasons for quitting.
• Women who smoke while pregnant risk having low-birth-weight • Remind yourself that there is no such thing as just one cigarette.
babies or miscarriage.
PLAN FOR COMMUNITY PARTICIPATION IDENTIFY BENEFITS AND BARRIERS

• Form partnerships and establish support from schools, work sites, Benefits
faith communities, and hospitals. • Damage to appearance, including stained teeth, bad breath, wrinkled
• Develop or adopt public education campaigns (e.g., public service skin, and yellowed fingernails, is reduced.
announcements, "Smoke-Out" dates) and public visual-media oppor- • Food tastes better, and the sense of smell returns.
tunities (e.g., advertisements in newspapers, on billboards, or on • Ordinary activity no longer leaves you short of breath.
public transportation. Consider use of social media such as text mes- • Social acceptance is increased.
sages as stop smoking tips or reminders). • Money spent on tobacco is saved.
• Identify funding sources.
• Identify and publicize possible incentives for individuals and busi- Barriers
nesses to become involved, such as reduced insurance premiums or • Nicotine is an addictive drug, leaving the smoker physically and
healthier employees with decreased absentee rates. Â�psychologically dependent.
• Gather resources and materials. Be sure to include resources for • Withdrawal symptoms such as depression, irritability, headache, or
those with access to online technology, traditional print media, and increased appetite are increased.
information on telephone counseling and other means of support. • Not all health care providers counsel smokers on quitting, which
Â�provides the message that it is “OK” to smoke.
IMPLEMENT PROGRAMS FOR INDIVIDUALS
AND GROUPS
Smoking cessation suggestions—four important factors: EVALUATE THE SUCCESS OF YOUR
1. Make the decision to quit. COMMUNITY-WIDE PROGRAM
2. Set a quit date and choose a quit plan • Has a change occurred in policies about smoking in public places,
• Get rid of all cigarettes, lighters, and ashtrays. such as restaurants?
• Keep active. • Are employees participating in workplace smoking-cessation
• Drink plenty of water. Â�programs? Are community members attending smoking-cessation
• Use nicotine replacement if that is your choice. group activities?
• Avoid high-risk activities or situations in which the urge to smoke • Do the health care providers in your area counsel smokers at every
is strong. clinical visit on the benefits of stopping?
Data from American Cancer Society. (2011). American Cancer Society guide to quitting smoking. Retrieved from http://www.cancer.org/Healthy/
StayAwayfromTobacco/GuidetoQuittingSmoking/index.
also been developed on the CDC website. An example of a suc- Â�

health-promotion behaviors to determine the major health
cessful program to decrease exposure to secondhand smoke risks that can potentially affect the client's overall health and
among residents living in multi-unit housing in a disadvan- well-being. In assessing needs, the community/public health
taged community is highlighted on the CDC site Communities nurse must also examine social, environmental, and cultural
Putting Prevention to Work: Success stories (2011b) (http://www. influences on health behaviors of families and communities.
cdc.gov/CommunitiesPuttingPreventiontoWork) . A comprehensive health-promotion and health-protection
Another large-scale community-wide project that reaches assessment of an individual should include a complete health
a large and diverse population group is WISEWOMAN: Well- history and periodic routine health-maintenance examinations.
Integrated Screening and Evaluation for WOMen Across the Physical fitness evaluations and nutrition assessments provide
Nation. The project is part of the CDC, Division for Heart valuable data to assess overall health status. Health-risk apprais-
Disease and Stroke Prevention (CDC, Division for Heart als may be used to collect data on individual health risks and
Disease and Stroke Prevention, 2011c, http://www.cdc.gov/ health behaviors and to determine an individual's risk of devel-
wisewoman/). The mission of the project is to provide low- oping certain illnesses over his or her lifetime.
income and underinsured or uninsured women of all races and
ethnic groups the knowledge and skills to improve their health Health-Risk Appraisal
through lifestyle modification with the ultimate goal of reduc- The health-risk appraisal (HRA) (also termed the health-
ing cardiovascular and chronic disease. The priority age group hazard appraisal) is a method for estimating an individu-
is women age 40 to 64. The site provides health information, al's health threats because of demographic, behavioral, and
interactive health-risk assessments, and personal success sto- personal characteristics (Pender etÂ€al., 2006). Personal risk
ries designed to empower women to stop smoking, increase profiles are developed based on information provided by
physical activity, achieve a healthy weight, and manage stress. the client and information from laboratory data or other
The site is geared toward multicultural groups such as African assessments.
Americans, Latinos, and Native Americans and includes reci- HRAs have both assessment and motivational purposes. One
pes and prevention information in numerous languages. The goal of the HRA is to collect and organize personal health data
site also includes links to other reliable health information to provide an accurate, individualized assessment of risk factors
resources. that may lead to health promotion. A second major goal of the
An excellent example of a smaller, well-designed health pro- HRA is to stimulate the necessary behavioral changes that may
motion project is Kent on the Move (2011) (http://www.kenton- reduce health risks. The assumption holds that each person,
themove.org). This program, under the leadership of a public having his or her own set of risk factors, can be compared with
health nurse, was designed by a group of community volun- others with similar factors to establish morbidity and mortality
teers and includes government, business, education, school, and estimates. Also assumed is that, armed with this knowledge, the
faith-based organizations. The goal of Kent on the Move is to client will be motivated to change high-risk behaviors (Pender
increase physical activity and promote healthy eating in an effort etÂ€al., 2006).
to decrease overweight and obesity and the associated chronic The HRA, when first developed in the early 1970s, focused
health problems among residents of a rural county. Although on assessing risk for specific disease entities and was primar-
not a “nursing only” intervention, the steps of the nursing pro- ily intended for physician use. However, since that time, a sig-
cess are evident including links to an assessment of the over- nificant number of HRA tools have been published that reflect
weight and obesity epidemic, state and local plans and public broader interests, such as health attitudes, social supports,
strategies with detailed descriptions of interventions includ- stressful life events, and coping strategies. In addition, spe-
ing information on healthy eating, and resources for physical cial versions of HRAs have been developed for different age
activity. In addition to the Internet links, a downloadable guide groups.
is available that includes photographs of multiple ethnic HRAs enable the community/public health nurse to individ-
groups, genders, and ages, and links to a community newsletter ualize assessment of risks and to recommend behavior changes
with ongoing evaluation of progress and new initiatives. that are compatible with a healthier lifestyle. In addition, HRAs
can be administered to large groups and can be generated and
HEALTH PROMOTION AND NURSING PRACTICE analyzed electronically.
Appraisals usually begin with a questionnaire that identi-
The community/public health nurse uses the nursing process fies factors contributing most directly to individual risk. HRA
to assist people and groups to become more self-directed and instruments include questions regarding age, gender, ethnic
motivated in taking actions that promote and maintain health background, personal and family history of disease, and lifestyle
and prevent disease. The community/public health nurse can be factors (e.g., smoking, drinking, exercise, sexual activity, driv-
seen as an advocate for health, assisting individuals and groups ing practices, seat belt use, job stress). Physical measures such as
in collaborative efforts to assess their level of wellness and access blood pressure and weight may be assessed, and blood tests may
health resources. The community/public health nurse also probe obtained. In addition, risk factors for diseases that are ame-
vides health education and options for health care and helps nable to early detection efforts, such as breast and colon cancer,
Â�clients establish goals for lifestyle changes. are noted (see ChapterÂ€19).
Personal data are compared with mortality data from
Appraisal and Assessment cohort groups who share similar characteristics. Risk factors
The first step of the nursing process is assessment. The com- are weighted to determine the magnitude of the risks using
munity/public health nurse must assess the client's (individ- (1) statistical formulas based on professional, medical, or
ual, group, aggregate, or population) health care needs and actuarial judgment; (2) average risks for the population; and
(3) established epidemiological and mathematic rules and a spouse may help individuals cope more effectively with a
assumptions. The magnitude of these risks is then shared with potentially Â�devastating life experience.
the client. In addition to the classic Holmes and Rahe scale, interactive
An example of an HRA, which includes recommendations risk assessments related to stress can also be found on the previ-
on improvements to health, is called Healthfinder.gov (http:// ously mentioned healthfinder.gov website through the personal
healthfinder.gov). This site is coordinated by the ODPHP and health tools link. These assessments include work site stress,
its health information referral service, the National Health stress as a result of a disaster, the stresses related to caregiving,
Information Center (U.S. Department of Health and Human and stress in children related to holidays.
Services, ODPHP, 2011). The user can navigate to personal
health tools such as body mass index calculators, risk of heart Lifestyle Assessments and Wellness Inventories
disease, or a stress scale. Health information grouped by gen- Lifestyle assessments and wellness inventories are wellness-
eral topics such as nutrition or everyday health and wellness is focused appraisals that place greater emphasis on promoting
available, and by entering age and gender, specific risk assess- health rather than identifying risk factors for specific diseases.
ments are available. Lifestyle assessments focus on daily patterns of behavior that
A health risk assessment can also be found on the home page affect health and over which the individual has some control.
of Healthy People 2020. This HRA identifies the top 10 causes Through the AHRQ Internet site and the Prevention and Care
of death across populations with a focus on health disparities. Management area of the website, individuals can access a life-
A comparison between ethnic or age groups can also be style assessment for men or women called Stay Healthy at Any
obtained with links to the Healthy People objectives and Age (AHRQ, 2011). The assessment includes information on
interventions. recommended screening tests, immunizations, and healthy life-
Community/public health nurses have an ethical responsi- style choices such as maintaining a healthy weight and increas-
bility to provide feedback, education, and appropriate follow-up ing physical activity. This site also provides downloadable files
for identified risks. The follow-up must be planned into of health information, which can be printed as brochures. This
community health-promotion programs that use HRA instru- is useful for health care providers to reinforce health assessment
ments. Individuals may be notified in writing or through recommendations for those who do not have Internet access.
follow-up counseling sessions on the findings of their HRAs. A printable health screening record, which includes the recom-
Recommendations for lifestyle changes or for seeking follow-up mendations, date and results of screenings, and a place to take
medical evaluation should be explained to each participant (see notes, is included in the brochure. Similar resources are available
ChapterÂ€19). for men of any age, men and women over the age of 50, and are
also accessible in Spanish.
Stress-Risk Assessment Other lifestyle assessments may take a more focused approach
The Social Readjustment Rating Scale developed by Holmes to specific problems. For example, The National Heart, Lung,
and Rahe (1967) is a classic well-known tool used to assess the and Blood Institute (NHLBI) sponsors a lifestyle assessment
stressful effects of significant life events on adults. The scale related to healthy weight. The program is called Aim for a
is based on the assumption that stressful events may precipi- Healthy Weight and encourages individuals to calculate their
tate illness or have an additive effect in contributing to illness. body mass index, obtain a waist circumference, and examine
The scale has also been used to identify links between stress- other lifestyle risk factors (National Institutes of Health, NHLBI,
ful life events during the previous year and the development 2011). Assistance in menu planning and lifestyle changes is also
of illness; high scores on the tool have been found to predict provided. Be sure to also look at the healthy weight tools includ-
the occurrence of illness. Stressful life events require a signifi- ing the menu planner and the “portion distortion quiz” which
cant lifestyle adaptation or coping behavior on the part of the identifies everyday “super-sized” foods including a mocha cof-
individual. fee, muffin, bagel, and even a calorie-laden super-sized Caesar
Coddington (1972) developed several stress measurement salad. The portion distortion slide show and accompanying
tools for use with children of various ages. An interesting portion-size learning cards can be downloaded for a fun inter-
note is that many of the life events for children are similar active health education tool.
to those for the adult. Nurses working with families to teach
coping skills need to recognize the impact of family events on Developing a Health-Promotion Plan of Care
the children. Both the Holmes and Rahe Social Readjustment After a comprehensive assessment of lifestyle, health behaviors,
Rating Scale for Adults and the Coddington Life Change Unit and specific risks to health, the community/public health nurse
Values for Children are available on the book's website as develops a health-promotion plan of care with clients in the
Website Resources 18A and 18B . community. A plan for health promotion and health protection
The nurse should critically analyze the social readjustment should be targeted to specific clients. The health-planning pro-
scale to determine how to interpret results for the client. Some cess should involve both the nurse and the client using the fol-
cultural and community values might affect the meaning of the lowing steps (Pender etÂ€al., 2006):
value of the life change event. For example, in some communi- • Summarization and review of the information collected in
ties, an unwed pregnancy or fathering an unwed pregnancy will the assessment
necessitate more life adjustments than it would in other • Identification and reinforcement of strengths
communities. Additionally, the scale does not account for
Â� • Development of health goals and appropriate lifestyle
Â�factors that mediate the degree of distress a person Â�experiences change options
in a stressful situation. Factors such as receiving support • Identification of desired health and behavioral outcomes that
or counseling to deal with a Â�painful divorce or the death of would signify a successful outcome from the client's perspective
• Design of a behavior change plan that takes into consider- recent study on health messages for adolescents designed
ation the client's preferences and current stage of change to promote responsible sexual behaviors, it was found that
• Creation of a reward system for reinforcement of behavior mass media communication such as television, Internet, and
• Review of environmental and interpersonal facilitators and Â�computer-assisted instruction were all effective for increasing
barriers to behavior change knowledge and changing attitudes (Delgado & Austin, 2007).
• Development of an implementation time frame Other examples of information-dissemination programs
• Commitment to the proposed behavior change goals and the include posters and commercial announcements, articles in
support needed to accomplish them local newspapers, and billboards and bumper stickers such
This process of care planning is appropriate for both individ- as those that encourage seat belt use. Although information-
uals and populations. However, when planning care for popula- dissemination programs are a helpful approach to promoting
tions, of particular importance is to develop partnerships with health in the community, information alone is insufficient to
community members, achieve consensus on health goals that affect large-scale, community-wide behavioral change. For
are appropriate to the community, and gain commitment from example, despite widespread dissemination of literature on
key community leaders in supporting health-promotion efforts the health risks of obesity, overweight and obesity continues
(see Unit IV). to increase.
Intervention Strategies Lifestyle Modification

The community/public health nurse should consider the fol- Lifestyle modification is a more comprehensive approach to
lowing strategies when assisting individuals and communities effecting changes in health-promotion behaviors. Lifestyle-
in recognizing patterns and adaptation of healthy practices: modification programs encourage self-responsibility for health
• Dissemination of health-related information to inform and and represent the action phase of health behavior. Assisting cli-
educate ents in implementing lifestyle changes often necessitates fre-
• Encouragement and enhancement of client self-efficacy quent contacts between the health professional and the client
through lifestyle modification so the health professional can serve as a change agent, suggest-
• Development of environments that are conducive to health ing alternative behaviors and referring the client to resources in
and healing practices the community to facilitate positive lifestyle changes. Also dur-
• Use of partnerships in health promotion to strengthen ing these contacts, the community/public health nurse should
social networks and support and influence policy (State assess the client's motivation and readiness to change behav-
plans, partnerships, coordinators and supporting organiza- iors to a more positive lifestyle. A useful model for assessment
tions are listed on Healthy People 2020; however, this is not of the readiness to change is the transtheoretical model of
meant to be an exhaustive list. Local groups such as previ- behavioral change developed by Prochaska and DiClemente
ously mentioned faith groups or school groups also play a (1983). The model identified five stages of change, which can
part in supporting healthy communities and making posi- allow for tailoring of support and interventions based on the
tive change.) client's needs and stage of change. Sample client behaviors and
nursing interventions are presented in TableÂ€18-1. In clinical
Information Dissemination practice, the transtheoretical model and other social-cognitive
Information dissemination refers to mass communication of theories were evaluated to determine how they could be
health-promotion information to the community in the most applied to effect changes in physical activity (Plotnikoff &
effective and efficient manner. Information may be dissemi- Karunamuni, 2011). The study found that while useful and
nated by using mass media such as television, social media applicable to create change, additional work with this model
(such as Facebook, e-cards, or text messages), billboards, and other behavioral change models is needed to promote and
brochures, posters, or exhibits. It must be noted that eco- ensure appropriate amounts of physical activity among indi-
nomically disadvantaged groups or those with other health viduals and groups.
disparities may not have the same amount of access to elec-
tronic health information. Information is often disseminated Environmental Restructuring
through a health fair or exposition. A health fair is a commu- Environmental restructuring is an approach that facilitates
nity event offering health screenings, information, resources, healthful lifestyles by creating environments that are con-
and counseling and referral services in a location that is conducive to information dissemination, health appraisal and
venient and accessible to community members. It is impor- assessment, and lifestyle modification. Environments are
tant to offer these events in locations that would reach the restructured to optimize the healthful conditions existing
segment of the population who have limited access to health in the environment (Cohen etÂ€al., 2000). Restructuring may
information via the Web or social networks as mentioned. also mean increasing the availability of healthful options
(See ChapterÂ€19). in the community by providing greater opportunities and
The goal of information-dissemination programs is to resources to engage in health-promoting behaviors (Pender
inform the community of ways to promote health and pre- etÂ€al., 2006). Healthy options allow people to make more
vent disease. Information dissemination is a consciousness- healthy choices.
raising activity that alerts the community to health-damaging The community/public health nurse can educate commu-
behaviors and environmental health hazards, and attempts nities on potentially harmful agents in the physical environ-
to motivate the community to adopt healthier lifestyles. The ment and on ways to eliminate, reduce, or minimize threats to
presentation format of the information must be appropri- health. For example, the community/public health nurse may
ate for the intended recipients of the health message. In a be involved in restructuring the physical environment to protect
TABLEÂ€18-1â•…â•‡STAGES OF CHANGE: THE TRANSTHEORETICAL MODEL AND SAMPLE CLIENT

BEHAVIORS AND NURSING INTERVENTIONS RELATED TO HEALTH-PROMOTION
GOAL OF INCREASING PHYSICAL ACTIVITY AND EXERCISE
NURSING INTERVENTION TO
STAGE OF CHANGE CLIENT BEHAVIOR TYPICAL CLIENT COMMENT ASSIST CLIENT TO NEXT STAGE
1. Precontemplation Client has no interest in Client: “I don't like to exercise when I get Raise client awareness about personal
change and is comfortable home from work; I enjoy relaxing on the risks and alternative behaviors; discuss
with current behavior. sofa.” success rates, not failure rates, of
behavioral change.
2. Contemplation Client is considering Client: “I might like to start exercising Elicit and address decision making;
behavior change. when the weather is warm in a few encourage client to attempt an
months.” alternative behavior; explore
motivators and client's perspective of
perceived costs and benefits; identify
client's timeline; focus on short-term
possibilities; provide ongoing counseling.
3. Preparation Client is planning to change Client: “I intend to start walking three Reinforce new behavior; help client
behavior. days per week to improve my physical restructure environment and social group
appearance and reduce stress.” to reinforce new behavior; set realistic
goals.
4. Action Behavior change is initiated. Client: “I bought walking shoes and Help overcome setbacks; encourage client
walked for 20 minutes yesterday.” self-evaluation and monitoring; build in
rewards.
5. Maintenance Behavior change has been Client: “I have been walking since the Acknowledge that relapse occurs; extend
initiated and maintained Spring and my clothing fits better and goals; monitor progress.
for 6â•›months. IÂ€feel more energized. I seldom skip a day
of walking.”
Adapted from Croghan, E. (2005). Assessing motivation and readiness to alter lifestyle behavior. Nursing Standard, 19(31), 50-52; and data from Maibach, E.,
& Cotton, D. (1995). Moving people to behavioral change: A staged social cognitive approach to message design. In E. Maibach & R. L. Parrott (Eds.),
Designing health messages: Approaches from communication theory and public health practice (pp. 41-64). Thousand Oaks, CA: Sage Publications.
health by promoting smoking cessation and helping to establish people to be more physically active. The review indicated that
smoking guidelines in public buildings. social support interventions can result in a 44% increase in
The environment may also be improved aesthetically, time spent being physically active and a 20% increase in the fre-
socially, and economically to promote or enhance health. For quency of physical activity. Some of the social support inter-
example, overcrowding may contribute to physical (infec- ventions included setting up a buddy system, making a contract
tious disease) and psychological (anxiety) disturbances. with others to specify levels of physical activity, or setting up
Work environments can be monitored for noise and dust lev- groups to provide friendship and support.
els, temperature variations, and levels of toxicants. An inter-
esting example of an environmental intervention to promote Public and Private Partnerships for Political Action
health is found on the CDC (2011b) site Communities Putting Creating a community environment of support for health pro-
Prevention to Work: Success Stories. The site describes an inter- motion also requires partnerships between the public and pri-
vention in Kauai, Hawaii, a location with surprisingly high vate sectors. The community health nurse should advocate and
obesity and elevated risk for chronic disease. The interven- promote legislation that provides the funding and resources
tion, called “Complete Streets” created safe areas for walking needed to conduct community health-risk assessment and
and biking including safe routes to school, and a program to health education programs, promote environmental health
encourage groups to exercise and walk together. ChapterÂ€9 and safety, enhance existing support systems in the commu-
provides a more in-depth discussion of environmental health nity, and promote research on health promotion and health
concerns. protection/risk reduction. The community/public health nurse
may mobilize consumer interest groups, businesses, commu-
Strengthening Social Support nity agencies, and other organizations to influence lawmakers
The sociocultural environment may also contribute to health and private policymakers to develop and support policies that
promotion and community wellness. Social support refers to result in the adoption of laws and programs that foster health
the supportive value of the interactions within relationships promotion.
that encourage behavioral change. The CDC National Center for
Health Marketing conducted a systematic review of nine studies Evaluation
on the use of social support to increase physical activity (CDC, The evaluation of health-promotion and health-protection
National Center for Health Marketing, 2005). The review indi- program outcomes involves a process of systematic data collec-
cated that social support interventions were Â�effective in Â�getting tion, analysis, and interpretation to make informed decisions
regarding program effectiveness, continuation, or revision instruments and scales available in social science and health
(also see ChapterÂ€17). Evaluating preventive programs for literature. Evaluation of health-promotion programs on a com-
Â�individuals, families, and communities is imperative to deter- munity level is based on an epidemiological model. (BoxÂ€18-5
mine whether program goals have been met and whether gives criteria for evaluation of health-promotion programs in
the program has been effective in meeting the health needs the community.)
of the targeted group. Evaluation may be ongoing and con- Evaluation data may be collected from analyzing vital statistics,
tinuous with the assessment and intervention phases. Health- observations, questionnaires, and other records. Evaluating health-
promotion or health-protection programs may be evaluated promotion and health-protection programs allows the community
while they are in operation and after the program is com- and community/public health nurse to determine whether the
plete. The NCHS (2011), the nation's principal health sta- benefits of the program outweigh the costs of time, money, and
tistics agency (http://www.cdc.gov/nchs), provides a wealth of resources devoted to the project and to rate how the program
data sources and links to health surveys that evaluate existing compares with alternative programs and interventions that may be
programs and suggestions for measurement of other health-Â� equally feasible and cost-effective.
promotion programs. The effectiveness of a health-promotion or health-Â�protection
Although individuals, families, and the community as a intervention in a particular group may be measured by com-
whole may benefit from preventive programs, the criteria for paring that group with a control group that did not receive the
evaluating the success of programs differ depending on the intervention to determine whether the goals of the Â�program
client focus. Individuals and families, for example, may expe- would have been achieved in the absence of the intervention.
rience more direct and readily applicable benefits (e.g., bet- Based on evaluation of the program's Â�effectiveness, implications
ter health and increased life satisfaction) from participating in for changes in social and health policy may be made.
preventive programs. (BoxÂ€18-4 gives criteria for evaluation of
health-promotion and risk-reduction programs that focus on
individuals and families.) Perceived life satisfaction, self-esteem,
social support, and life stress may be measured using published BOXÂ€18-5â•…â•‡CRITERIA FOR EVALUATING
HEALTH-PROMOTION
PROGRAMS IN THE
COMMUNITY
BOXÂ€18-4â•…â•‡CRITERIA FOR EVALUATING 1. Reduced community-wide morbidity and mortality rates
HEALTH-PROMOTION 2. Decreased number of days (on an aggregate level) missed from
PROGRAMS FOR THE work owing to disability or illness
INDIVIDUAL OR FAMILY 3. Decreased incidence of preventable communicable diseases
4. Decreased disability days, insurance usage, and unemployment
1. Improved health status owing to health reasons
2. Improved communication among members 5. Increased social satisfaction, quality of life, and self-esteem on
3. Increased income owing to increased employment an aggregate level
4. Higher levels of work productivity 6. Decreased health care costs and reported hospitalizations
5. Decreased personal expenditures for health 7. Decreased antisocial behaviors (e.g., arrests, driving while
6. Reported increases in life, work, and family satisfaction intoxicated)
7. Satisfying use of leisure time 8. Decreased monies spent on alcohol, drugs, and cigarettes in
8. Reduced dependency on family members community
9. Improved self-esteem 9. Decreased rates of divorce and domestic violence
10. Decreased reported life stress 10. Reported increases in exercise, fitness, nutrition, and other
11. Increased awareness and use of supportive social networks health-promotion behaviors
Data from Borus, M., Buntz, C., & Tash, W. (1982). Evaluating the Data from Borus, M., Buntz, C., & Tash, W. (1982). Evaluating the
impact of health programs: A primer. Cambridge, MA: MIT Press. impact of health programs: A primer. Cambridge, MA: MIT Press.
KEY IDEAS
1. Controlling risk factors related to lifestyle and health habits that provide economic and political support for health-
(e.g., poor diet, lack of exercise, smoking, drug and alcohol promotion services in the community.
abuse) can increase the span of a healthy life. 5. Continuing work on health models and their application
2. Health promotion involves focusing on individuals and to research is needed to better understand the relation-
populations as a whole and not solely on people who are at ship between changes in behavior and the actual effects of
risk for specific diseases. behavior modification on health status.
3. Health promotion is a social project and not solely a medi- 6. The community/public health nurse applies the nursing
cal enterprise. process in developing and sustaining health-promotion
4. The ability of the health care system to engage in health pro- and risk-reduction programs throughout the community
motion is determined by national legislation and Â�policies to promote community/public health and well-being.

Initiating a Workplace Health-Promotion Program
Karen is an occupational health nurse working in a steel plant. Over • In 6â•›months, at least 70% of employees participating in the program
the years, she noted a high incidence of hypertension; heart disease; will report improvements in job satisfaction, self-esteem, and feel-
cancer of the larynx, throat, and lung; and substance abuse in her client ings of well-being.
population. Karen grew increasingly concerned about these statistics. • In 12â•›months, employee health care costs and hospitalizations will
Although a few screening programs were available in the facility (e.g., have decreased by at least 25%.
blood pressure screening, chest radiographs) to detect disease at an
early stage, Karen believed that a need existed for a comprehensive Implementation
program that intervened before the onset of disease. Under Karen's direction and coordination, the committee developed a
workplace health-promotion program. Information about the program
Assessment was disseminated throughout the corporation through brochures, post-
After securing agreement and support from the plant management, ers, and mass mailings. The program included educational programs on
Karen worked in partnership with her employer to assess her clients' fitness, nutrition, stress management, accident prevention, and reduction
health risks, perceptions of need, and receptivity to a workplace health- of environmental hazards (e.g., toxins, air pollutants, noise). Smoking-
promotion program. She developed a questionnaire to assess employee cessation programs were offered at convenient times during the day and
health perceptions, determinants, and behaviors. She discovered that evening. Support groups were developed for employees to share con-
the majority of her clients defined health in terms of role performance. cerns, discuss work-related issues, and promote supportive social rela-
As one steel worker noted, "I feel I'm healthy as long as I can work." tionships. Monthly activities (e.g., ballgames, picnics) were planned for
She also found that 70% of respondents did not routinely engage in employees and their families to provide opportunities for meaningful
health-promotion activities because of cost, poor access, lack of social interaction and to promote a spirit of community. Mental health
knowledge, or inconvenience of health-promotion services. Karen also counseling services were offered on site to assist clients who were expe-
administered an HRA tool to all employees who frequented the work- riencing marital, family, or occupational stress. Supervisors and executive
place clinic. personnel met to discuss ways to restructure the environment to optimize
She analyzed the data and identified risk factors, such as an increased health and enhance the aesthetics of the workplace.
risk of morbidity and mortality based on age, family history, smoking,
drug and alcohol use, stress, and poor nutrition and fitness patterns. In Evaluation
addition, individuals lacked knowledge of health-promotion behaviors After the program was in operation for 6â•›months, the committee began
and risks to health. Identified environmental hazards included concerns to analyze data to evaluate the program's effectiveness. Evaluation
over exposure to air pollutants and chemicals in the workplace, lack of occurred at 6-month intervals while the program was in operation. Data
access to affordable workplace health-promotion services, and lack of revealed the following:
supportive social networks to encourage healthful behaviors. Based on • A 25% decrease in number of days missed from work as a result of
these findings a plan was developed. disability or illness
• A 30% increase in reports of job satisfaction, self-esteem, and feel-
Planning ings of well-being
Karen presented the findings of her study to the administration. • A 25% decrease in reported health care costs and hospitalizations
Company executives viewed the cost of funding a health-promotion • A 30% decrease in reported antisocial behaviors (e.g., arrests, driv-
program as a barrier to implementation. Karen provided information ing while intoxicated, incidents of domestic violence)
about the benefits of a workplace health-promotion program, including Employees also reported a 15% decrease in tobacco use (chewing
evidence from other studies that health promotion in the workplace has and smoking) and a 10% reduction in alcohol and drug use. In addi-
been found to reduce rates of employee absenteeism, improve worker tion, 30% of employees reported maintaining a nutrition and fitness
productivity, decrease the use of medical insurance and workers' com- regimen 1â•›year after the program was in operation. Karen also noted a
pensation claims, and improve employee morale and company image. 20% decrease in the number of clinic visits resulting from on-the-job
Karen formed a committee consisting of steel worker employees and accidents and a decreased incidence of hypertensive episodes during
administrative and support personnel at different levels of the corpora- blood pressure screening clinics.
tion. The committee agreed that priority should be placed on address- Less progress was reported in the area of environmental restruc-
ing smoking cessation, alcohol and drug abuse, stress management, turing. Although standards of safety were reportedly more closely
exercise and fitness, nutrition, accident prevention, and reduction followed, lack of fiscal resources was cited as a major deterrent to
of environmental hazards. The committee also decided that services securing improvements in lighting, temperature, and workspace to
would be offered on site and on company time as an incentive for par- produce a healthier, more comfortable, and attractive environment.
ticipation. The following goals were developed for the program: Nonetheless, measurable improvements in employee health, well-
• Six months after initiation of the program, the number of days missed being, and productivity were substantial enough to justify continued
from work owing to disability or illness will decrease by 20%. employer support of the program.
1. Develop a health-promotion plan for a client using one of related to factors in the specific client? How does the model
the models of health presented in this chapter. Compare your influence development of your care plan?
plan with that of a fellow classmate who has chosen another 2. Talk with an individual client, family member, and colleague,
model of health. What similarities or differences do you notice exploring their ideas about health. Ask them to describe
between the plans of care? To what extent are differences what being healthy means to them. Have them relate a
Â�
personal experience in which they felt "better than ever" or this experience like for you? What facilitated or hindered
"on top of the world." What was this experience like for them? your ability to effect a healthful behavior change?
What might have influenced their perceptions of health? 6. As an occupational health nurse working in a textile fac-
3. Explore conceptions of wellness and illness with people tory, you are responsible for planning and implement-
from different socioeconomic, occupational, or cultural ing health care programs in your facility. Major health
groups. What similarities or differences exist among these needs of your client population include substance abuse,
persons? What influences the meaning of wellness or illness respiratory problems, hypertension, cancer, and back
to different populations? injuries. Although you would like to develop programs
4. Reflect in writing on your perception of what being healthy reflecting primary, secondary, and tertiary levels of pre-
means. Share your reflections with an individual who is vention for all the major health needs, inadequate fiscal
experiencing acute or chronic illness. and human resources prevent you from doing so. Given
5. Complete a wellness assessment or HRA tool. What risks the scarcity of resources, what health needs would you
to health are you able to identify in your own attitudes address first, and why? What level of prevention would
and behaviors? Identify one personal high-risk behavior in your program target? What are the positive and negative
which you routinely engage, and attempt to modify your implications of your decisions? What additional infor-
lifestyle in this area for 1â•›week. For this behavior, identify mation do you need to gather to prioritize health needs
what stage of change you are in (see TableÂ€18-1). What was effectively?

Information about each organization listed here is found on its Community Preventive Services Task Force, The Guide to
website. Community Preventive Services: http://thecommunityguide.
Agency for Healthcare Research and Quality: http://www.ahrq.gov/ org/index.html
Agency for Healthcare Research and Quality, Stay Healthy at Any Healthfinder.gov: http://healthfinder.gov/
Age, for men and women: http://www.ahrq.gov/clinic/ppipix. Healthy People 2020: http://www.healthypeople.gov/2020/default.
htm (accessed under Prevention and Care Management for aspx
Consumers/Patients) Kent on the Move: http://www.kentonthemove.org/
American Cancer Society, Guide to Quitting Smoking: National Center for Health Statistics: http://www.cdc.gov/nchs/
http://www.cancer.org/Healthy/StayAwayfromTobacco/ National Guideline Clearinghouse: http://www.guideline.gov/
GuidetoQuittingSmoking/index National Heart, Lung, and Blood Institute: http://www.nhlbi.
Centers for Disease Control and Prevention: http://www. nih.gov/
cdc.gov/ National Heart, Lung, and Blood Institute Aim for a Healthy
Centers for Disease Control and Prevention, Chronic disease Weight: http://www.nhlbi.nih.gov/actintime/rhar/lew.htm
prevention and health promotion: Tools and resources: http:// National Prevention, Health Promotion and Public Health
www.cdc.gov/chronicdisease/ Council National Prevention Strategy: http://www.healthcare.
Centers for Disease Control and Prevention, Communities gov/prevention/nphpphc/strategy/report.pdf
Putting Prevention to Work: http://www.cdc.gov/Communities Office of Disease Prevention and Health Promotion: http://
PuttingPreventiontoWork/ odphp.osophs.dhhs.gov/
Centers for Disease Control and Prevention, Tobacco Cessation The guide to community preventive services: http://www.Â�
Program: http://www.cdc.gov/tobacco/quit_smoking/cessation/ thecommunityguide.org/index.html
Centers for Disease Control and Prevention, WISEWOMAN: U.S. Preventive Services Task Force: http://www.ahrq.gov/clinic/
http://www.cdc.gov/wisewoman/ uspstfix.htm

• NCLEX Review Questions 18A: Social Readjustment Rating Scale for Adults
• Critical Thinking Questions and Answers for Case Studies 18B: Life Change Unit Values for Children
• Care Plans
• Glossary
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2005 update. The Art of Health Promotion, July/ programs: Outcome-based literature review. structural model of health behavior: A pragmatic
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CHAPTER
19
Screening and Referral
Gail L. Heiss
FOCUS QUESTIONS
What is the value of screening in maintaining the health of What are the responsibilities of the community/public
people in the community? health nurse in selecting, establishing, implementing, and
How is screening linked to health promotion and evaluating screening programs?
maintenance? What is the relationship between screening and referral?
What principles guide the selection, development, and What are the responsibilities of the community/public health
targeting of screening programs? nurse in the referral process?
CHAPTER OUTLINE
Definition of Screening Planning
Criteria for Selecting Screening Tests: Validity and Reliability Implementation
Validity, Sensitivity, and Specificity Evaluation
Reliability of Screening Tests Screening and the Referral Process
Contexts for Screening Establishing Criteria for Referral
Screening of Individuals Establishing a Resource Directory
Screening of Populations Investigating Procedure for Initiating Referral
Major Health Threats in the General Population Determining Criteria for Service Eligibility
Settings for Screening Investigating Payment Mechanisms
Community/Public Health Nurse's Role in Screening Assessing Client Receptivity
Assessment Evaluating Effectiveness of Referral
KEY TERMS
Case finding Presumptive identification of disease Secondary prevention
Health fair Process evaluation Sensitivity
Mass screening Referral Specificity
Multiphasic screening Reliability Validity
Outcome evaluation Screening
An essential component in maintaining the health of a com- discussed in Healthy People 2020 (U.S. Department of Health
munity is early detection of disease. Although ideally the and Human Services [USDHHS], 2010). Determinants of
hope is to prevent disease, not all diseases are completely pre- health incorporate personal factors such as biology and
ventable. For example, although some risk factors associated genetics and access to health services, such as early detection
with the development of heart disease are known and can be and screening tests. Also included in determinants of health
avoided (e.g., high-fat diet, smoking, sedentary lifestyle), oth- are social factors such as the environment in which people
ers are unmodifiable (e.g., age, sex, family history). For this live and work. (See ChapterÂ€18.)
reason, diseases that cannot be completely prevented must Secondary prevention is aimed at the early detection and
be detected early in their natural history when they are more treatment of illness. Screening is a major strategy for secondary
amenable to treatment. The concept of early detection and prevention. When previously unrecognized illnesses are iden-
treatment of disease is relevant to the Determinants of Health tified through screening, referrals must be made for follow-up
486
CHAPTER 19â•… Screening and Referral 487
diagnosis and treatment. This chapter explores the concept of Screening is conducted by applying tests and procedures.
screening and the responsibilities of the community health These tests can be applied rapidly and inexpensively to popu-
nurse in the screening and referral process. lations. In other words, these tests should be appropriate for
administration to a large group of people. To screen large groups
DEFINITION OF SCREENING in a timely manner, a test must be able to be administered rap-
idly and with ease. Tests should be relatively inexpensive so they
Screening is the process of using clinical tests and/or examina- are accessible to more economically diverse populations.
tions to identify patients who require diagnosis and additional Mass screening is used to denote the application of screen-
health-related interventions. The goal of screening is to differing tests to large populations. These groups may be typical of
entiate correctly between persons who have a previously unrec- the general population or be selectively at a higher risk for cer-
ognized illness, developmental delay, or other health alteration tain problems. Because mass screening of the general popula-
and those who do not. Screening recommendations most often tion is often costly and does not necessarily detect enough new
used for health screening events and routine health care appoint- cases of disease to balance the cost of screening, money may
ments are based on the clinical research and evidence-based pre- be better spent on targeting selected populations known to be
ventive care presented by the U.S. Preventive Services Task Force at high risk for certain illnesses. For example, in a large city
(USPSTF). The Preventive Services Task Force is sponsored by where elevated lead levels in children are a problem because of
the Agency for Healthcare Research and Quality (AHRQ) and inadequate housing, the community/public health nurse might
is recognized as the leader in prevention and screening recom- suggest targeting screening toward children from minor-
mendations (USPSTF, 2010). The screening recommendations ity groups and low-income children living in impoverished
may be found online or a print copy of the guide (AHRQ, 2011, neighborhoods.
publication number 10-05145) may be obtained at no cost from Case finding is screening that occurs on an individual or a
the AHRQ Publications Clearinghouse on a single copy basis one-on-one basis. Case finding uses screening tests to identify
(http://www.ahrq.gov/clinic/pocketgd.htm). previously unrecognized disease in individuals who may pres-
Screening involves several key concepts. Screening is aimed ent to the health care provider for health maintenance checks or
at the presumptive identification of disease. In other words, for an unrelated complaint. A good example is when the com-
if a screening test is positive (abnormal), one can only presume munity/public health nurse makes a home visit and checks the
that the disease may be present. A screening test in itself is not blood pressure of each member of the family. In this instance,
sufficient to establish a positive diagnosis of disease because a the nurse may detect previously unrecognized disease in family
single screening test, taken in isolation, is not always 100% accu- members who are unaware that a problem even exists. Another
rate. For example, inaccuracies in test measurement can lead to example is an individual who obtains a new job and has a pre-
false-positive or false-negative test results. For this reason, when employment physical; an elevated cholesterol level may be
a screening test is positive, a referral is made for follow-up diag- detected in this manner.
nostic testing to confirm whether the disease is present. Multiphasic screening is used to denote the application of
Screening tests detect previously unrecognized disease, multiple screening tests on the same occasion. A health fair held
meaning that screening tests are often conducted on seemingly at a church, synagogue, or mosque for example, may include
healthy populations. Persons who undergo screening tests may screening for blood pressure, depression, colorectal cancer,
be asymptomatic of disease and unaware that a problem poten- and diabetes. Persons may present to different stations or pro-
tially exists. The goal, and value, of a screening test is to detect viders and receive several screening tests during a single visit.
disease in an earlier stage than it would be if the client waited for TableÂ€19-1 presents some suggestions on selecting screening
clinical symptoms to develop before seeking help. tests when planning a multiphasic health fair.
TABLEÂ€19-1â•…â•‡PLANNING A MULTIPHASIC HEALTH FAIR

NURSING PROCESS EXPLANATION
Assess: The diseases being screened Select screening tests based on demographic data and relevance of the problem to the community.
should be significant health problems in For example, it would be appropriate to conduct a screening for osteoporosis at a community center
the Â€community. serving primarily white women.
Plan: Gather support from the community Issues such as available dates and times, space, volunteers, funding for screening tests, advertising,
and consider all the details. and cultural issues must be considered from the beginning. For example, it would not be appropriate
to conduct a hypertension screening at the Jewish Community Center during the Jewish New Year
in September.
Implement: The screening tests should be Tests to consider might include screening for hypertension, diabetes, elevated cholesterol levels, and
safe, simple to administer, cost-effective, cancer. Some cancer screenings such as colon and rectal screening may be done with noninvasive
and acceptable to the client population. fecal occult blood stool cards that the patient takes home. Invasive procedures should be avoided in
mass screening settings.
Evaluate: Follow-up diagnosis and A screening program should not be conducted unless adequate community resources are available
treatment of persons with positive test to deal with the outcome of positive test results. If no resources exist in the community, the
results is important. community/public health nurse has a responsibility to advocate for funding for such resources and to
mobilize needed resources so that community health and well-being are protected.
488 CHAPTER 19â•… Screening and Referral
CRITERIA FOR SELECTING SCREENING TESTS: Ideally, a screening test would be 100% sensitive and 100%
VALIDITY AND RELIABILITY specific. However, because this combination of perfect accuracy
and precision in measurement is not likely, screening tests are
Validity, Sensitivity, and Specificity not used to confirm a diagnosis positively and are not consid-
Validity is defined as the ability of the screening test to distin- ered to be diagnostic.
guish correctly between persons with and those without the dis-
A nurse is working in her community to help reach the Healthy
ease. If a screening test were 100% valid, it would never have a
People 2020 goals of preventing diabetes and help reach the
false-positive or false-negative reading. The result would always
target of 80% of persons with diabetes whose condition has
be positive in people who had the disease and negative in people
been diagnosed. She decides to implement a screening day
who did not. The validity of a screening test is measured using
for diabetes at the local pharmacy. The pharmacy owner has
sensitivity and specificity.
agreed to donate the supplies for the screening. Participants
Sensitivity is the ability of a screening test to identify correctly
are requested to have fasted for 10 to 12 hours before arriving
persons who have the disease. When the disease is correctly
at the screening.
identified, this result is known as a true-positive test. A test with
If the normal blood glucose level ranges from 70 to 100Â€mg/dl
poor sensitivity will miss cases and will produce a large propor-
and for this screening event any level greater than 70 mg/dl
tion of false-negative test results; people will be incorrectly told
was considered abnormal (that is, diabetes potentially pres-
they are free of disease. The statistical formula for calculating
ent), what would happen to the sensitivity and specificity of
sensitivity is the following:
the screening test? Because it is highly unlikely that anyone
Number of true-positive test results
with diabetes would have a blood glucose level lower than
70Â€mg/dl, sensitivity would approach 100%. However, nor-
Number of people with disease
mal individuals with blood glucose levels between 70 and
(Number of true-positives + false-negatives) 100 mg/dl would be considered to potentially have diabetes;
their positive test result would give a false picture of the pres-
Notice that the denominator in the formula is all persons with
ence of diabetes. There would be a large number of false-Â�
the disease. After a screening test, persons with the disease might
positive results. Specificity would then decrease, and the
have a screening result that is either true-positive (i.e., they do,
nurse would be making many, many referrals for potential
in fact, have the disease) or false-negative (i.e., the screening test
diabetes. Therefore the relationship between sensitivity and
is normal, but they do actually have the disease). The greater
specificity is inverse. The greater the sensitivity is, the lower
the number of false-negative test results, meaning the larger the
the specificity will be, and vice versa. The more sensitive a test
number of persons with disease who have not been identified, the
is made, the less specific it becomes. The nurse, in this case,
lower the sensitivity of the screening test.
would be wise to use the screening criteria suggested by the
Specificity is the ability of the screening test to identify per-
American Diabetes Association (ADA, 2007). Clients with a
sons who are normal or without disease and who correctly test
fasting blood glucose level between 100 and 126 mg/dl would
negative when screened. The formula for specificity is as follows:
be instructed to receive another screening test. Clients who
Number of true-negative test results
have a fasting blood glucose level of greater than 126Â€mg/dl
would be instructed to see their health care provider as soon
All persons without disease
as possible. In addition, the nurse might want to target the
(Number of true-negatives + false-positives) screening event for patients at high risk for diabetes, such as
adults of any age who have a body mass index (BMI) equal
In this case, persons who are healthy may have one of two
to or greater than 25 kg/m2, or screening individuals with
test results. They may have either a true-negative finding (i.e.,
other risk factors such as a family history of diabetes, physi-
they do not have the disease, and the test findings are normal)
cal inactivity, or if they are from a high-risk ethnic group
or a false-positive finding (i.e., they do not have the disease, but
such as African American, Latino, or Native American. In
their screening test result is positive for disease). The greater
the absence of these risk factors, the nurse should consider
the number of false-positive test results, the lower the specific-
screening adults over age 45 (Standards of Medical Care in
ity of the screening test. TableÂ€19-2 summarizes sensitivity and
Diabetes, 2011).
specificity.
TABLEÂ€19-2â•…â•‡SENSITIVITY AND SPECIFICITY

Sensitivity is the ability of the test to correctly identify persons who have a disease.
High sensitivity Numerous true-positive results. People who actually have the disease correctly test positive.
Low sensitivity Numerous false-negative results. People have a normal screening, but actually have the
disease.
Specificity is the ability of the test to identify persons who do not have disease who correctly test negative.
High specificity Numerous true-negative results. People who do not have disease correctly test negative.
Low specificity Numerous false-positive results. People have an abnormal screening, but they do not have
the disease.
Is having a high sensitivity and a moderate or low specific- history and risk factors. Population-based mass screenings can
ity better, or should attempts be made to improve specificity, be offered in conjunction with national screening days, such as
even though sensitivity may be compromised? The answer to skin cancer screening or depression screening, or they may be
these questions depends on the disease for which the individual selected based on demographic and epidemiological data.
is being screened and the physical, psychological, and financial
impact of false-positive versus false-negative test results. In the Screening of Individuals
case of diseases that are potentially fatal if not detected early, A routine health-maintenance examination is one example
sensitivity may be more important. However, the psychological of a multiphasic, case-finding intervention. Periodic health
trauma and financial cost of being labeled incorrectly as hav- checkups include a comprehensive health history, physical
ing a disease can be devastating. For example, if a client receives examination, and relevant laboratory and diagnostic stud-
news that he has a fatal disease, and then commits suicide, a ies. Many health care providers and organizations follow the
false-positive reading has had significant consequences. In this screening guidelines available through the National Guideline
case, high specificity is as important as high sensitivity. Clearinghouse (NGC). The NGC is sponsored by the AHRQ
An interesting discussion of sensitivity and specificity relating and provides recommendations based on evidence-based clini-
to school nurse screening for scoliosis is found on the iScolio- cal practice (http://www.guideline.gov). This website organizes
sis website (http://www.iscoliosis.com/symptoms-screening.html) recommendations for periodic screening of adults by topic such
and in Website Resource 19A. The screening of adolescents as hypertension, lipid disorders, obesity, colorectal cancer, and
for scoliosis occurs in schools in all 50 states. The purpose of others (NGC, 2011). The site includes comparisons and rec-
the screening is to detect scoliosis at an early stage. The test is ommendations of other key agencies and highlights similari-
described as sensitive (always detects the presence of scoliosis ver- ties, differences and evidence-based resources. Several screening
sus a normal back) and has a low false-negative rate (does not guidelines are presented in TableÂ€19-3.
miss kids that need treatment). The test is also determined to be In addition to screening guidelines, the nurse and the
specific (finding scoliosis as opposed to other problems). A figure of patient may use family history to determine which screening
the test and additional information on this screening test are also tests are most appropriate. A useful tool for document-
located in Website Resource 19A. ing family health history called My Family Health Portrait,
sponsored by the U.S. Department of Health and Human
Reliability of Screening Tests Services (2011), Office of the Surgeon General, can be com-
Reliability refers to the consistency or reproducibility of test pleted online, saved, and printed for use during visits with the
results over time and between examiners. A test is reliable when health care provider. The tool is available in English, Spanish,
it gives consistent results when administered at different times Italian, and Portuguese at https://familyhistory.hhs.gov/fhh-
and by different persons. web/home.action.
Another health tool of interest designed specifically for
In a community, a blood pressure screening event is held at African American families is a collaborative education and
the entrance to the shopping mall every first Friday of the awareness program developed in 2006 by the American Heart
month. The event is well publicized on the radio and with Association (AHA) and the American Stroke Association called
flyers at the senior center and places of worship. The screen- the Power to End Stroke. The materials include a family reunion
ing is easy to find, the entrance is a well-known location and toolkit including suggestions for compiling a family health
is advertised as being the “mall entrance near the merry-go- history and a tool for documenting stroke awareness and the
round.” At the screening, the community health nurse obtains importance of seeking medical care if a family member has two
a blood pressure reading of 190/110 mm Hg on a participant. or more risks factors such as elevated blood pressure, elevated
She seeks another nurse to recheck the findings. The second cholesterol or a history of physical inactivity (http://powerto-
nurse obtains a reading of 120/80 mm Hg. This difference endstroke.org/tools-family-reunion.html).
indicates poor reliability; the results were not consistent. The
skill level of the nurses, degree of sensory impairment, or Screening of Populations
condition of the equipment may have affected reliability. As On a population level, choice of screening tests is based on
a solution, checking equipment, monitoring the correct pro- general sociodemographic rather than individual risk fac-
cedure of the nurses working at the health fair, or altering tors. To determine what screening tests should be admin-
environmental noise level might improve the reliability of istered, the community health nurse must assess the risks
this screening test. The nurses may want to move the blood inherent in the target population. What diseases are the tar-
pressure screening to a location in the mall that is quiet— get population most at risk of developing? Are these diseases
perhaps near an entrance that does not have the merry-go- easily screened?
round. An alternative solution to improve reliability when Age, gender, and ethnicity factors have an impact on the risk
conducting blood pressure screening in a noisy environment status of a population. A nurse planning a health fair in a local
with multiple screeners is the use of automated blood pres- women's center, for example, may include screening for breast
sure monitoring equipment. cancer. An individual attending the health fair may not be at an
increased risk of developing breast cancer based on age or per-
CONTEXTS FOR SCREENING sonal and family history. Nevertheless, because the population
group as a whole has been determined to be at risk, instruc-
Screening programs may be targeted to individuals (i.e., case tion on breast self-exam and information on recommendations
finding) or to populations (i.e., mass screening). For individ- for mammography and sources for screening mammograms are
uals, screening tests are selected based on the client's personal made available.
TABLEÂ€19-3â•…â•‡RECOMMENDATIONS FOR SELECTED ADULT HEALTH SCREENINGS
SCREENING METHOD RECOMMENDATION
BREAST CANCER SCREENING
Breast self-examination* Indicated once a month for women older than 20 years
Clinical breast examination* Women younger than 40 years: every 3 years
Women 40 years and older: every year
Mammography* Annually ages 40 and older
COLON/RECTAL CANCER SCREENING FOR MEN AND WOMEN*

Tests That Find Polyps and Cancer
Flexible sigmoidoscopy Every five years starting at age 50
Colonoscopy OR Every 10 years starting at age 50
Double contrast barium enema OR Every five years starting at age 50
CT colonoscopy (virtual colonoscopy) Every five years starting at age 50
TESTS THAT MAINLY FIND CANCER

Fecal occult blood test with at least 50% test Annual, start at age 50
sensitivity for cancer or fecal immunochemical test Note: A take-home multiple sample method should be used. A digital rectal exam in the doctor's
(FIT) with at least 50% test sensitivity for cancer office is not adequate for screening.
Papanicolaou test women 18 +* Start 3 years after a woman starts having vaginal intercourse, but no later than age 21.
At or after age 30, women who have had three consecutive normal tests may get screened every two
to three years with cervical cytology or every three years with an HPV DNA test plus cervical cytology.
Women 70 or older who have had three or more normal pap tests and no abnormal test in the past 10
years or who have had a total hysterectomy may choose to stop cervical cancer screening.
Testicular self-examination* Monthly for postpubertal males
Prostate specific antigen (PSA) test with or Asymptomatic men with at least a 10-year life expectancy should have an opportunity to discuss risks
without digital rectal exam. Men age 50 +* and benefits of screening and make an informed decision with their health care provider.
BLOOD PRESSURE
Blood Pressure and Classification Recommendations for Referral to a Source
of Hypertension† of Medical Care
Normal: Systolic less than 120 mm Hg; Normal: Recheck in 2 years
diastolic less than 80 mm Hg
Prehypertensive: Systolic 120-139 mm Hg; Prehypertensive: Recheck in 1 year; provide advice about lifestyle modifications
diastolic 80-89 mm Hg
Hypertensive Hypertensive
Stage 1: Systolic 140-159 mm Hg; diastolic Stage 1: Confirm within 2 months; provide advice about lifestyle modifications
90-99Â€mm Hg
Stage 2: Systolic ≥ 160 mm Hg; diastolic Stage 2: Evaluate or refer to source of care within 1 month; for those with pressures ≥180/110
≥ 100 mm Hg mm Hg, evaluate and treat immediately or within 1 week, depending on clinical situation
CHOLESTEROL‡ Desirable values: Check once every 5 years or more frequently if indicated
Total cholesterol: less than 200 mg/dl
Low-density lipoprotein (LDL) “bad”
cholesterol: less than 100 mg/dl optimal
High-density lipoprotein (HDL) “good”
cholesterol: 40-60 mg/dl
Triglycerides: less than 150 mg/dl
DIABETES SCREENING§ Annually for high-risk individuals (e.g., family history, personal history of glucose intolerance, obesity,
older than age 45 years, people from minority races); otherwise during routine medical examinations
Screening may be verbal or written; only individuals with high risk or physical symptoms should
be referred for blood testing
SKIN CANCER SCREENING¶ Complete body skin examination every 3 years ages 20 to 40 years, annually ages 40 and older
MANTOUX TEST WITH PURIFIED Annually for high-risk groups (e.g., human immunodeficiency virus [HIV]-positive persons, known
PROTEIN DERIVATIVE-TUBERCULIN contact with tuberculosis patient, immunosuppressed persons, persons who live or work in long-
(PPD) SKIN TEST** term care facilities or work in hospitals or schools, foreign-born persons from countries with high
tuberculosis rates, persons living in the United States in areas where TB is common such as a
homeless shelter, persons who inject illegal drugs); otherwise as indicated
*American Cancer Society. (2011). Cancer facts and figures. Screening guidelines. Available online at http://www.cancer.org.
**Centers for Disease Control and Prevention. (2011). Testing for TB infections. Available online at http://www.cdc.gov/tb.
†
National Heart, Lung, and Blood Institute, National Institutes of Health. (2004). The seventh report of the Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure. Washington, DC: Author. Available at http://www.nhlbi.nih.gov/guidelines.
‡
National Cholesterol Education Program. (2007). Guidelines for clinical preventive services. Washington, DC: National Heart, Lung, and Blood
Institute. Available at http://www.nhlbi.nih.gov/guidelines.
§
American Diabetes Association. (2007). Facts and figures. Available at http://www.diabetes.org.
¶
American Academy of Dermatology. (2011) Skin cancer prevention. Available at http://www.aad.org.
African American men are at a higher risk of developing HEALTHY PEOPLE 2020
malignant hypertension than are women or white men; there-
fore advertisements for some health fairs might be targeted to Reduce the Risk of Cardiovascular Disease
the African American community. Osteoporosis is more com- Hypertension
mon in white and Asian postmenopausal women than it is in 1. Increase to 68% the proportion of adults with high blood pressure
other population groups; thus a women's event might be a good whose blood pressure is under control (baseline: 25% in 1994; 44%
place for this screening. Population data are an important con- in 2000).
sideration for nurses planning mass screenings. 2. Increase to 95% the proportion of adults who have had their blood
pressure measured within the preceding 2 years and can state
Major Health Threats in the General Population whether their blood pressure was normal or high (baseline: 90% in
Chronic diseases such as heart disease, stroke, cancer, and dia- 1998: 93% in 2000).
betes are the leading causes of death and disability in the United 3. Increase overall cardiovascular health in the U. S. population (devel-
States. Heart disease and stroke, the first and third leading causes opmental goal: no baseline).
of death, account for more than one-third of all U. S. deaths. In
Serum Cholesterol
2007 of all adults who died of cardiovascular disease, 150,000
1. Reduce to 13% the proportion of adults with high total blood cho-
were under age 65 (Centers for Disease Control and Prevention
lesterol level (baseline: 21% of adults ages 20 years and older had
[CDC], 2011a). Cancer, the second leading cause of death, is
total blood cholesterol of 240 mg/dl or greater in 1994; 15% of
responsible for the deaths of more than 1500 people every day adults had total cholesterol 240 mg/dl or greater in 2000; showing
in the United States (CDC, 2011a). The cost of chronic disease is improvement).
also dramatic. It is estimated that the direct and indirect (such as 2. Reduce to 177.9 mg/dl the mean total blood cholesterol level
loss of productivity) costs of cardiovascular disease and stroke among adults (baseline: 206 mg/dl in 1994; 197.7 mg/dl in 2000;
in the United States in 2011 were $444 billion. The financial showing improvement).
costs of cancer, the second leading cause of death, responsible 3. Increase the proportion of adults with elevated LDL cholesterol who
for over 560,000 deaths in 2007 alone, also are overwhelming. have been advised by a health care provider regarding cholesterol-
According to the National Institutes of Health, cancer costs the lowering management including lifestyle changes and, if indicated,
United States an estimated $263.8 billion in medical costs and medication (developmental goal: no baseline).
lost productivity in 2010 (CDC, 2011a).
From U.S. Department of Health and Human Services. (2010). Healthy People
Mental illnesses are also major threats to the health of the gen- 2020. Washington, DC: Author. Available at http://www.healthypeople.gov.
eral population. In addition to screening for physical problems,
community/public health nurses can also screen for depression,
anxiety, and substance abuse. (See ChaptersÂ€25 and 33.) Hypertension. Screening programs aimed at the early identi-
fication of hypertension contribute greatly to the early diagno-
Cardiovascular Disease, Stroke, and Hypertension sis and treatment of this potentially fatal condition by making
The principal risk factors for heart disease and stroke include people aware of their blood pressure status and by referring
hypertension (blood pressure reading of 140/90 mm Hg or those with elevated readings for follow-up diagnosis and treat-
higher), elevated serum cholesterol level (greater than 200 mg/dl), ment. A committee representing the National Heart, Lung, and
tobacco use, overweight and obesity, family history of athero- Blood Institute (NHLBI) publishes guidelines every few years to
sclerotic disease, advancing age, and physical inactivity (CDC, guide the diagnosis and clinical treatment of hypertension. In
2011b). A surprising fact for some health care consumers is that May 2004 the Seventh Report of the Joint National Committee on
although cardiovascular disease is frequently considered a male Prevention, Detection, Evaluation and Treatment of High Blood
health problem, cardiovascular disease is the leading killer of Pressure (JNC-7) published the guidelines, which are reflected
women in the United States. It is estimated that one in two women in TableÂ€19-3. (The next report is scheduled for publication in
will die of heart disease, compared to one in 25 who will die of breast spring 2012). In addition to the guidelines, the report indicated
cancer. More than half of the total deaths each year from heart that nearly 30% of adults in the United States remain unaware
disease occur in women. Women continue to have limited knowl- of their blood pressure, and the report discussed the strain
edge about risk factors and symptoms of coronary heart disease. that undiagnosed and untreated hypertension places on the
Assessment of women's knowledge with subsequent education health care system (NHLBI, 2004). It is estimated that an aver-
and behavior modification is a viable strategy to promote healthy age reduction of 12-13 mm Hg of systolic pressure over 4 years
lifestyle and risk reduction (Thanavaro etÂ€al., 2010). can reduce the total cardiovascular disease deaths in the United
Many of the risk factors related to cardiovascular disease are States by 25% (CDC, 2011b).
modifiable, making cardiovascular disease highly amenable to Serum Cholesterol. Elevated serum cholesterol is a signifi-
prevention efforts. Selected Healthy People 2020 objectives for cant risk factor in the development of cardiovascular disease.
reducing the risk of cardiovascular disease through secondary Current guidelines for cholesterol levels are seen in TableÂ€19-3.
prevention measures are presented in the Healthy People 2020 Lifestyle changes including dietary changes and increased phys-
box. In addition to the initiatives related to Healthy People, in ical activity are emphasized by the American Heart Association.
2006 the Centers for Disease Control and Prevention (CDC) Screening for cholesterol is emphasized because persons with
created the Division for Heart Disease and Stroke Prevention elevated serum cholesterol have no symptoms. (AHA, 2011).
(DHDSP), which provides national leadership and research to In 1985 the NHLBI initiated the National Cholesterol
reduce the burden of disease, disability, and death from heart dis- Education Program to increase public awareness of the rela-
ease through strategies and policies that promote healthy lifestyle, tionship between cholesterol level and heart disease. The pro-
healthy environments, and access to detection and treatment. gram continues to update detailed guidelines for identifying
and treating individuals with elevated serum cholesterol levels. accounting for 1 in every 5 deaths (CDC, 2011f). Pulmonary
The clinical guidelines for cholesterol health known as the ATP function studies are conducted to measure damage to respira-
III Guidelines are available online (http://www.nhlbi.nih.gov). tory function that may be caused by smoking or by other lung
Initiating cholesterol screening programs in the community diseases. Screening for pulmonary dysfunction with prompt
may assist in preventing heart disease through early identifica- referral to smoking-cessation programs and medical provid-
tion of at-risk persons and counseling and referral for interveners for follow-up may halt progression of heart and lung dis-
tions aimed at modifying dietary fat consumption, instituting ease caused by the harmful effects of tobacco. Even without
exercise programs, or initiating pharmacotherapy to reduce the use of pulmonary function screening, persons who smoke
blood lipid levels. FigureÂ€19-1 shows a screening for cholesterol should be referred to smoking-cessation programs regardless of
and Â�glucose. In addition, efforts are being made to include chil- their pulmonary status. Nursing involvement in tobacco cessa-
dren and families in healthy lifestyle choices as a way to Â�promote tion intervention is essential and is supported by the American
heart health. Online education and self-risk tests for adults Nurses Association.
and Â�children are found on the American Heart Association
(http://www.heart.org/HEARTORG/Conditions/Conditions/ Cancer
_UCM_001087_SubHomePage.jsp) and the National Heart, Cancer is the second leading cause of death in the United States,
Lung, and Blood Institute websites. exceeded only by heart disease. Approximately one in four of all
Obesity. Obesity is increasing and is present in approximately deaths are from cancer (American Cancer Society [ACS], 2011).
34% of the adult population of the United States (USDHHS, Screening examinations conducted regularly by a health care
2010). Among children and adolescents, overweight rates are professional can result in the detection of many cancers, includ-
dramatic—one in every five children between the ages of 6 and ing cancer of the breast, colon, rectum, cervix, prostate, testes,
19 is overweight. Overweight and obesity contribute to the car- and skin, at earlier stages when treatment is more likely to be
diovascular burden of the nation, and contribute to the costs of successful. The relative survival rate for all cancers is approxi-
other diseases such as diabetes, hypertension, degenerative joint mately 66%. This survival rate represents the percent of cancer
disease, and certain cancers such as breast and colon cancer. In patients who are alive after a certain amount of time (usually
2008, overall medical care costs related to obesity for U.S. adults 5 years) but does not distinguish between patients who have
were estimated to be as high as $147 billion. People who were been cured and those who have relapsed or are still in treatment.
obese had medical costs that were $1429 higher than the cost The Healthy People 2020 box on this page lists selected national
for people of normal body weight. Using screening tests that health objectives for the early detection and treatment of cancer.
include percentage of body fat measurements, triceps skinfold
test, computerized analyses, and body mass index (BMI), people
who are overweight may be identified and referred for nutri- HEALTHY PEOPLE 2020
tional and fitness counseling. There are various resources for Selected National Health Objectives for Early
professionals and consumers, including the obesity education Cancer Detection
initiative AIM for a Healthy Weight (2011), which can be found
1. Increase to 93% the proportion of women age 18 or older who
by accessing the National Heart, Lung, and Blood Institute site
receive a cervical cancer screening based on the most recent guide-
(http://www.nhlbi.nih.gov/).
lines (baseline: 84% in 2008). This is a rewording of the previous
Smoking. An estimated 46 million Americans—nearly
but similar objective based on new screening recommendations.
21%—smoke, even though this single behavior is known to 2. Increase to 71% the proportion of adults who receive a colorec-
be the leading cause of preventable death in the United States, tal screening based on the most recent guidelines (baseline: 54%
in 2008). This is a rewording of the previous but similar objective
based on new screening recommendations.
3. Reduce to 160 deaths per 100,000 the overall cancer death rate
(baseline: 200.8 cancer deaths per 100,000 in 1999; 178.4 cancer
deaths per 100,000 in 2007; showing improvement).
4. Increase the proportion of men who have discussed with their
health care provider whether or not to have a prostate-specific
antigen (PSA) test to screen for prostate cancer (developmental:
no baseline).
People 2020. Washington, DC. Available at http://www.healthypeople.gov.
Lung Cancer. Lung cancer is the leading cause of cancer

deaths and the most prevalent form of cancer in both men and
women. Lung cancer accounts for about 14% of all cancer diag-
nosis. Cigarette smoking is the most important risk factor for
lung cancer, with risk increasing with the quantity and dura-
tion of smoking (ACS, 2011). Since 1987 more women have
died each year from lung cancer than from breast cancer. The
FIGUREÂ€19-1â•‡ A screening for cholesterol and glucose. (Photograph lung cancer rates for men are slowly declining and the rates
taken at St. Luke's Hospital, Chesterfield, MO.) for women began to decline in 2003 after decades of steady
increases. The gender differences reflect historical differences in Recently, there has been a considerable amount of publicÂ�
uptake and reduction of cigarette smoking between men and concern about the recommendations for mammography,
women over the past 50 years. There is no early screening test which is known to be the most effective method of early
available for lung cancer. Most often, a patient has symptoms detection. For many years, the American Cancer Society has
and the cancer has spread to other organs before diagnosis. For recommended women obtain a screening mammography
this reason, mortality is high; the 5-year survival rate for lung annually beginning at age 40. In December of 2009, the U.S.
cancer is only 15%. Preventive Services Task Force published recommendations
Breast Cancer. Except for skin cancer, breast cancer is the that women aged 40 to 50 discuss the benefits of mammog-
most commonly diagnosed type of cancer for females and the raphy with their health care provider prior to obtaining a
second most common cause of cancer death in women (second mammogram, and that woman aged 50 to 74 have a mam-
only to lung cancer). Age is the most significant risk factor for mogram every other year. They also indicated that there
developing breast cancer. Other risk factors include family his- may be no significant benefit to a screening mammogram
tory, early menarche, late menopause, late or no childbearing, for women over 75 years. This change in recommendations
lengthy exposure to postmenopausal estrogen, and use of oral was the cause of political discussion and concern about the
contraceptives. Some breast cancer risk factors can be modi- accessibility of what many women considered basic health
fied, including obesity, physical inactivity, use of hormones after care. Many health care providers and insurers adopted the
menopause, and consumption of one or more alcoholic bever- USPSTF recommendations. The only group to not alter their
ages per day (ACS, 2011). recommendation for annual mammography beginning at
Early diagnosis is essential to breast cancer survival. age 40 was the American Cancer Society. In July of 2011, the
Screening efforts aimed at the early detection of breast cancer American College of Obstetrics and Gynecology joined the
include breast self-examination (BSE), a clinical breast exam- American Cancer Society and revised their opinion state-
ination by a health professional, and mammography. In ment to recommend mammography annually for all women
FigureÂ€19-2, a community/public health nurse is demonstrat- beginning at age 40.
ing the correct procedure for BSE to a client. A breast self-exam, Cervical Cancer. While not as prevalent as breast can-
and the associated concept of breast self-awareness, should be cer, cervical cancer presents a risk for many women, and
explained to women in their 20s. Young women should be symptoms such as abnormal vaginal bleeding do not usu-
instructed about the importance of reporting any change in the ally appear until the cervical cells have become cancerous.
breast to their health care professional. Many women choose Early detection through regular screening (Pap testing) has
not to do BSE or do it irregularly; however, a clinical breast decreased the mortality rate for cervical cancer. The primary
exam (CBE) is recommended as part of a periodic health exam cause of cervical cancer is infection with certain types of the
(ACS, 2011). human papillomavirus (HPV). Women who begin having sex
at an early age or who have numerous sexual partners are at
increased risk, but a woman can be infected even if she only
has one sexual partner. The progression of the HPV infection
to cancer may be influenced by other health factors including
immunosuppression, cigarette smoking, and long term use of
oral contraceptives. There are two vaccines approved for use
in women ages 9 to 26 years for the prevention of cervical
cancer caused by HPV: Gardasil and Cervarix. The vaccines
do not protect against all types of HPV, but they do offer pro-
tection from most types of HPV viruses that cause cervical
cancer. The vaccines also protect against some types of genital
warts. The vaccine is not effective for existing cases of HPV.
In 2010 Gardasil was also approved for use in males ages 9
to 26 years to prevent anal cancer and precancerous lesions
(ACS, 2011).
Colorectal Cancer. Following lung cancer, colorectal cancer is
the third leading cause of cancer deaths in the United States for
both sexes, accounting for 9% of all cancer deaths (ACS, 2011).
The number of new cases (incidence) has decreased steadily since
1985 and mortality from colorectal cancer has also declined. The
overall national decline may be a result of greater use of screen-
ing methods and removal of polyps before they become can-
cer. Annual fecal occult blood testing (FOBT) is recommended
beginning at age 50 years. A recent change from previous phy-
sician office practice is that the test must be taken home and
the patient obtains multiple samples. The previous practice of
obtaining a sample during a digital rectal exam is no longer con-
sidered adequate for screening. Also beginning at age 50, flexible
FIGUREÂ€19-2â•‡Community/public health nurse demonstrates sigmoidoscopic examinations or colonoscopy are recommended
the correct procedure for breast self-examination to a client. (ACS, 2011).
A recent development in screening for colon cancer is the use national effort to provide depression screening tests to identify
of computed tomographic (CT) colonoscopy. Known in many patients with depression and to identify patients with suicidal
communities as virtual colonoscopy, the procedure involves thoughts and intentions (Screening for Mental Health, 2010).
some of the same elements of traditional colonoscopy, includ- Mental health volunteers such as psychiatrists, psychologists,
ing a bowel prep and insertion of air into the colon for visual- nurses, and counselors meet individually with participants to
ization. However, in the new CT colonoscopy, the client is not administer and interpret nationally accepted screening ques-
sedated for insertion of the endoscope but is alert for the CT tionnaires. Screening may also be done using electronic/online
scan. Because of lack of sedation, some clients report more dis- tools (http://www.mentalhealthscreening.org/). Use of electronic
comfort with the new procedure (resulting from air inserted screening has been piloted by a group of nurses for use in rural
into the colon for visualization), but others prefer it, and it may areas and is seen as a promising innovation to reach this vul-
be useful for clients who cannot tolerate sedation. However, an nerable population (Farrell etÂ€al., 2009). Depression is preva-
advantage of the traditional colonoscopy is being able to iden- lent among older adults but is often not recognized. Symptoms
tify and remove small growths such as polyps, which cannot be such as loneliness, sleeplessness, lethargy, and lack of interest
performed with the virtual colonoscopy. in activities are frequently attributed to aging but may be undi-
Skin Cancer. More than 1 million new cases of skin cancer agnosed as depression. Depression screening and appropriate
occur annually, making skin cancer the most common cancer in treatment can enhance the quality of life for all age groups.
the United States. Almost 90% of these skin cancers are caused The National Institute for Mental Health (NIMH) is another
by exposure to sunlight or a tanning bed. Use of a tanning resource for patients experiencing other mental health prob-
bed can increase the risk of skin cancer by 75%. Early detec- lems, including anxiety, posttraumatic stress disorders, and
tion of skin cancer is critical. Adults should be taught how to substance abuse problems. To obtain information on National
do monthly skin self-examinations and how to examine their Depression Screening Day and other mental health screen-
children and significant others. Throughout the year, organiza- ing, refer to the Community Resources for Practice box at the
tions are asked to participate in a national skin cancer-screening end of this chapter. Substance abuse screening is discussed in
program sponsored by the American Academy of Dermatology ChapterÂ€25.
(AAD). Dermatologists volunteer their time to perform the
screenings. The AAD regularly updates the website with loca- Newborn Screening for Genetic and Metabolic Disorders
tions of local skin cancer screening. Education on prevention All newborns born in the United States are screened within a few
including use of sunscreen and protective clothing and limited days of birth for a variety of conditions that cannot be detected
exposure to ultraviolet rays is an important component of the clinically. Improvements in newborn screening techniques are
screening program (AAD, 2011). among the top ten public health improvements since 2001 (Ten
Cancer Disparities and Ethnicity in the United States. Cancer great public health achievements–United States, 2001-2010,
does not affect everyone equally. The incidence and death rates 2011). All states now screen for at least 26 disorders, which has
from cancer are disproportionately higher in African Americans led to earlier treatment for more than 3400 newborns per year
than in any other racial or ethnic group in the United States. Other with genetic or endocrine disorders.
groups including Asian Americans, Hispanic/Latinos, Native Many of these disorders can now be detected from a blood
Americans, and underserved whites are more likely than the gen- sample. The National Newborn Screening and Genetics Resource
eral population to be diagnosed with and die from cancer. Cancer Center (2011) at the University of Texas, San Antonio, maintains
is the leading cause of death among Asian Americans, whereas the National Newborn Screening Information System (NNSIS),
heart disease is first among all other racial and ethnic groups which has existed since 2001 in collaboration with the Genetic
(CDC, 2011d). African Americans have a higher death rate than Services Branch of the Maternal and Child Health Bureau,
whites for each of the major cancer sites (colorectal, male lung, Health Resources Services Administration. The website (http://
female breast, and prostate) as well as a higher incidence rate for nnsis.uthscsa.edu/) allows a user to select a U.S. state to find man-
all of these cancers except female breast (ACS, 2011). dated disorders tested for, test methods, the numbers of speci-
The causes of these inequalities are thought to be related to men tested annually, whether a follow-up program exists, and
disparities in income, education, housing, and overall standard laboratory fees. Heritable disorders tested via laboratory tests
of living, and to barriers to high-quality cancer prevention, early include metabolic disorders (organic acid, amino acid, and fatty
detection, and treatment (ACS, 2011). In response to the increased acid), hemoglobin disorders, and others. Cases and incidence
incidence of cancer in minority groups, since 1987 the third of specific disorders are reported by year and state. The Center
week of April has been designated “National Minority Cancer also maintains a list of all conditions screened for in U.S. states
Awareness Week” by the National Cancer Institute. The purpose (http://genes-r-us.uthscsa.edu/nbsdisorders.htm) and Canadian
of this event is to provide focus on cancer issues for persons from newborn screening programs.
minority groups, with an emphasis on early detection and early The Centers for Disease Control and Prevention maintains
treatment to improve overall survival rates. Healthy People 2020 a website on Pediatric Genetics (2011e). This site—in both
has included a new foundation health measure with the focus on English and Spanish—includes reasons for genetic testing
health disparities including those based on race/ethnicity. and resources listing board-certified genetic specialists. Public
health nurses often are involved in providing follow-up to
Mental Health Screening families of newborns who screen positive. One Healthy People
In addition to screening for physical problems, providing 2020 (USDHHS, 2010) objective is to reduce the proportion
screening for mental health issues is an important role for of children diagnosed with a disorder through newborn blood
the community/public health nurse. National Depression spot screening who experience developmental delay requiring
Screening Day (NDSD), usually held in the fall, is a cooperative special education services.
National Objectives and Recommendations health problems that allow for age and sociodemographic
TableÂ€19-3 presents national guidelines with parameters and appropriate health counseling and preventive care.
times for screening common health problems in the general
adult population. Screening recommendations as set forth Settings for Screening
by the U.S. Preventive Services Task Force and the American The places where screening programs are conducted vary.
Academy of Pediatrics, which are presented in TableÂ€19-4, Individual case finding may occur in the home, clinic, or office.
represent screening tests based on population-based priority To access groups and populations, screening programs are
TABLEÂ€19-4â•…â•‡SCREENING TESTS FOR SELECTED POPULATIONS*

GENERAL ADULT POPULATIONS
Priority Health Issue Screening/Preventive Intervention
Cardiovascular disease Blood pressure, lipid screening, tobacco use screening, height/weight/obesity, physical activity
Cancer Colorectal screening, breast cancer (CBE or mammography), prostate counseling, cervical (Pap)
screening, testicular exam, skin/melanoma exam, tobacco counseling
Diabetes Blood glucose testing, height/weight/obesity, physical activity
Mental health Depression, suicide risk
Lifestyle Obesity, physical activity, sexually transmitted diseases (STDs)
Substance abuse Alcohol, tobacco, drugs, HIV screening
Injuries Fall risk (65 +), domestic violence (physical and emotional abuse)
Aging-related issues Vision, hearing, podiatry
ADOLESCENTS AND YOUNG ADULTS: AGES 11 TO 21 YEARS

Growth and Development - Physical Blood pressure, height/weight/BMI, Pap, breast self-exam, testicular self-exam, dental
Growth and Development - Behavioral Alcohol and drug use, depression, schizophrenia, eating disorders
Sensory Vision ages 12, 15, 18; hearing
Immunizations Age-appropriate immunizations
Screenings STDs, lipids, PPD, hemoglobin/hematocrit
MIDDLE CHILDHOOD: AGES 5 TO 10 YEARS

Growth and Development - Physical Blood pressure, scoliosis, height/weight/BMI, dental
Growth and Development - Behavioral Behavioral screening, anticipatory guidance
Sensory Vision, hearing
Screenings Lipids, PPD, hemoglobin/hematocrit, lead
EARLY CHILDHOOD: AGES 12 MONTHS TO 4 YEARS

Growth and Development - Physical Height/weight/length, BMI, head circumference (up to 2 years), weight for length, blood pressure,
dental referral at 3 years
Growth and Development - Behavioral Denver Development Screening Tool (DDST), autism screening usually at 18 and 24 months,
psychosocial assessment, anticipatory guidance
Sensory Vision, hearing, speech development
Screenings Lead, hematocrit/hemoglobin initially at 1 year, lipids, PPD at 1 year or earlier if at risk
INFANT/NEONATE: BIRTH TO
â•› 12 MONTHS
Growth and Development - Physical Height/weight/length, head circumference, weight for length, blood pressure
Growth and Development - Behavioral Denver Development Screening Tool (DDST) at 9 months, psychosocial assessment, anticipatory guidance
Sensory Vision, hearing
Screenings Newborn metabolic panel including phenylketonuria (PKU) and other screenings required by state law,
lead, hematocrit/hemoglobin, PPD
*In all population groups, periodic age-appropriate physical examinations are indicated.
Data from Bright Futures/American Academy of Pediatrics. (2011). Recommendations for preventive pediatric health care. Retrieved from http://
brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf; and U.S. Preventive Services Task Force. (2011).
Guide to clinical preventive services, 2011. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/clinic/
pocketgd.htm.
frequently held in public places, such as in schools, religious BOXÂ€19-1â•…â•‡ASSESSING RESOURCES

facilities, businesses, shopping malls, community centers and TO SUPPORT SCREENING
apartment complexes. Such accessibility helps provide essential PROGRAMS
screening services to people where they live and work. Key to
the selection of the setting should be considerations of space Consider the following questions when assessing resources to sup-
needed, confidentiality, equipment, and privacy. A health fair is port a screening program:
a type of screening program that usually includes a large num- 1. Is funding available to support a health fair or a wellness program
ber of exhibits, resources, and services, including screening tests in the local community?
that are specific to the targeted population, general health infor- 2. What is the cost of implementing such a program?
mation, and counseling and referral services. 3. What are the personnel and equipment needs to run screening
For example, a community health nurse could plan a health booths or health education exhibits?
fair at a local senior center. With general knowledge of the 4. Is volunteer support available in the health care community to pro-
population, the nurse plans for culturally and age-appropriate vide needed services or to loan screening equipment?
screenings such as blood pressure, vision, hearing, tobacco use, 5. Are diagnostic and treatment services available to refer clients in
whom presumed illness is detected?
and depression. The setting for the screening, the senior citizen
6. What facilities are available for follow-up of persons who receive
center, would provide a familiar and accessible setting for the
abnormal screening results?
participants. Additionally, based on population outcomes, the 7. Are key community leaders supportive of the program?
nurse could target future health-promotion and other healthy
lifestyle events to meet the needs of the senior citizen group.
lists specific questions to ask in order to assess community
COMMUNITY/PUBLIC HEALTH NURSE'S ROLE resources to support screening programs.)
IN SCREENING Finally, assessing the appropriate time and site for conduct-
ing a screening program is important. When and where will the
Using the nursing process, the community health nurse is able to community/public health nurse have the most access to the tar-
plan and implement screening programs that benefit the com- get population? For example, a school would be a good place to
munity. A process similar to the nursing process for commu- screen for scoliosis (see Website Resource 19A) , or a senior
nity planning and health promotion is outlined online via the housing site would be a good place to screen for hypertension.
Guide to Community Preventive Services (Community Guide, When screening large populations, estimating the number of
2011). The Community Guide was developed by a task force people who will likely participate and having the necessary
with members appointed by the Centers for Disease Control space and personnel to accommodate the anticipated partici-
and Prevention who analyze scientific literature and the effec- pants is important. If possible, requesting preregistration for
tiveness and feasibility of interventions to improve commu- specific screening tests allows more accurate arrangements for
nity health and prevent disease. Physical Activity Promotion personnel, equipment, and space. In addition, clients are better
in a University Community is an example of a small but suc- prepared to participate (e.g., they would fast if registering for
cessful intervention that followed the steps presented in The blood work), and the participant waiting time can be reduced.
Community Guide (Heath etÂ€al., 2010).
Another example of a community planning process that Planning
closely resembles the nursing process can be found in Healthy After assessing the community's health needs and resources,
People 2020. This process is called MAP-IT. The process begins the nurse is ready to plan a screening program. Program pri-
with Mobilizing the community and developing coalitions, orities and goals need to be established at the outset. To iden-
Assessment, Planning, Intervention, and Tracking. The paral- tify problems accurately and set goals that are meaningful to the
lels to the nursing process using this method are evident. community, people who are most likely to be influenced by the
program should have a voice in program development. Key per-
Assessment sons, who will help secure needed resources or implement the
Initially, the community/public health nurse must determine program, need to have input in the planning process, includ-
the need for a screening program by identifying the at-risk pop- ing health care personnel, volunteers, and community leaders.
ulation. Determining risk status of an individual or commu- Persons who can help identify and overcome cultural and other
nity is based on an analysis of sociodemographic characteristics barriers to accessing the program are also valuable assets.
such as age, sex, ethnicity, cultural practices, and environmental The community/public health nurse must also design easy-
hazards. When the community/public health nurse determines to-use forms for documenting screening data. An appropri-
the risk status of the community, she or he is performing a com- ate form to obtain consent for screening is essential. A written
munity assessment to determine the needs and risks of the tar- form that documents screening test results, normal parameters,
geted population (see ChapterÂ€15). and counseling and referral information should be developed
In addition to considering risks, the community health nurse and given to the participant for use in the screening program.
should determine the resources available in the community. For FigureÂ€19-3 shows a sample form. Additional information such
example, what screening programs are already in place in local as health history data and participant health goals should be
hospitals, senior centers, work sites, schools, or faith communi- included. The form provides the written documentation of test
ties? The community/public health nurse should avoid replicat- results and health instructions, and is important for participant
ing existing screening programs in the community. If screening follow-up and for program evaluation.
programs in the community are insufficient, the nurse then Additionally, the family health history tools previously men-
investigates resources for establishing new programs. (BoxÂ€19-1 tioned in the discussion of screening of individuals could also
Sample Screening Form
Biographical Information
Date:
Participant name:
Address:
Telephone (home, cell, work):
e-mail address:
Health History
Have you or anyone in your family ever had (circle answer)
Heart Disease SELF: yes no FAMILY: yes no
High Blood Pressure SELF: yes no FAMILY: yes no
High Cholesterol SELF: yes no FAMILY: yes no
Chest Pain SELF: yes no
Cancer SELF: yes no FAMILY: yes no
Lung Disease SELF: yes no FAMILY: yes no
Shortness of Breath SELF: yes no
Diabetes (sugar) SELF: yes no FAMILY: yes no
Do you smoke? YES NO If yes, packs per day:
Do you drink alcohol? YES NO If yes, How much? How often?
Screening Normal Range Participant Result

Blood Pressure 120/80 or less Example: 142/88
Weight or BMI provide a height/BMI chart Example: BMI 28
Total Cholesterol less than 200 mg/dl Example: 230 mg/dl
Participant Health Goals:
Recommendations and/or referrals: The example participant above needs referral to a primary
care provider for evaluation of potential cardiovascular disease based on BP results, elevated
total cholesterol, and BMI.
Signature of health screener:

FIGUREÂ€19-3â•‡ Sample screening form.
be used during the health fair to collect health history data. If

An occupational health nurse wants to develop a screening
available at the health fair, the nurse could access the Internet,
program for a large manufacturer. The nurse establishes a
collaborate with the patient to complete the form, then print it
planning task force that consists of representation from
for use during the health fair event, giving a copy to the patient
administration, employees at all levels of the industry, and
for future reference. If the patient has e-mail at home, the nurse
health care providers in the employee health suite.
could also send the patient a link to the health history resource
Assess. The task force assesses the perceived health care
or provide the Web address for the patient to access the site
needs of the target population, the extent of interest in con-
independently.
ducting workplace screening, and the resources available to
National screening programs may have forms that are ready
conduct the program. During the planning meetings, health
to use and based on national criteria, such as skin cancer screen-
care personnel note a high incidence of hypertension among
ing, anxiety screening, or depression screening. In addition to
employees, but the employees express concern that they do
necessary forms, procedure manuals are available for download
not have the time to attend a screening program. The commit-
or may be sent to the community nurse who is organizing a
tee considers alternatives to holding a 1-day health fair dur-
screening. These manuals include planning guidelines, sample
ing a Â�designated time period. Management officials note that
materials, publicity materials, and follow-up information.
Â�
limited space and funding are available to conduct the pro- BOXÂ€19-2â•…â•‡PUBLIC SERVICE
gram but the administration is willing to schedule all employ- ANNOUNCEMENT
ees on a rotating basis through the employee health suite for Public service announcements are messages on behalf of nonprofit
hypertension screening. Open hours are held in conjunction groups presented like advertisements.
with the rotating schedule provided by the managers to maxi-
mize convenience and accessibility of the screening program Advantages
to all interested employees. Volunteer support is solicited from Aired free by radio or television
outside agencies to assist in implementing the program. Reach mass audience
Plan. The next step is to establish program goals and objec- Identify sponsoring group(s)
tives. In this example, the task force establishes the following On television, visual aids can be used
goal: to improve the health status of employees through early
detection and treatment of hypertension. The following spe- Disadvantages
cific objectives are included: (1) One month following the Station determines if and when message is aired
screening program, all participants who received abnormal Must be presented to station several weeks before airing
Each station may have specific requirements:
test results will have received follow-up diagnostic testing
Must be brief: 30-second spot = 75 words
and treatment, if indicated. (2) In 6 months, the incidence
and prevalence of hypertension will have increased by 5% Content
in the target population. Note here that if a screening pro- Discuss how listeners will benefit
gram is effective, the incidence and prevalence of the disease Give next step
being screened for will increase because screening results in Name sponsoring groups
the early detection of previously unrecognized illness. (3) In Tell listeners to call for more information
1 year, the number of days of absenteeism, number of dis-
ability days, and rate of hospitalization for illnesses resulting Example of 45-Second Announcement
from complications of hypertension will decrease by 20%. Would you like to know what your blood pressure is? Has it been a
while since you had your vision checked? If so, come to the health fair
on Saturday, April 18, Valley View Mall from 1:00 to 8:30 pm. The health
Implementation department and the Junior Chamber of Commerce are sponsoring this
After assessing the secondary prevention needs of a target popu- health fair for you, your friends, and your family. Representatives from
lation and planning a screening program to address these needs, many health groups will be on hand to conduct screening tests and
the community health nurse is ready to implement a program teach you how to improve your health!
plan. Some of the steps to implement a community screening For more information call (123) 123-4567.
are outlined in italic.
• Advertise the program: To implement a successful mass
screening program, using media resources to disseminate implementation. For example, members of organizations
information to the community is often helpful. Flyers, mass whose goal is to do community service can be trained in
mailings, notices on community websites, and local adver- clinical services and assist in ongoing programs. Other good
tisements in newspapers or on radio and public television resources are retired nurses who wish to remain active in the
help inform the target population of the program's exis- community and nursing students from local schools. A train-
tence. Information provided to the media should include the ing session may need to be conducted with persons who will
location, dates, and times of the program; services offered be administering selected screening tests to ensure accuracy
through the program; fees, if any, that may be required from in test measurement and to improve reliability of test find-
the participant for obtaining selected screening tests or ser- ings. Training may occur at a time separate from the actual
vices; and any additional preparatory instructions that the program date, or persons may be asked to arrive early on the
client may need. For example, if blood tests are offered in the date of the program to review procedures.
screening program, participants may need to be informed • Set up the site: The site where the program is to be held
that they should fast at least 8 to 12 hours before receiving will often need to be set up to accommodate the antici-
the blood test. BoxÂ€19-2 gives an example of a public service pated number of participants and to provide tables, chairs,
announcement. or other equipment for service providers. A good practice
• Another method to advertise a program or to encourage for morning screening events is to set up the evening before.
attendance is to invite participants electronically. A message Consideration must also be given to persons with disabili-
about the health fair or screening event can be sent via text, ties to ensure access to all stations. Booths may be set up so
e-mail, or via other social media to groups of patients. The that persons can move in a logical manner from station to
Centers for Disease Control and Prevention (CDC, 2011c) station as they make their way toward the exit. When the
has free health related e-cards on their website that can be program begins, the community nurse coordinator should
used as reminders of health behaviors or invitations to health be available to circulate among stations and to address any
screening events. The cards may be customized with personal last-minute problems, such as screeners or providers who do
greetings to remind high-risk individuals of health events, or not attend as planned. In this instance, the nurse may need
may provide specific health information. to reorganize service providers and volunteers to fill in gaps
• Identify and train screeners: Partnerships may be formed with and to run selected stations during peak service times.
volunteer and community organizations, health care pro- • Consider space needs: The facility in which the program is
viders, and other interested persons to assist with Â�program conducted should be capable of accommodating a large
number of people in terms of both space and restroom facili- advanced disease complications, and decreased health care costs
ties. An exception to this rule is the use of mobile vans, which for treatment of advanced disease.
bring screening services directly to neighborhoods, schools, Process evaluation focuses on actual program performance,
or work sites. Although schools, places for worship, work- regardless of whether the goals that have been set for the pro-
places, malls, and community centers are usually equipped gram are achieved. Process evaluation may include the num-
to deal with large aggregates, the program may draw more ber of people served by the program, number of volunteer
people than some facilities can accommodate. hours needed to conduct the program, reliability and validity
• Be ready for case finding: Another potential problem is the dis- of screening tests, efficiency in test administration and report-
covery of a severely abnormal test result. It is important to ing of results to participants, and choice of appropriate loca-
have protocols for emergency intervention—such as finding tion and timing of program in terms of community interest and
a blood pressure of 240/130 mm Hg in a participant—so it convenience to community members. The community/public
is clear to all providers when immediate referral is indicated. health nurse may also consider a follow-up survey of partici-
Referral guidelines may be based on national criteria, such as pants, feedback from service providers who worked the screen-
those listed in TableÂ€19-3. Participants should not leave the ing program, and feedback from community agencies to which
screening until they have secured the telephone number of a referrals from the screening program were made.
health provider to handle their identified problems.
• Feed the workers and the participants: Nutrition is an impor- SCREENING AND THE REFERRAL PROCESS
tant consideration when conducting a mass screening pro-
gram. If the program is scheduled for the entire day, persons Referral, an essential component of any screening program,
working in the program will need meals and rest breaks. is the process of directing persons to resources to meet needs.
Local businesses or restaurants may provide free lunches as Clients who participate in a screening program must obtain
a community service or in exchange for advertising. If blood appropriate counseling and referral for follow-up of any abnor-
tests are part of the screening program, participants may be mal test results. It is considered unethical to obtain data indicating
required to fast the night before; and afterward, orange juice, an individual might be ill and then do nothing about it. A separate
graham crackers, or healthy snacks should be provided. counseling and referral station is often provided in a health fair
• Plan to follow up: The nurse will want to know the number setting, and participants are required to move through this sta-
of participants attending the program and will also need a tion before leaving the health fair. At the referral station, trained
way to follow up with those participants who have abnormal volunteers review the findings from the health fair with the par-
screening results. A suggestion is for the participants to sign ticipant, reinforcing health-maintenance activities and ensur-
a consent form for screening as they enter and register for the ing the participant understands his or her test results, including
screening event. The forms can be pre-numbered for ease in the need for follow-up evaluation, if indicated. An alterna-
counting. This action serves the purpose of a tally of partici- tive method for referral and counseling is to have these activi-
pants and also is a legally responsible practice. In a case in ties completed at each health fair station. For example, a nurse
which screening test results are not known at the completion screening for hypertension can use national guidelines to coun-
of the program (e.g., laboratory blood tests that may take sel and refer clients to a medical care provider and can provide
several days or weeks to process), a mechanism for follow- health education materials.
up is needed to ensure that participants receive the screening Participants must be advised that a screening program is not
results. One idea may be to ask the participant to self-address a substitute for receiving ongoing health supervision from a
an envelope at the registration table. Laboratory results with health care provider. In many screening programs, participants
a letter of explanation are sent to the participant as soon as are given written information that highlights this fact. Believing
possible. that they have been checked over and found healthy is not
uncommon for persons who participate in screening programs.
Evaluation
Evaluation, an essential component of screening programs, is Establishing Criteria for Referral
conducted to justify continued program operation and funding The nurse uses outcome-based clinical evidence to establish
from outside parties, to improve service delivery, or to deter- guidelines for initiating referrals. Referrals are initiated when
mine the impact of the program on community health. Program screening test results fall outside of normal parameters and
evaluation enables the community/public health nurse to deter- require follow-up. For example, any participant with a blood
mine whether the benefits of the program outweigh the cost of pressure reading of 140/90 mm Hg or higher, or serum choles-
time, money, and resources devoted to the program and will terol level of 200 mg/dl or higher, should be referred for follow-
help the nurse plan or change (or both) the screening for the up. A good practice for clients with results that are significantly
next implementation date. Evaluation includes both process and outside acceptable parameters is for the nurse to place a follow-
outcome dimensions (see ChapterÂ€17). up telephone call to the clients in addition to the initial referral.
Outcome evaluation refers to the actual end results of the Mechanisms for this quality level of follow-up should be part of
program. Were program objectives achieved? Common out- the planning process.
come criteria for screening programs reflect epidemiological
trends such as an increased incidence and prevalence of disease Establishing a Resource Directory
(note that a secondary prevention measure, when effective, actu- Participants who have identified needs that require further
ally increases the number of reported cases of disease), increased intervention are referred to their own health care provider or
numbers of persons receiving medical care, decreased mortal- organizations and programs in the community. When possible,
ity from disease, reduced disability and decreased Â�incidence of participants should be given a choice of providers if more than
one exists. The community nurse planning a screening program clients. For example, local health departments will often serve
should maintain a list of community health organizations and only the residents of a particular locale or region. Local depart-
programs for referral. Information on community resources ments of aging provide services to older adult residents. Some
may be obtained through local and state health departments, government programs, such as medical assistance, are provided
local and state medical societies, national organizations, local only to clients who meet specific eligibility criteria, such as
information and referral centers, police and fire departments, income level, verification of need, age, or other health criteria.
libraries, local government offices, or the local chamber of com- The nurse should also be aware of agencies that are willing to
merce. A community/public health nurse may want to keep her serve undocumented immigrants.
or his own personal directory; this can be as simple as a pocket-
sized notebook or as sophisticated as a palm-sized personal Investigating Payment Mechanisms
electronic organizer or smart phone. The community health nurse should also be aware of payment
The nurse's directory should be kept up to date and include mechanisms that referral agencies require. For example, does
(1) the name, address, and telephone number of the agency; (2) the agency accept Medicare or medical assistance? Do fees need
hours of operation; (3) major services provided; (4) eligibility to be paid immediately on delivery of the service? Knowledge of
requirements for utilization of services; (5) procedure for activat- the policies and procedures of the agency can assist the nurse in
ing services; (6) source of funding for the program and payment making appropriate referrals based on the client's unique needs.
mechanisms; (7) the name of the director and names of other The client is also better informed of the agency's practices and
important contact persons; and (8) a statement reflecting the is more likely to have realistic expectations of what services the
general impressions received when interacting with the agency. agency is capable of providing. If the client is not eligible for
When possible, health information from local resources services because of an inability to pay, the nurse may need to
should be available at the health screening event. TableÂ€19-5 seek out other resources in the community to assist with pay-
presents a possible way to organize and present community ment. Civic groups such as the Lions Club, Rotary, or Knights
resource information to participants of a health screening. of Columbus may provide donations or financial support to a
client in need.
Investigating Procedure for Initiating Referral
Whether in the context of case finding or a mass screening Assessing Client Receptivity
Â�program, the community health nurse should be aware of the The community/public health nurse also needs to assess the cli-
procedure for initiating referrals to an organization. For exam- ent's receptivity to the referral. Is the referral acceptable to the
ple, can the client or the health care provider make a referral client and likely to be followed up? Has the client had a previous
over the telephone? Does the referral need to be in writing? negative experience with the agency to which she or he is being
Must specific forms be completed? If the participant speaks referred? What has the client been told about her or his role in
English as a second language, can this be accommodated? the referral? Does the client have particular beliefs, values, or
cultural biases that prevent him or her from using the services?
Determining Criteria for Service Eligibility Additional barriers to acceptance of a referral may include
The criteria for service eligibility should be assessed before initi- differences in perception of needs between client and health
ating a referral; some agencies have specific criteria for accepting care provider, lack of transportation to access the program or
TABLEÂ€19-5â•…â•‡PRESENTING COMMUNITY RESOURCE INFORMATION TO PARTICIPANTS

OF A HEALTH SCREENING
COMMUNITY HEART FAMILY MISSION HEALTH CARE FOR THE
HEALTH AGENCY CARE AGENCY HOMELESS AGENCY
Location 1 West Street Mobile van parked at various Lost Souls Outreach Center
locations; schedule available
Phone (800) 222-1234 Call announced location for details (330) 678-0000
Hours M-F, 8 am to 2 pm M, W, F, 3 pm to 8 pm Fri, Sat, Sun, 10 am to 4 pm
Services provided Wellness, prevention, diet Prevention, counseling, family Urgent care
counseling, exercise groups planning,Â€stop-smoking group
classes
How to initiate referral Self-referral accepted Must be referred by community No referral needed
health nurse or faith community
leader
Service eligibility WIC recipients, family income Residents of Cook or Baker Counties Homeless
at or below poverty level unable to purchase health insurance;
services designed for working poor
Payment mechanisms $5 per individual visit, $2 per Donations accepted Medical assistance, Medicare
exercise class or counseling
group
Name of contact person Ms. Carly Vessel Mr. Kindly Ms. Outreach Worker
TABLEÂ€19-6â•…â•‡EVALUATING THE EFFECTIVENESS OF A REFERRAL

Name of Agency:
QUESTIONS YES NO COMMENTS
To Ask the Patient:
Were you able to access care? If not, what barriers did you experience?
Did you have problems with payment?
Did the services provided meet your expectations?
Were you treated with dignity and respect?
Did you need additional services not offered by this agency?
Would you return to this agency for additional services?
To Ask the Agency:

Did the patient bring enough background information from the health fair to
assist with establishing service?
Was the referral appropriate? If not, why not?
Were additional needs identified that this agency was not able to meet?
What were they?
Do you have any recommendations for future processing of referrals?
service, competing demands and responsibilities (e.g., child- awareness of cardiovascular disease and risk-reduction
care, working hours) that make it difficult for the client to estab- strategies (Jensen etÂ€al., 2009). In addition, to assist the
lish contact and keep appointments, or inadequate finances to community health nurse in establishing and maintaining
pay for services. the previously mentioned resource directory, a follow-up
call to the agency is also useful. The nurse calls to discuss
Evaluating Effectiveness of Referral the appropriateness of the referral and suggestions for the
People who are referred for additional services should be future. Of special concern during this call is client privacy.
contacted after the screening program to see whether they The nurse must be careful to discuss the referral process
followed through with the referral. The impact of this type without compromising confidentiality. Information gath-
of nurse telephone intervention after a health fair was ered about the referral process will enhance future referral
examined and found to have a positive effect on participant practices (TableÂ€19-6).
KEY IDEAS
1. Screening is an important secondary prevention strategy. The major health risks in the target population and the available
purpose of screening is to detect diseases in an early stage of constraints to and resources for implementing a screening
development when they are more amenable to treatment. program. Goals and objectives that specify desired outcome
2. The settings for administering screening interventions criteria for the screening program are developed.
are diverse and variable and depend on the client focus. 7. The community/public health nurse implements the screen-
Screening programs may be geared toward individuals or ing program in partnership with community members, vol-
populations. unteers, and health care providers.
3. Case finding is the application of screening tests to individ- 8. Evaluation of the effectiveness of a screening program is
uals on a one-on-one basis. based on analysis of epidemiological data and feedback
4. Mass screening is the application of screening tests to large from participants and collaborating agencies.
groups or populations. 9. Every screening program must include counseling and
5. Consider the following questions when selecting screening referral services. The community/public health nurse
tests: How significant is the disease being screened for? coordinating a screening program must provide for par-
• What is the cost versus benefit of screening? ticipant follow-up to ensure that referrals were followed
• How acceptable is the test to participants? up and that the client received the appropriate therapeutic
• What is the test's reliability and validity? intervention.
• Is the test easy to administer? 10. In making referrals, the community/public health nurse
• Does the test detect disease at an early stage? must investigate the procedure for initiating referrals,
• Is treatment available for the disease being screened for? determine criteria for service eligibility, assess client recep-
6. To determine what diseases should be screened for in a com- tivity, investigate payment mechanisms, and evaluate the
munity, the community/public health nurse assesses the effectiveness of the referral.

Organizing a Health Fair and Case Finding
Organizing a Health Fair free screenings and a yearly “wellness” visit that became available in
A community/public health nurse is assigned to a geographical dis- 2012 from their provider who accepts Medicare assignment (USDHHS,
trict in which a large older adult population resides. Her experience 2011). Criteria are established for the students to make urgent referrals
with home visits to clients reveals that many of the older adults in to health care providers.
the community regularly attend the local senior center and are very
interested in maintaining personal health and fitness. However, Implementation
because they live on a fixed income, these older residents are hav- The community/public health nurse asks that health fair workers arrive
ing difficulty meeting their basic living expenses. Because of finan- early on the day of the fair for a general orientation. At this time, the
cial constraints, many clients hesitate to see their personal health discovery is made that the representative from the local chapter of the
care providers unless they become ill; they also cite difficulty with department of aging is ill and will be unable to attend. The community/
transportation as a major deterrent to seeking routine preventive public health nurse modifies her original plan; she provides persons
health care. at the counseling and referral station with the address and telephone
Based on an analysis of sociodemographic risk factors, the commu- number for general information on the department of aging for distribu-
nity/public health nurse determines that this population is at risk of tion to interested residents. She also calls the department of aging and
illness from chronic diseases, such as hypertension, heart disease, investigates the possibility of obtaining some literature to be delivered
stroke, and cancer. Because many of these diseases can be prevented via courier before the health fair begins.
or treated effectively if diagnosed early, the community health nurse
decides to conduct a health fair. She selects the local senior center as Evaluation
the desirable location for the fair because it is highly accessible and During the health fair, the community/public health nurse circulates
well used by the target population. between stations to assess progress and address any problems that
may develop. At the completion of the health fair, participants are
Planning asked to complete an evaluation form, indicating their satisfaction with
In planning the fair, the nurse obtains the help of key community lead- the health fair.
ers, the director of the senior center, and senior residents in the com- After the health fair, the community health nurse compiles a list of par-
munity who will likely benefit from the program. These individuals ticipants with abnormal test results and conducts follow-up telephone
meet as a planning committee and identify program goals, resources, calls 2 to 3 weeks later to determine whether individuals have followed
and constraints. The general goal for the screening program is to pro- through with counseling and referral recommendations. For individuals
mote and maintain the health of older adults in the community through who have not, she makes an effort to identify barriers to care and then
early detection and treatment of disease. attempts to empower the client to overcome these barriers.
The director of the senior center indicates that members of the Six months after the health fair, the community/public health nurse
center would be willing to volunteer to assist with implementing the surveys all participants to gather data on the impact of the screening
program. The community/public health nurse investigates support program on health status. She notes that participants report greater
from others in the community and requests the help of local nurs- awareness of the need for early detection. Several participants indi-
ing students. The community/public health nurse selects appropriate cate that because of the screenings, previously unrecognized dis-
screening tests to administer based on cost factors, client accep- eases such as hypertension, diabetes, and glaucoma were detected
tance, availability, and reliability. She decides to conduct screen- and treated early. These participants report no complications from
ings for hypertension, diabetes, glaucoma, vision, hearing, podiatry, advanced disease and believe that early detection greatly improved
height and weight, and cholesterol level. In addition, volunteers from their current health status. In addition, the community/public health
the local chapters of the American Cancer Society and the American nurse surveys the nurse practitioner in the senior center's medical
Heart Association are asked to participate and run booths with infor- clinic to obtain feedback on perceived helpfulness of the mass screen-
mation on heart disease, hypertension, brain attack, nutrition and ing program. As expected, the nurse practitioner reports an increased
cholesterol, breast self-examination, mammography, and prostate incidence of hypertension and diabetes because of early detection.
and colon cancers. Based on the positive evaluation findings, the community/public
Other local community and health organizations such as the depart- health nurse recommends that the local department of aging sponsor
ment of aging are invited to participate and to distribute information health fairs for the older adult population at convenient and accessible
about their programs, services and resources. Equipment for vision locations on an annual basis.
examinations is provided by the Society for the Prevention of Blindness.
A local audiologist agrees to conduct hearing screenings. A local medi- Case Finding
cal laboratory agrees to administer blood tests for cholesterol level and A nurse practitioner works in an employee health clinic at a steel
diabetes. The American Diabetes Association is also asked to partici- plant. A 52-year-old African American male client comes in for an
pate and provide health education literature. employee health physical. The client states that he is in good health
The community health nurse establishes a list of community resources and denies symptoms of illness, but his family has a history of stroke,
and guidelines for counseling and referring participants in the screen- heart disease, and diabetes. He acknowledges smoking three packs
ing program who have abnormal screening test results. Guidelines for of cigarettes a day for 20 years. Based on an analysis of individual
referral are based on nationally established criteria for normal test risk factors, the nurse practitioner performs a comprehensive physi-
results. Nursing students at the local university are asked to conduct cal examination, with special emphasis on blood pressure status and
blood pressure screening and to run the counseling and referral sta- cardiac, respiratory, and peripheral vascular assessments. In addition,
tion. Part of the information will be a Medicare update describing more she monitors blood glucose and serum lipid levels and performs an
Continued

Organizing a Health Fair and Case Finding
Â�electrocardiogram. Based on these screening tests, the nurse practitio- exercise program. In addition, he reports being referred to a smoking-
ner finds that the client is overweight and has elevated blood pressure, cessation program.
cholesterol and glucose levels. The electrocardiogram is within normal Three months later, the nurse practitioner sees the client for a follow-up
limits. The client is counseled regarding his risk factors and is referred employee health check. The client reports adhering to his prescribed regi-
to his medical provider for follow-up diagnosis and treatment. men and feeling more energetic and less fatigued. With the client's per-
The nurse practitioner contacts the client 1 week later to assess mission, the nurse practitioner contacts the client's provider, who reports
whether the client has followed through in seeking medical evaluation. that the client's blood glucose, cholesterol levels, and blood pressure are
The client reports that he returned to his medical provider and was within normal limits and that the client has lost 10 pounds. He continues to
placed on blood pressure medications, a low-fat diabetic diet, and an smoke but has reduced his consumption to one pack of cigarettes per day.
1. Select a family member, client, or group in your commu- variables and personal and family health history in your risk
nity (e.g., members of a faith community, members of an assessment. What screening recommendations are applicable
organization to which you belong). Assess the risk factors to you? To what extent are you compliant with these screen-
in the chosen individual or group. Identify screening tests ing recommendations? What factors have an impact on your
that would be appropriate to administer to this individual or decision to seek screening services?
group based on the criteria for selecting screening tests out- 5. Reflect on a time when you were referred for assistance in
lined in the chapter. meeting an unmet need. What was the nature of the referral?
2. Interview a friend or family member on her or his perception What was it like for you to be referred? To what extent did
of the meaning and value of screening and early diagnosis you follow through on the referral? What affected your deci-
of disease in personal health. To what extent does this indi- sion making and behavior related to your acceptance of the
vidual engage in secondary prevention? When was the last referral? What was the outcome of the referral?
time she or he had a physical examination or other recom- 6. A community/public health nurse working in a hyperten-
mended screening tests, considering individual risk factors? sion screening clinic discovers a client with dramatically high
What motivates the individual to take advantage of health blood pressure. In attempting to make a referral for follow-
screenings? What barriers prevent her or him from comply- up care, the nurse discovers that the client has no financial
ing with general recommendations for health screening? access to treatment. In what way does this situation consti-
3. Compare perceptions of the value of screening among indi- tute an ethical dilemma for the nurse? What can the nurse do
viduals from different socioeconomic or cultural back- to resolve this dilemma?
grounds. Do similarities or differences exist? What do you 7. Select an article from the nursing literature that discusses
think accounts for the differences? the evaluation of a screening program. Identify the methods
4. Analyze your own personal risk factors for developing ill- used to evaluate the program, the desired outcomes, and the
nesses that are amenable to early detection and treatment actual outcomes. In what ways would you have evaluated the
(e.g., heart disease, cancer, diabetes). Consider demographic program differently?

Information about each organization listed here is found on its National Institute of Mental Health: http://www.nimh.nih.gov/
website. index.shtml
American Heart Association: http://www.heart.org/HEARTORG/ The National Newborn Screening and Genetics Resource Center,
Conditions/Conditions_UCM_001087_SubHomePage.jsp National Newborn Screening Information System (NNSIS):
Centers for Disease Control and Prevention: http://www.cdc.gov/ http://nnsis.uthscsa.edu/xreports.aspx?XREPORTID=5
Centers for Disease Control and Prevention, National Center National Scoliosis Foundation: http://www.scoliosis.org/
for Chronic Disease Prevention and Health Promotion: Screening for Mental Health: http://www.nimh.nih.gov/health/
http://www.cdc.gov/chronicdisease/index.htm topics/depression/index.shtml
Electronic health cards: http://www2c.cdc.gov/ecards/ U.S. Department of Health and Human Services My Family
Guide to Community Preventive Services: http://www.thecom- Health Portrait: https://familyhistory.hhs.gov/fhh-web/home.action
munityguide.org/index.html U.S. Preventive Services Task Force: http://www.ahrq.gov/clinic/
National Guideline Clearinghouse: http://www.guideline.gov/ pocketgd.htm
National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/
WEBSITE

• NCLEX Review Questions 19A: What Is Scoliosis?
• Care Plans
• Glossary
REFERENCES
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Pocket guide for adults. Retrieved July 2011 from preventive services. Retrieved July 2011 from (2011). My family health portrait. Retrieved July
http://www.ahrq.gov/ppip/adguide/. http://www.thecommunityguide.org/. 2011 from https://familyhistory.hhs.gov/fhh-web/
American Academy of Dermatology. (2011). Skin Farrell, S., Zerull, L., Mahone, I., etÂ€al. (2009). home.action.
cancer prevention. Retrieved July 2011 from Electronic screening for mental health in rural U.S. Department of Health and Human Services,
http://www.aad.org. primary care. CIN: Computers, Informatics, Centers for Medicare and Medicaid Services.
American Cancer Society. (2011). Cancer facts and Nursing, 27(2), 93-98. (2011). Medicare and you: 2012. Retrieved from
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from http://www.cancer.org. Physical activity promotion in a university U.S. Preventive Services Task Force. (2010). Guide to
American College of Obstetrics and Gynecology. community. American College of Sports Medicine clinical preventive services, 2010-2011. Retrieved July
(2011). Press release, Office of Communications. Health & Fitness Journal, 14(5), 7-11. 2011 from http://www.ahrq.gov/clinic/pocketgd1011/.
Annual mammograms now recommended for Jensen, L., Leeman-Castillo, B., Coronel, S. M., etÂ€al.
women beginning at age 40. July 20, 2011. (2009). Impact of a nurse telephone intervention
Retrieved July 21, 2011 from http://www.acog.org. among high-cardiovascular-risk, health fair SUGGESTED READINGS
American Diabetes Association. (2007). Facts and participants. Journal of Cardiovascular Nursing,
figures. Retrieved from http://www.diabetes.org. 24(6), 447-453. Causey, C., & Greenwald, B. (2011). Promoting
American Heart Association. (2006). Power to National Guideline Clearinghouse. (2011). Retrieved community awareness of the need for colorectal
end stroke. Retrieved July 2011 from http:// July 2011 from http://www.guideline.gov/index.aspx. cancer prevention and screening; a replication
powertoendstroke.org/tools-family-reunion.html. National Heart, Lung, and Blood Institute. (2004). The study. Gastroenterology Nursing, 34(1), 34-40.
American Heart Association. (2011). About seventh report of the Joint National Committee on DeSevo, M. (2010). Genetics and genomics resources
cholesterol. Retrieved July 2011 from http:// detection, evaluation, and treatment of high blood for nurses. Journal of Nursing Education, 49(8),
www.heart.org/HEARTORG/Conditions/ pressure. Retrieved July 2011 from http://www.nhlbi. 470-474.
Cholesterol/Cholesterol_UCM_001089_ nih.gov/guidelines/hypertension/index.htm. Fletcher, B. J., Himmelfarb, C. D., Lira, M. T.,
SubHomePage.jsp. National Heart, Lung, and Blood Institute. (2011). etÂ€al. (2011). Global cardiovascular disease
Centers for Disease Control and Prevention. Obesity education initiative: AIM for a healthy prevention: A call to action for nursing. Journal of
(2011a). Chronic disease resources: At a glance weight. Retrieved July 2011 from http://www. Cardiovascular Nursing, 26(Suppl. 4), S35-S45.
reports. Retrieved July 2011 from http://www.cdc. nhlbi.nih.gov/health/public/heart/obesity/lose_wt/ Hawkins, J., Pearce, C., Skeith, J., etÂ€al. (2009).
gov/chronicdisease/resources/publications/aag.htm. index.htm. Using technology to expedite screening and
Centers for Disease Control and Prevention. Screening for Mental Health. (2010). National intervention for domestic abuse and neglect.
(2011b). Division for Heart Disease and Stroke depression screening day. Retrieved July 2011 from Public Health Nursing, 26(1), 58-69.
Prevention. Addressing the nation's leading killers: http://www.mentalhealthscreening.org/. Loerzel, V. W., & Bushy, A. (2005). Interventions
At a glance 2011. Retrieved July 2011 from http:// Standards of Medical Care in Diabetes, American that address cancer health disparities in women.
www.cdc.gov/chronicdisease/resources/publications/ Diabetes Association. (2011). Diabetes care, Family and Community Health, 28(1), 79-89.
AAG/dhdsp.htm. 34(Suppl. 1), S11-S61. Retrieved July 2011 from National Newborn Screening and Genetic Resource
Centers for Disease Control and Prevention. http://care.diabetesjournals.org. Center. (2009). Retrieved October 2011 from
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omhd. Nurse Practitioners, 22(1), 62-69. Who accepts a rapid HIV antibody test? The role
Centers for Disease Control and Prevention. The National Newborn Screening and Genetics of race/ethnicity and HIV risk behavior among
(2011e). Pediatric Genetics. Retrieved October Resource Center. (2011). National Newborn community adolescents. Journal of Adolescent
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pediatricgenetics/index.html. October 2011 from http://nnsis.uthscsa.edu/. Vandenburg, S., Wright, L., Boston, S., etÂ€al. (2010).
Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. Maternal child home visiting program improves
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CHAPTER
20
Health Teaching
Gail L. Heiss
FOCUS QUESTIONS
What is the distinction between patient education and health What teaching strategies should the nurse use with the
education? identified target group for education?
How do the Healthy People 2020 objectives and overarching How does the nurse determine the appropriateness of
goals affect the role of the community/public health educational aids such as print, audiovisual, or Internet
nurse? materials for the learners?
How does the community/public health nurse identify health How will the nurse know whether the teaching strategies have
education needs? been effective?
What impact do the community environment and culture have What community resources are available to enhance health
on these learning needs? education?
CHAPTER OUTLINE
Health-Teaching Process Selecting Content
Definitions Selecting Teaching Strategies
Policies Selecting Evaluation Strategies
Expanding Opportunities Health-Related Educational Materials
Research Evidence: What Works in Client Health Education? Print Materials
Multiple Tools and Methods Nonprint Materials
Individualization and the Adult Learner Sources of Educational Materials
Support Systems Internet Resources
Nursing Assessment of Health-Related Learning Needs Preparation of Teaching Aids
Assessment of Community Learning Needs Principles of Teaching
Assessment of the Learner Physical Environment
Working with Groups of Learners Educational Environment
Construction of Health Education Lesson Plans
Creating Behavioral Objectives
KEY TERMS
Andragogy Health literacy Process evaluation
Behavioral objectives Low literacy Self-efficacy
Emotional readiness Outcome evaluation SMOG
Experiential readiness Patient education Teaching–learning process
Health education PRECEDE model
The concept and practice of teaching clients in the community This chapter provides the community/public health nurse
have been evolving since the days of Lillian Wald and continue with the concepts and tools needed to develop and implement
to change with the profession of nursing. Today, individuals and community health education programs. With the opportunity
families expect to be more involved in decisions about health care, for health education, members of the community will have
and they want to learn about illness prevention and Â�behavioral the resources and support to strive for personal, family, and
changes required to maintain health and an active lifestyle. Â�community health.
505
506 CHAPTER 20â•… Health Teaching
HEALTH-TEACHING PROCESS teaching–learning opportunities as a distinct intervention by

the community/public health nurse. Health education interven-
Definitions tions may be conducted with individuals, families, and groups
Patient Education in health care institutions, homes, schools, communities, and
Differentiating between patient education and health educa- the workplace. Health education nursing interventions are
tion is helpful. The term patient education is normally used often implemented in partnership with community members,
to describe a series of planned teaching–learning activities Â�community leaders, and other health care providers.
designed for individuals, families, or groups who have an iden-
tified alteration in health. The nurse uses a systematic process to Financial Reimbursement
assess patient learning needs that relate to the health problem Nurses quite possibly have the greatest opportunity to Â�implement
and then implements the teaching plan to accomplish changes educational programs because of the extensive amount of time
in attitude or behavior (Redman, 1997). they spend with individuals and families in the community.
Currently, the structure of insurance companies in the United
Health Education States is based on reimbursement for illness care rather than for
Health education focuses on health promotion and disease pre- wellness promotion. Reimbursement is available for physician-
vention. The role of the community/public health nurse includes ordered education relating to existing illness such as diabetes
educating and empowering people to avoid disease, to make management. A disappointing note is that in many instances, no
lifestyle changes, and to improve health for Â�themselves, their method exists for direct reimbursement of the nurse who pro-
families, the environment, and their community. The difference vides health promotion education to the community. However,
between patient education and health education is that health current practices in primary care settings provide opportuni-
education is directed toward individuals or Â�populations who ties for nurses to combine health-promotion education with
are not experiencing an acute alteration in health. Community required health screenings to detect or prevent disease.
assessment identifies individuals, families, groups, and pop- Community educational programs are sometimes offered to
ulations who would benefit from additional information on the community for a fee. Individuals who value self-care and
healthy behaviors and healthy lifestyles. The U.S. Department of health will often pay out of pocket for educational Â�programs such
Health and Human Services monitors the effectiveness of health as weight management or childbirth education. In this case, the
education as it relates to the population of the United States nurse does receive payment for teaching and Â�preparation time.
and publishes this information regularly in the Healthy People Unfortunately, people who cannot afford to pay for Â�educational
reports. Data is collected, reviewed and published at the Healthy services are excluded.
People website (U.S. Department of Health and Human Services Some nurses provide health education as a part of their
[USDHHS], 2010a). See the Healthy People 2020 box. jobs, such as nurses working for managed care organizations,
and are reimbursed with a salary. This group may also include
Policies Â�occupational health nurses, school nurses, and nurses in the
Quad Council of Public Health Nursing Organizations traditional public health setting. In addition to planning group
The Quad Council of Public Health Nursing Organizations education, public health nurses often have a caseload of families
collaborated to produce Public Health Nursing: Scope and
Â� and individuals who need direct care and home visits. Careful
Standards of Practice (American Nurses Association [ANA], time management is required for planning and implementing
2007), which outlines health education and the provision of health education.
HEALTHY PEOPLE 2020

Objectives Relevant to Health Education
Physical Activity and Fitness Include the following topics for both males and females: abstinence,
1. Increase the proportion of employed adults who have access to birth control methods, prevention of HIV/AIDS, and prevention of
and participate in employer-based exercise facilities and exercise Â�sexually transmitted diseases.
Â�programs (developmental: no baseline).
Nutrition Educational and Community-Based Programs

2. Increase the proportion of worksites that offer nutrition or weight 5. Increase to 28.2% the proportion of elementary, middle, and senior high
management classes or counseling (developmental). schools that provide comprehensive school health education to prevent
health problems in [all] the following areas: unintentional injury; vio-
Tobacco Use lence; suicide; tobacco use and addiction; alcohol or other drug use;
3. Increase the number of States and the District of Columbia, unintended pregnancy, HIV/AIDS, and STD Â�infection; unhealthy dietary
Territories, and Tribes with sustainable and comprehensive evidence- patterns; and inadequate physical activity Â�(baseline: 25.6% in 2006).
based tobacco control programs (developmental). 6. Increase the proportion of worksites that offer an employee health
promotion program to their employees (developmental).
Family Planning 7. Increase the proportion of local health departments that have estab-
4. Increase the proportion of adolescents who received formal instruc- lished culturally appropriate and linguistically competent community
tion on reproductive health topics before they were 18â•›years old. health promotion and disease prevention programs (developmental).
Adapted from U.S. Department of Health and Human Services. (2010). Healthy People 2020. Washington, DC: Author. Available at http://www.
healthypeople.gov.
CHAPTER 20â•… Health Teaching 507
Expanding Opportunities Individualization and the Adult Learner

In today's health care delivery system, the community/pub- Individual characteristics such as age, social status, cultural
lic health nurse has unique opportunities to shape the future. attributes, and educational level influence teaching effective-
A growing emphasis has been placed on the allocation of ness and long-term health behaviors. Standard lecture Â�methods
resources to consumer health education for health promotion that do not consider these or other individual differences may
and disease prevention, and nursing opportunities outside of be ineffective in teaching health promotion and self-care.
the traditional hospital roles. Nurse entrepreneurs can use the Therefore, the educational program should be individualized to
public demand for health education to develop and Â�market meet the learner's needs.
educational Â� programs that meet population needs. Nurses The nurse needs to assess the learner's teaching–learning
who work in community health agencies can use the health style. Clients may prefer to learn by reading, watching video-
Â�education trends to expand their job descriptions and advance tapes, viewing a demonstration, participating in groups, or
Â�professionally. Nurses can also work politically to influence listening and then attempting new behaviors. Matching learn-
public policy regarding development and funding of health ing style and the nurse's ability to meet the learner's style will
education programs. affect how well people learn. Assessment of andragogy, or the
Health promotion through health education and utilization Â�teaching–learning style, is most important in the process of
of resources is also of interest to the nurse in the occupational teaching adults.
setting. The occupational nurse can work with distinct groups Knowles (1980) identified some basic tenets that are con-
to assess health needs and provide education on topics such sistently recognized in adult education; adults learn best when
as stress management, smoking cessation, nutrition, exercise, they are actively involved, when the information is repeated,
and weight management. The nurse is also an important link when prompt feedback is received, and when the adult attaches
between employees and community resources. importance to the topic (TableÂ€20-1). Learners remember best
what is taught first, so the use of focusing activities early in the
RESEARCH EVIDENCE: WHAT WORKS IN CLIENT education session is important. Other strategies that are useful
when teaching adults include the following:
HEALTH EDUCATION? • Relate the content to life experiences
Research on health education has been extensive. Some of the • Focus on real-world problems
most prominent public health research regarding individu- • Relate the activities to learner-focused goals
als' adherence to health promotion activities was initiated • Teach what the learner wants to know before you continue
in the 1950s by Becker, Hochbaum, Kegeles, and Rosenstock (learners will not be able to focus on instruction if questions
(see Rosenstock, 1974; see also ChapterÂ€18). According to are not answered when asked)
the research of these authors, participation in prevention • Listen to and respect the opinions of the learner
activities such as educational programs will influence health • Encourage the learner to share resources with you and other
behaviors. learners
Multiple Tools and Methods Support Systems

No doubt, health education works, and actual changes The presence of a peer group can enhance learning by providing
in Â� behavior and attitudes occur after health education encouragement to learners as they try new behaviors and by
Â�interventions. Health education includes a variety of strategies, giving positive reinforcement when goals are met. In Â�addition,
such as lecturing,
Â� Â�storytelling, modeling, providing printed or teaching a supportive family instead of just one family Â�member
Â�audiovisual materials, and use of games and interactive experi- is more effective in achieving learning objectives and Â�modifying
ences. Also Â�available are technology-based educational oppor-
tunities including Â�telehealth conferencing and counseling of
TABLEÂ€20-1â•…â•‡CHARACTERISTICS OF
individuals on how to identify reliable health-related Internet
sites. All of these methods are effective in increasing knowledge ADULT LEARNERS
or skill level. Using multiple methods of teaching is more effective CHILDREN (PEDAGOGY) ADULTS (ANDRAGOGY)
because individuals learn in different ways. Others decide what is important Decide for themselves what
Continued nursing research is needed on the use of web- they want to learn
based techniques and other technologies for instruction and Accept information as you Validate and evaluate
their effectiveness for diverse populations. An interesting pilot teach it information based on life
study comparing the effectiveness of web-based instruction experiences and beliefs
and written instruction for rural mothers on communication Have limited past experience Have a lifetime of experience
with their adolescent children regarding sex found that both Expect to use information in the Want the information to be
methods of education were effective. The low-income women future immediately useful
who had little or no previous experience using computers Focus on the facts Focus on application of the facts
were able to effectively learn using web-based materials (Cox Teacher is the authority Teacher and learners
etÂ€al., 2009). Cost-saving efforts in health care delivery are collaborate
a priority. An article on the effectiveness of videoconferenc- Teacher plans the lesson Planning of content is shared
ing as a cost-effective method of providing patient education Passive recipient of information Active participant in the
(Winters & Winters, 2007) indicated that the use of technol- learning process
ogy is both cost-effective and leads to favorable patient health Data from Knowles, M. S. (1980). The modern process of adult
outcomes. education: From pedagogy to andragogy. New York: Cambridge Books.
behavior. For groups of community learners, special efforts to resources and learner skills that facilitate or hinder attainment
include culturally appropriate information and the use of of health behaviors. Reinforcing factors are the actual or expected
Â�culturally sensitive materials may enhance Â�participation and rewards and feedback a learner receives after engaging in a
learning. For example, provision of culturally Â�appropriate health behavior. These three types of factors influence health-
instruction, support group interaction, and behavioral related behavior, which, in turn, contributes to the presence or
Â�contracting were methods used to enhance adherence to a absence of health problems that are linked with quality of life.
Â�walking program among postmenopausal African American The phases of the PRECEDE model are similar to the steps
women (Williams etÂ€al., 2005). of the nursing process. Phases 1 through 4 involve assessment,
phase 5 is priority setting and planning, phase 6 is implementa-
NURSING ASSESSMENT OF HEALTH-RELATED tion, and phase 7 is evaluation (TableÂ€20-2).
LEARNING NEEDS Most of the seven phases of the PRECEDE model begin
with a diagnosis. In each phase, the health educator looks to the
The development of content, strategies for teaching, and Â�preceding cause and factors that influence the diagnosis. The
Â�evaluation of the effectiveness of the health education Â�program educator answers why a situation is occurring before planning
Â�
should be carried out in a systematic manner to achieve the most the educational intervention. Analysis of the causes of the
Â�effective results. This systematic method is the Â�teaching–Â�learning health problem helps eliminate the risk of planning ineffective
process. The teaching–learning process Â�parallels the Â�nursing Â�interventions based on guesswork.
Â�process (FigureÂ€20-1). The nurse will use both the Â�nursing Â�process
and the teaching–learning process to intervene for Â�community Assessment of the Learner
health promotion. Assessment of the learner is essential to planning the educa-
tional program. Assessment of the learner also helps Â�facilitate
Assessment of Community Learning Needs the learner's acceptance and use of the information being
To create a health education program for a community, both offered. Within the community, the learner may be an individ-
the needs of the community and the learning needs of the indi- ual, family, or group. Initial assessment of the learner is often
vidual participants should be assessed. Assessment of the com- referred to as assessment of the learner's readiness to learn.
munity is based on epidemiological and demographic data, In an early publication, which continues to have relevance,
observations made by health care personnel in the community, Redman (1984) described two aspects of readiness: emotional
results of surveys, and conversations with community members and experiential.
(see ChapterÂ€15). The need for community education can be
assessed using the four classifications of educational needs as Emotional Readiness
originally described by Atwood and Ellis (1971): Emotional readiness is the learner's motivation, or the willing-
• A real need is one that is based on a deficiency that actually ness to put forth the effort needed to learn. Motivation to learn
exists. is based on attitudes and beliefs about health-related behaviors.
• An educational need is one that can be met by a learning Motivation may be internally or externally reinforced.
experience. Internal motivation is more self-directive and longer lasting and
• A real educational need indicates that specific skills, knowl- involves satisfaction in health-promoting activities based on the
edge, and attitudes are required to assist the client in attain- belief that the action is useful or enjoyable. External motivation
ing a more desirable condition. must be constantly reinforced by rewards or praise. For exam-
• A felt need is recognized as important by the learner. ple, an individual who joins a weight-loss group is more likely to
The combined community assessment and educational achieve and maintain a weight loss if he or she joins the group to
needs assessment provide the impetus for planning a health satisfy his or her own need for health, wellness, and self-esteem
education program. (internal motivation). If he or she joins the group to receive the
A model that combines community assessment and edu- rewards of buying new clothes or garnering the praise of others
cational planning is the PRECEDE model. PRECEDE is an (external motivation), the person is less likely to maintain the
acronym for predisposing, reinforcing, and enabling causes in weight loss.
educational diagnosis and evaluation (Green & Kreuter, 1991).
Predisposing factors are characteristics of the learner; these Experiential Readiness
include knowledge, attitudes, and perceptions that motivate Experiential readiness includes the client's background, skill,
health-related behavior. Enabling factors are environmental and ability to learn (Redman, 1984). Assessment of the client's
TEACHING Identify learning needs Learning Behavioral Teaching. Evaluate achievement

PROCESS and readiness to learn. diagnosis. objectives. of behavioral objectives.
ASSESSMENT DIAGNOSIS GOALS INTERVENTION EVALUATION
NURSING Health screening, Nursing All goals related All nursing Evaluate continuing
PROCESS identification of diagnosis. to the health actions. health needs.
the health need. May include need. Evaluate ability
If the patient needs knowledge Some are for self-care.
to learn, use the deficit. learning goals. Evaluate continued
teaching process. need for teaching.
FIGUREÂ€20-1â•‡ Relationship of the teaching and the nursing processes.
TABLEÂ€20-2â•…â•‡PHASES OF THE
â•› PRECEDE MODEL: SAMPLE COMMUNITY EDUCATIONAL PLAN
PHASE QUESTIONS EXAMPLE
Assess
Phase I: Social diagnosis What are the general concerns of the Teenagers hang out at local stores where alcohol and cigarettes
population? are available.
Phase II: Epidemiological diagnosis What are the specific health problems? Alcoholism and drug abuse
Car accidents related to intoxication
Asthma
Phase III: Behavioral diagnosis What are health-related behaviors? Underage drinking
Illegal drug use
Smoking
Phase IV: Educational diagnosis What are predisposing, enabling, and Predisposing: Teenagers desire to belong to peer groups.
reinforcing factors? Enabling: Cigarettes, alcohol, and drugs can be purchased.
Reinforcing: Teenagers who do not use substances are excluded by
other teenagers.
Plan
Phase V: Analysis of educational Which of the priority factors will be Teenagers' desire to belong to a group; teen needs for activities
diagnosis focused on during education? Belief that substance use is necessary to belong
Community accessibility of substances in local teen meeting places
Implement
Phase VI: Administrative What specific objectives and resources For teenagers:
diagnosis are needed for health education? Objective: Adolescents will explore alternative ways of being together.
Resources: Young adult small-group facilitators needed.
Action: Youth meetings and recreational activities at drug- and
substance-free sites.
For community:
Objective: Community leaders will provide substance-free
recreation sites and programs.
Resources: Community education at civic associations and local
government meetings regarding adolescent needs.
Action: Dedicated funding and resources for teen activities.
Evaluate
Phase VII: Evaluation What are the results of education? Civic club sponsors sports and games in substance-free site within
3â•›months.
Thirty percent of teenagers attend and report reduced smoking and
drug use.
PRECEDE, Predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation.
Data from Green, L., & Kreuter, M. (1991). Health promotion planning: An educational and environmental approach. Mountain View, CA: Mayfield Publishing.
background examines cultural factors, the home environment, Finally, in determining experiential readiness, the client's
and socioeconomic status. This background information is ability to learn should be assessed. Very pertinent is determin-
Â�useful in describing current health behaviors and the learner's ing the client's educational level. Direct questioning related to
ability to use education to change behavior. years of formal education is useful but does not always provide
Client skills and self-perception of skills are part of experien- Â�complete and accurate information. For example, although a
tial readiness. A client who is learning to bathe a newborn needs client may have completed college, if the client did not study
both coordination and the belief that he or she can learn. It is medicine or nursing, he or she may not understand complex
also useful to assess how clients prefer to learn Â�procedures or medical terminology. In addition, reading ability and learning
skills. Based on experience, do clients prefer to try Â�themselves, disabilities should be considered (BoxÂ€20-1).
correcting their own mistakes, or do they prefer to be led
through the process step-by-step several times until they feel Barriers to Learning
confident? Assessment of the learner also requires assessment of Â�barriers
Developmental stages of both the individual and the Â�family to learning. Barriers may be cultural, language, or physical bar-
present another aspect of experiential readiness. Educational riers. One of the foundation health measures in Healthy People
content should be developmentally appropriate. For example, 2020 is the elimination of health care disparities such as those
a session on the dangers of teenagers' drinking and driving that may be inherent in health education Â�programs. Inclusion
would have similar content on the dangers of drinking and tips of culturally appropriate teaching materials and a Â�culturally
to Â�prevent or resist alcohol use whether delivered to a group sensitive approach to individual and family Â� education is
of teens or to a group of their parents. However, the material required. Culturally appropriate teaching materials for diverse
would be presented differently to the two groups. groups are available through several resources including
BOXÂ€20-1â•…â•‡ASSESSMENT OF READINESS TO LEARN: QUESTIONS FOR THE

NURSEÂ€TOÂ€ASKÂ€THE LEARNER
EMOTIONAL READINESS Learning a Concept
What sorts of things do you currently do or try to do to keep healthy? How do you feel about learning these new ideas?
Assesses attitudes about health promotion and disease Â�prevention, How often do you need something repeated before you feel comfortable
sense of control over the ability to stay healthy, and Â�self-Â�satisfaction with a new idea?
in health-seeking behaviors How do you think you learn best: by hearing? by seeing? by doing? by a
What things in your life make keeping healthy difficult? combination of these?
Assesses perceptions of stressors or barriers to health-promotion
activities and cost of healthy behaviors Ability to Learn
Why did you join this health education group? What is your level of education? What did you study in school?
Assesses internal or external motivation to learn What subjects did you enjoy the most?
What would you like to know more about? Assessment of formal level of education is not always sufficient;
Assesses priorities Â�ability to read should be assessed using a readability formula.
What personal health goals do you hope to achieve by the end of the How is your sense of sight? hearing? speech?
experience? Do you trust your memory? What things, if any, do you find difficult to
Assesses expectations for the future and client's interest in learning remember? What do you do when you cannot remember?
Assesses ability to memorize information
EXPERIENTIAL READINESS To what degree do the surroundings (e.g., noise, people) influence your
Background ability to concentrate?
Tell me about yourself, your family, and your lifestyle. Would you say that your Assesses adequacy of the educational environment
cultural background has influenced your beliefs about health and illness? How long can you concentrate before getting tired?
Describes current health behaviors and cultural traditions that may Assesses the need for short or long teaching sessions and the need
influence adherence to health-promotion behaviors for periodic breaks
Which of the following things have you said about yourself: “I heard it,
Skills but it just didn't register.” “I heard it, but my mind went blank.” “I can
Learning a Manual Skill tune everything else out.”
How would you describe your ability to learn this skill? Assesses the ability of the learner to listen carefully and attentively
How would you describe your manual dexterity at the present? OR may identify a learning disability
How much practice do you usually need to master a new skill?
Assesses the learner's actual and perceived manual dexterity and
coordination
the U.S. Department of Health and Human Services (2011) advertised education program; the group may also be formed
Healthfinder.gov site (http://www.healthfinder.gov), and the as a result of screening and identification of families with health
Office of Minority Health (2011) (http://minorityhealth.hhs. needs (BoxesÂ€20-2 and 20-3).
gov). The Healthfinder.gov site can be viewed entirely in Spanish In a group, background, skills, abilities, and motivation
and the Office of Minority Health website includes links for are different for each group member. An assessment of each
numerous population groups including African Americans, learner's readiness to learn before the first group meeting is
American Indians and Alaskan Natives, and Asian Americans. useful for determining group composition. If performing
In addition, the community/public health nurse should estab- an individual assessment before the group meeting is not
lish partnerships with leaders of the community. These partners possible, some introductory time during the first meeting
can help the nurse develop understanding of the population(s) might be used to assess readiness to learn and the learners'
and interpret their acceptance (or lack of acceptance) of health needs and motivations for behavioral change. The nurse
recommendations. may want to ask a colleague to record the information about
Physical barriers are also important in assessing the learner. learning needs and abilities so the task of taking notes will
Some physical barriers are obvious, such as the use of mobility not distract from the important task of establishing rap-
aids, and the nurse will be able to help clients with these difficul- port. An easy technique to use during the first group meet-
ties access the learning environment. Less obvious are physical
Â� ing to assess learners' needs is a flip chart and Â�m arkers. Each
barriers such as vision or hearing problems, brain injury, or member of the group may be asked simple questions Â� dur-
learning disabilities. The nurse should make sure that the Â�setting ing introduction time, such as, “What brought you to the
accommodates learners with these problems so that they do not meeting today?”, “What would you like to learn?”, or “How
become frustrated with health education. Large-print materials, do you like to learn new things?” Answers are recorded on
good lighting, reduction of background noise, and appropriate the flip chart.
seating are a few easy modifications that can reduce or eliminate
physical barriers to learning. CONSTRUCTION OF HEALTH EDUCATION
Working with Groups of Learners LESSONÂ€PLANS
The community/public health nurse frequently implements The next step in the teaching–learning process is the con-
health education programs with groups of learners. The group struction of the health education lesson plan. In the Â�initial
may come from within the community to participate in an phase of the teaching–learning process, the nurse assesses
BOXÂ€20-2â•…â•‡FACTORS IN A GROUP OF LEARNERS

TYPE OF MEMBERSHIP • Very large groups can be divided into smaller learning clusters
Homogeneous Membership based on learning needs. Clusters can reconvene for large-group
• Members have similar learning needs, abilities, and learning style. sharing.
• Some homogeneity is needed so that members feel they belong • Small clusters can prevent members from being bored or Â�overwhelmed
(e.g.,Â€age, sex, background). (either of which can decrease motivation to attend group).
• No one member should stand out as different.
• Planning of educational strategies may be easier for the nurse. STABILITY OF MEMBERSHIP
• Assessment of learning needs and selection of members provide less
Heterogeneous Membership dissatisfaction and more stability of group.
• Variation exists among members regarding learning needs, abilities, • Time-limited behavioral change groups have a more stable Â�membership
and learning style. than do continuing community groups. Some examples are Weight
• Differences among members may enhance learning by allowing Watchers, La Leche League, or Parents Without Partners.
members to listen and understand the experiences of others.
BOXÂ€20-3â•…â•‡TIPS AND TRICKS FOR WORKING WITH GROUPS

Be prepared: Having materials and supplies on hand • Before starting the activity, set up a clear refocus signal to allow you
will lower your anxiety, keep you feeling good, and to get control of the group without shouting. A whistle or bell (in your
enhance learning kit) or a raised hand will work for this process.
• Keep a teacher's kit with markers (water soluble and dry erase), • Use the format of a game show that many people know how to play.
chalk, pens and pencils, masking tape, Scotch tape, paperclips, rub- Using this format will cut down on explanation time and give your
ber bands, Post-It notes, push pins, scissors, and a bell or whistle. group more time for the activity.
• Keep an emergency “repair anything” toolkit ready, including a screw- • Wait to give handouts or materials for the group activity until after
driver, hammer, pliers, string, duct tape, extension cords, and an extra you have given the instructions; otherwise people will be reading
copy of your presentation on a flash drive. instead of listening to you.
• Think about a teaching method that does not use a computer just in • Arrange seating so members participating in small-group activities
case of a total technology failure—be ready to use flip charts, hand- can see each other and maintain eye contact.
outs, or a white board and use your drawing skills. • Have your game props counted and ready, which makes you look
• Make a kit for yourself with mints, bottled water, a snack, lip balm, relaxed and prepared.
and a first aid kit, including bandages and something for a headache.
• Keep a supply of various colored index cards available. Use them for Audiovisual tips: Confidence in using equipment will
recording ideas, asking questions, etc. help you concentrate on the learning experience
• Zip-lock bags are good for storing everything! Flip Charts
• Use the broad side of the marker when writing to make big, bold
Presentation tips: A great presentation makes the day letters.
fly by for you and your learners • Print in upper and lowercase letters, do not use cursive script.
• Know your subject backward and forward and inside out. Your learn- • Use deep-colored markers that are easy to read; blue, green, and
ers will see you as the expert on the subject. black are best.
• If someone asks a question and you do not know the answer, say so • Tape notes for yourself on the back of the easel.
and remark “what a great question.” If appropriate, open the question • Cut some pieces of masking tape and put these on the back of the
to the group for solutions or work to find the answer at break time. easel for quick access.
• As you are speaking, if you think of a new idea, use the index cards
or Post-It notes to write it down so you can continue to improve your Computer Projection
presentation next time. • If your participants need to take notes, turn the lights down so they
• Drink the water from your kit above; water at room temperature is can see the screen, but not completely off.
best for your voice. • Keep your visuals simple, with limited words on each slide.
• Be positive! Your nonverbal messages come through loud and clear. • Do not read to the audience from your visuals; elaborate on the
• If you make a mistake, fix it and move on. Most groups are forgiving. main points and face the audience. Caution: keep your discussions
• Start your own library of articles on adult learners and presentation Â�pertinent to the slide being shown or this will confuse the group.
techniques. • Forward to a blank screen or slide when you need to make a point or
you want to diverge from the current topic; this technique helps you
Group activities: Adult learners remember experiences make eye contact with the audience and helps them focus.
when they are actively involved • To help you avoid walking in front of the image when you move about
• Divide, mix, and move the group before you give instructions. People the room, consider putting the screen in a corner or making a barrier
often forget the instructions during the shuffle. so you do not walk in front of the projector.
From Gail L. Heiss, MSN, RN, BC, Nursing Education Specialist, VA Maryland HealthCare System; and Backer, L., Deck, M., & McCallum, D. (1995).
The presenter's survival kit—It's a jungle out there. St. Louis: Mosby.
what the learner wants or needs to be able to accomplish.

TABLEÂ€20-3â•…â•‡SAMPLE BEHAVIORAL
The next step, creating the lesson plan, begins with state-
OBJECTIVES
ments of the results the nurse wants the learner to achieve.
Each statement is a behavioral objective. The result of the After attending the health education program entitled “Low-Fat Meals
education may be a change in attitude, skill, behavior, or for Your Family,” the participant will:
knowledge, but it must be stated before the actual teaching POORLY PHRASED WELL-PHRASED
begins. BEHAVIORAL OBJECTIVES BEHAVIORAL OBJECTIVES
Creating Behavioral Objectives Cognitive Domain

Understand the importance of a Describe the health benefits of a
Behavioral objectives reflect changes in the learner that are healthy diet low-fat diet
observable or measurable. If the behavioral objectives are prop- Know what high-fat foods the Name at least three foods or
erly written, they will be useful tools in helping the instructor family eats recipes enjoyed by the family
1) decide which content and activities will get the learner to the that are high in fat
desired outcomes and 2) evaluate the outcome. An important
point to remember is that behavioral objectives are statements Psychomotor Domain
of what the learner achieves, not statements of the teacher's Cook meals without as Rewrite the “family favorite”
activities. A classic resource on the writing of behavioral objec- much fat recipe using low-fat ingredients
tives (Grolund, 1970) identifies the use of behavioral objectives Buy low-fat foods When shopping, compare nutrition
to accomplish the following: labels of popular snack foods
• Provide direction for the teacher and indicate to others the (such as cookies and chips)
instructional intent Increase the percentage of
• Guide the selection of course content, teaching strategies, purchased foods that are low
and teaching materials in fat
• Facilitate evaluation of the educational program (evaluation Affective Domain
measures the achievement of the objectives) Adjust successfully to the new Predict the family reactions to
• Guide the student's learning by specifying what she or he is family eating patterns low-fat meals and snacks
expected to do at the conclusion of the program Appreciate the relationship Discuss possible solutions to
When behavioral objectives are written, an acceptable between food and comfort family resistance to change
Â�practice is to state a main objective in behavioral terms that
guides large segments of learning. If necessary, this main objec-
tive can be followed by more specific supporting objectives. Â� ecessary to incorporate a new health behavior into the learner's
n
The supporting objectives may represent the actions neces- life. Nurses generally want learners to do the following:
sary to accomplish the main objective (Redman, 1997). Main • Cognitively apply information
Â�objectives in the community may closely parallel the Healthy • Perform skills with some guidance and, eventually, indepenÂ�dently
People 2020 objectives, with supporting objectives specific to • Value the learning enough to use it
the community in which the program is implemented. Some
guidelines and examples of behavioral objectives are given in Selecting Content
BoxÂ€20-4 and TableÂ€20-3. Selection of the content of the health education program
Behavioral objectives are classified into three domains depends on the following:
of learning: cognitive (intellectual), psychomotor (motor • The needs identified by the target group of learners
skills), and affective (attitudes and emotions) (Bloom, 1984). • The nurse's determination of what the group needs to know
All behavioral objectives fit into one of these domains of • The health care delivery system's constraints on the nurse
learning. Needs of the learners lead to the development of the
By assessing learning needs, the nurse can evaluate the behavioral objectives; behavioral objectives lead to devel-
need for behavioral objectives in the cognitive, affective, or opment of the content. When developing the content of
psychomotor domain. All three domains of learning are usually the program, the nurse consistently refers to the behavioral
objectives for guidance. Behavioral objectives that were care-
fully developed from the needs assessment and that include
BOXÂ€20-4â•…â•‡GUIDELINES FOR â•›WRITING learning in all three domains will lead to the development
of a teaching plan that is tailored to the needs of the target
BEHAVIORAL OBJECTIVES
group (BoxÂ€20-5).
1. Begin each objective with an active verb (e.g., discuss, name, When the nurse is planning the educational program, start
Â�compare, describe, predict). with the information that the group is seeking, even if this infor-
2. State the objective as a learner outcome, not as a teacher outcome mation is not the most important component of the program
or intent. or is not the information that was scheduled to be taught first.
3. Include only one outcome per objective to facilitate evaluation of After the group introductions and brief learning needs assess-
outcomes. ment, the nurse might need to modify his or her lesson plan to
4. Be sure the stated objectives are appropriate for the learners' address the immediate need to know certain information. For
needs and abilities. example, in the sample flu lesson plan in BoxÂ€20-5, the nurse
From Grolund, N. E. (1970). Stating behavioral objectives for classroom could begin the session by discussing the flu vaccine if the group
instruction. New York: Macmillan. has identified fear of the vaccine as a priority learning need. By
BOXÂ€20-5â•…â•‡SAMPLE HEALTH EDUCATION LESSON PLAN

PREPARING YOUR FAMILY FOR THE FLU SEASON
This health education topic may be identified through community needs assessment, may be based on Healthy People 2020 or community goals, may
be derived through careful attention to national health care issues, or may be selected by health care organizations to promote cost savings.
Instructional Methods Time Allotted and
Behavioral Objectives Content Outline andÂ€Materials Evaluation Methods
COGNITIVE
At the conclusion of the Symptoms of the flu and a cold Methods: 30 minutes
program, the learner will be Methods of acquiring the flu virus, Lecture presentation; group Observe participation in
able to: including airborne (sneezing, discussion group discussion; note
• Identify the symptoms of coughing) and through contact such Materials: questions asked
theÂ€flu as handshaking Flip chart Return demonstration for
• Compare the flu and a cold Importance of reducing exposure of Posters knowledge of steps in
• Describe methods to reduce at-risk family members, such as older PowerPoint presentation hand-washing or “sneezing
exposure to the flu virus adults, to other potentially ill persons Prepared handout with comparison into elbow”
Use of hand-washing as a method of of flu and cold symptoms
prevention
PSYCHOMOTOR
Using the equipment and How to select and use over-the- Methods: 1 hour
materials provided by the counter medications and other items Group brainstorming activity to (20 minutes for small-group
health department, the learner to provide comfort care for persons create a culturally appropriate brainstorming; 10 minutes
will be able to: with the flu “flu list” for each family for large-group sharing; 30
• Create a list of items needed Use of a thermometer and Demonstration and return minutes for demonstration
in the home to care for a recommendation on when to use demonstration of thermometer and return demonstration
Â�family member with the flu medication and when to call the and hand gel use of use of thermometer and
• Demonstrate how to use a doctor for a fever Materials: hand gel)
thermometer Use of hand gel to prevent flu Paper and pencils
• Wash hands using hand gel transmission when caring for a Instructor master list of recommended
family member items for flu care
Thermometers
Prepared thermometer instructions
Hand gel
AFFECTIVE
At the conclusion of the Purpose of vaccination for prevention Methods: 30 minutes
program, the learner will be of flu Lecture presentation Observe participation in
able to: Myths and beliefs about vaccine and Group discussion group discussion
• Discuss the importance of the illness Materials: Have each participant
flu vaccine for high-risk groups CDC recommendations for Posters identify which members
• Evaluate the advantages and immunization CDC handouts of his/her family should
disadvantages of Â�immunization receive flu vaccine
for members of the family
• Decide whether or not the
learner and family members
will receive the flu vaccine
CDC, Centers for Disease Control and Prevention.
meeting this immediate need to know, the nurse captures inter-

A nurse conducts a group for pregnant adolescents, with the
est and motivates group members for further learning. In addi-
overall goal of decreasing child abuse and neglect by ado-
tion, if the information the group is seeking is not addressed,
lescent parents. Group-identified learning needs may focus
the learners may not be able to concentrate on other informa-
on the psychomotor aspects of new infant care and attitudi-
tion being taught.
nal changes necessary to becoming responsible parents. The
The nurse independently determines some of the content of
group might not identify the need for information on the
the health education program. Although the learners' or group
relationship between infant crying, development of infant
members' assessments of their own learning needs has been
self-comforting behaviors, and abusive behaviors such as
expressed, their list of learning needs may not be comprehen-
shaking exhibited by some parents in reaction to infant
sive. The nurse's expertise is necessary in identifying informa-
Â�crying. The nurse's responsibility is to include these concepts
tion and attitudes needed for behavioral change that members
and positive health behaviors in the educational plan.
of the group did not recognize.
The health care delivery system and the insurance industry and community values is necessary. Differences in learning
place constraints on health education programs. Time and money needs that were assessed influence the selection of the Â�teaching
are limited resources and often influence the length of a Â�program. strategy. Strategies should be suitable to the subject matter.
The nurse also needs to plan on using educational materials Numerous teaching strategies that are useful in group educa-
within the constraints of a budget. Although use of Â�purchased tion and factors that influence their selection are presented in
print and audiovisual materials may enhance the program, TableÂ€20-4.
Â�content still may be taught effectively using less expensive teach-
ing aids prepared by the nurse or the institution (the preparation Selecting Evaluation Strategies
of teaching aids is discussed later in the chapter). In addition, the Evaluation and revision of health education programs is
nurse must remember that some educational programs are reim- required for the community/public health nurse to adhere to the
bursed by third-party payers only if the content is approved by American Nurses Association's Public Health Nursing: Scope and
the insurer or is ordered by a physician. Alteration of content is Standards (2007). The evaluation should lead to the Â�development
sometimes required for compliance with these limitations. of new data for community planning. A prime example of con-
tinued evaluation and revision is the periodic modification of
Selecting Teaching Strategies the Healthy People 2020 health goals for the nation.
Selection of the teaching strategy or technique to achieve the To evaluate health education, two types of evaluation are
behavioral objectives is the next step in planning the health necessary: outcome evaluation and evaluation of teacher
education program. Teaching techniques must be suitable
Â� Â�performance. Outcome evaluation, or evaluation of the learner,
to the size, composition, and learning abilities of the group. is further divided into short- and long-term evaluation and the
Consideration of cultural differences, barriers to learning, evaluation of self-efficacy.
TABLEÂ€20-4â•…â•‡TEACHING TECHNIQUES
â•› FOR USE IN GROUPS OF LEARNERS
TECHNIQUE ADVANTAGE DISADVANTAGE
Lecture: Traditional presentation Effective in large groups; good for lower- Students are passive; students with
level cognitive learning increased intellectual ability may be bored
Use of examples: Begin with simple examples Useful for clarification; students may Failure to relate the example to principles
and progress; select examples based on be able to provide examples to verify being taught results in learners'
common life experiences of the group learning remembering only the example
Discussion: Often used to achieve objectives in Engages active participation of the Not as effective in large groups; students in
the affective domain learner; assists learner to focus, certain settings such as a lecture hall may
analyze, generalize not be able to hear the peer discussion
Role modeling: Provides members with model Learner is able to observe someone with Need to carefully select nurse leader who
for learning; also known as identification desirable traits possesses the desirable traits
Positive reinforcement: Useful when teaching Increases participation in discussion Reinforcement must be related to learner
a group with high anxiety level because members feel valued accomplishment, not the learner
Demonstration and guided practice: Effective Encourages involvement; safe place to Possibly difficult for left-handed learners
for learning psychomotor skills make mistakes
Simulation: Applies previously learned Involves active participation; increases Limited use for cognitive learning
knowledge; useful for psychomotor skills motivation and interest
practice and affective learning
Role playing: Provides exploration of attitudes Involves active participation, comparison Time consuming; experienced leader needed
and problem-solving skills of own beliefs to those of others to focus the discussion
Support groups: Highly effective for attitude and Decreases sense of “aloneness”; member Group can become “stuck” in self-pity; need
behavioral change when used with cognitive differences provide model for new an experienced group facilitator
teaching behaviors
Contracting: Written or verbal; emphasizes Allows for differences in learner needs; Learners with limited self-discipline will have
outcomes can monitor change over time difficulty adhering to contract
Stress-reduction exercises: Reducing anxiety Applicable to most learning situations; Nurse needs to be comfortable with
increases cognitive and affective learning can become part of regular mental technique
health
Computer-assisted instruction: Individualizes Useful for cognitive and affective Equipment costly; initially, highly
learning needs learning; voice-generated instruction individualized instructor time may be
useful to overcome reading disabilities needed to assist learners not familiar with
computers
Team teaching: Enhances teaching by using Presents different points of view to the Requires additional planning time and
knowledge of more than one teacher; also learner; teachers learn from each other additional use of staff, may lack continuity
provides backup in case of schedule conflicts for and can provide ongoing peer review
programs that have numerous sessions
Data from Babcock, D. E., & Miller, M. A. (1994). Client education theory and practice. St. Louis: Mosby; and Redman, B. (1997). The process of
patient education (8th ed.). St. Louis: Mosby–Year Book.
Outcome Evaluation
The “Crosswalk Campaign” is an example of community
Assessment of learner outcomes has traditionally been based
education and the effectiveness of partnerships over time.
on achievement of the behavioral objectives. If the Â�objectives
In a busy community in which there is a high incidence of
are properly written, each objective is measurable. Actual
pedestrian accidents that occur when people cross the street
Â�performance of the desired behavior provides the evaluation
without using the crosswalk, the health department and
data. The overall goal of community health education programs
other civic groups could collaborate to implement a cross-
typically is to teach a health-promoting activity that is incorpo-
walk safety education program. Public partners such as
rated into the learner's lifestyle over a long period.
health care providers, emergency management groups, pub-
Short-Term Evaluation. Measurement of cognitive knowledge
lic works agencies, and elected officials should be included.
is the most common type of short-term outcome evaluation
A media campaign to provide education via radio and local
and is best achieved by using questionnaires or standard-
television and a contest for schoolchildren to design
ized testing. Although this method of evaluation yields usable
Â�posters are examples of some possible efforts to educate the
data for comparison of groups, it is not always recommended.
Â�community. In addition, visual cues about the program may
Questionnaires and standardized tests can be time-consuming,
be Â�provided to the community with new signage at cross-
have limitations for learners who cannot read, and may remind
walks using the safety campaign slogan and logo. Evidence of
adult learners of their childhood schooldays. A negative expe-
implementation by public officials includes funding for inter-
rience with the use of a questionnaire or test might prevent
section upgrades such as new crosswalk lines on the streets;
adult learners from seeking out health education groups in the
larger, brighter crosswalk lights; or crosswalk lights that
future. A more positive method to evaluate cognitive knowl-
Â�indicate the time left to cross. A long-term indicator of the
edge is the use of a game-show format with groups. Learners
effectiveness of the program would be a measured decrease
are divided into teams and earn points for answering questions
in the incidence of pedestrian and motor vehicle accidents.
correctly.
In a small-group environment, an appropriate practice is to
evaluate behavioral outcomes by interviewing each member of Self-Efficacy. Self-efficacy is the motivational factor that
the group. A structured interview can be used to collect data determines if an individual participates in self-care activities
about personal behavioral successes. These data would be uni- and to what extent (Bandura, 1977). Self-efficacy is an impor-
form and provide for a simple analysis. If a structured interview tant attitude for learners. For example, living with chronic
is used, however, the structure and formality of the questions Â�disease involves more than knowing what to do; it is the ability
might prevent the learners from sharing some of the personal to organize and integrate cognitive, social, and behavioral skills
successes and benefits of the instruction. into daily living to produce desired outcomes. As an evaluation
If, instead of using a structured interview, the nurse measure, self-efficacy goes beyond cognitively knowing what to
interviews each group member informally, the member
Â� do. Self-efficacy provides a measure of the belief of the learner
might share more personal behavioral successes. Personal that he or she is capable of developing and performing skills
successes shared informally during group meetings Â�provide that will improve his or her health.
motivation for other group members. Informal sharing Self-efficacy can be fostered through the learner's experi-
about achievement of behavioral objectives also provides ences of success; vicarious successful experiences of others,
information about difficulties the learners are having and including teachers as models; and persuasion. Self-efficacy in
their satisfaction with the learning experience. The nurse is older adults was part of a health-teaching program presented
able to determine which objectives are difficult for the par- by Easom (2003). The study found that fostering self-efficacy
ticipants to achieve and can revise the educational strategies can improve health behaviors among participants in a health-
appropriately. promotion program. The learner outcomes in this program
Long-Term Evaluation. Direct observation by the nurse pro- were based on the long-term performance of self-care activities,
vides some indication of success, but the participant often does such as exercise, range-of-motion activities, rest, and relaxation.
actual measurement of the lifestyle change. Similar findings were demonstrated by Loeb (2004) in a study
of older men's health motivations and participation in health-
In the case of a health education intervention to increase promoting behaviors. The success of the self-efficacy approach
exercise for promotion of cardiovascular health, the nurse to health promotion may change the traditional approach to
may not be able to observe changes in the individual's providing health education and lead to an increased emphasis
pulse rate, blood pressure, weight, or cholesterol level before on encouragement and motivational factors. The older adults in
the end of a time-limited program. Also, only the learner whom the nurse fostered higher self-efficacy were more likely to
knows whether he or she actually meets the Â�behavioral continue with health self-care activities.
objective of walking daily for 30 minutes. The Â�participant
can provide subjective reports of lifestyle changes by keep- Teacher Performance Evaluation
ing a personal journal documenting exercise and activity Process evaluation includes evaluating both the content of
over time. Long-term evaluation by the nurse is possible, the lesson and the teacher as the lesson is being presented.
but cardiovascular changes over time may also be Â�influenced The performance of the teacher influences the achievement
by other factors, such as the use of cholesterol-lowering or of behavioral
Â� outcomes by the learners. Teacher performance
blood pressure medications. can be evaluated through observation by a peer, review of
Â�videotapes of the teaching session, or feedback from the partici-
Long-term evaluation also considers the effectiveness of the pants. Participant feedback on teacher performance can include
intervention for the community over time. nonverbal cues such as disinterest or confused expressions.
An observant instructor will not ignore these nonverbal cues higher risk of death. Learners often need to have the teaching
and will make brief pauses in the educational session to assess Â�experience supplemented with print materials that can serve to
understanding. Evaluation of the lesson frequently includes Â�reinforce information and provide reminders about new behav-
learners' self-assessment of their achievement of objectives. iors after the learner has left the educational setting. Studies of
When working with groups, teacher performance can be reading abilities indicate that approximately 50% of health care
enhanced using co-leaders. Co-leaders who have mutual trust Â�clients have difficulty reading educational materials written at
and respect can learn from one another as they use various the fifth-grade level (Doak etÂ€al., 1996).
teaching strategies. Particularly useful is to pair a novice teacher Clients frequently attempt to hide their inability to read, and
with one who is more experienced. problems with reading comprehension are often overlooked.
Teacher effectiveness and achievement of learning objectives Client-reported years of education often are not a good indica-
may be evaluated using the same feedback tool (TableÂ€20-5). tor of reading ability. Clients may self-report completing high
Feedback is most helpful when the learner feels free to give an school, but they may have graduated with only an elementary
honest opinion; therefore, the evaluation should be anony- school reading ability.
mous, or the inclusion of a name should be optional. Collection Low literacy not only indicates a client's lack of Â�reading
of feedback is less intimidating if the nurse places an envelope Â�ability, but it also affects his or her ability to understand oral
or folder on a table to collect feedback forms instead of having instructions. In many instances, when clients are questioned
learners hand them to her or him. about understanding, they will indicate that they do under-
stand, even if they do not. When confronted with a fast-paced
HEALTH-RELATED EDUCATIONAL MATERIALS educational program, low-literacy clients will sometimes
Â�withdraw from the situation, appearing to have low motivation
Print Materials to participate (Doak etÂ€al., 1996). When asked to participate in
Problems of Low Literacy instruction, they may show poor eye contact or comment that
The National Action Plan to Improve Health Literacy (USDHHS, they do not have their reading glasses with them. Clients with
2010c) defines health literacy as the ability of individuals to low reading and comprehension skills and limited vocabulary
obtain, process, and understand basic health information to are not able to express what is not understood and therefore
make health decisions. The Action Plan indicates that nearly may choose to conceal their illiteracy.
9 out of 10 Americans, however, have low health literacy and According to Doak and colleagues (1996), people who are
experience difficulty acting on health information provided to able to read at a higher level are not offended by easy-to-read
them. The link between low health literacy and negative patient materials. This finding has practical implications for the com-
outcomes was highlighted by the Institute of Medicine (2004) munity/public health nurse, who should consider using only
and the Agency for Healthcare Research and Quality (AHRQ) health education materials written at a sixth-grade level or lower.
(2011). Both reports indicated that limited health literacy is In addition, the nurse should include follow-up after providing
negatively associated with use of preventive services and man- health information and education to determine understand-
agement of chronic conditions such as diabetes. More recently ing. Instead of just asking clients if they understand, a useful
in an updated report, the AHRQ (2011) linked low literacy method to determine if the client has learned is the “Â�teach-back”
with the more frequent use of hospital emergency rooms and or “show-back” technique. Based on the teach-back Â�experience,
TABLEÂ€20-5â•…â•‡SAMPLE COMBINED TEACHER AND LESSON EVALUATION TOOL FOR THE

â•›
HEALTH EDUCATION PROGRAM “LOW-FAT MEALS FOR YOUR FAMILY”
PLEASE EVALUATE THE NURSE WHO PRESENTED THE LESSON.
Circle the appropriate number.
STRONGLY CANNOT STRONGLY
AGREE AGREE DECIDE DISAGREE DISAGREE
The nurse listened to my concerns. 5 4 3 2 1
The nurse understood what I needed to learn. 5 4 3 2 1
I was able to ask questions. 5 4 3 2 1
The nurse used language I could understand. 5 4 3 2 1
The nurse used examples that were familiar to me. 5 4 3 2 1
I had the opportunity to participate. 5 4 3 2 1
PLEASE EVALUATE YOUR ABILITY TO ACHIEVE THE OBJECTIVES.

Circle the appropriate number.
STRONGLY CANNOT STRONGLY
AGREE AGREE DECIDE DISAGREE DISAGREE
I am able to describe the benefits of a low-fat diet. 5 4 3 2 1
I can name three foods or recipes enjoyed by my 5 4 3 2 1
family that are high in fat.
I am able to rewrite a family recipe substituting Â� 5 4 3 2 1
low-fat ingredients.
I am able to read a food label to identify fat content. 5 4 3 2 1
the nurse can provide specific additional education that may Action Plan and recommended by others include use of
eliminate costly misinformation or self-care mistakes. The Â�picture-based instructions, inclusion of graphs when commu-
National Action Plan (USDHHS, 2010b) recommends the use nicating health risks, and the use of video or Â�computer-based
of a “universal precautions” type of approach to health literacy. interactive processes (Houts etÂ€al., 2006). Pictures can improve
Because it is impossible to tell who is affected by limited health comprehension when they show relationships between ideas
literacy, assume that patients will have difficulty understand- or when they have simply worded captions. To improve read-
ing health information and use clear communication, simple ability of text, use simple sentences with one noun and verb
language, and print materials with everyone to ensure patients and words with only one or two syllables when possible.
receive the information needed to make health care decisions. Medical terms may be used, but they should be defined when
A tool to help determine the health literacy of the patient first introduced.
(Weiss etÂ€al., 2005) is readily available online free of charge. Existing print materials can be analyzed for actual readabil-
Known as the Newest Vital Sign (NVS), it is a nonthreatening ity of the text. Readability formulas, such as the SMOG read-
tool that asks the patient to read a sample ice cream label and ability formula (McLaughlin, 1969), Fry readability graph (Fry,
answer six associated questions. The ability to read, understand 1977), or Flesch readability graph (Flesch, 1949), are useful in
and act on the information quickly determines the patient's determining the appropriateness of health education materials.
health literacy. The tool takes three minutes to administer, is The SMOG readability formula has been chosen for inclusion
available in English and Spanish, and has been found to be a in this text because it is easy to use without use of a computer-
reliable indicator of health literacy. A complete toolkit with ized program and the formula can be applied to print materi-
instructions for the health care provider or administrator of als of varying lengths, including pamphlets with fewer than 30
the test is available online: http://www.pfizerhealthliteracy.com/ sentences. The nurse should practice using the SMOG formula
asset/pdf/NVS_Eng/files/nvs_flipbook_english_final.pdf. until it becomes a natural part of his or her practice (BoxÂ€20-6
and FigureÂ€20-2).
Predicting Readability of Materials Another method of determining the readability of materials,
The challenge for nurses who are preparing health education particularly those on the Internet or materials designed by the
programs is to select or create print materials that the learners nurse, is to use a computerized formula such as those available
can understand. Some improvements suggested in the National in Microsoft Word “Spelling and Grammar”.
BOXÂ€20-6â•…â•‡THE SMOG READABILITY FORMULA

Method A 4. Multiply this average by the number of sentences by which the
To calculate the SMOG reading grade level, begin with the entire writ- Â�material is short of 30 (e.g., if the material has 20 sentences, multiply
ten work that is being assessed and follow these four steps: the average by 10).
1. Count off 10 consecutive sentences near the beginning, in the middle, 5. Add the resulting figure to the total count of polysyllabic words in the
and near the end of the text. material.
2. In this sample of 30 sentences, circle all of the words containing 6. Find the square root of the number obtained in step 5 and add a
three or more syllables (polysyllabic words), including repetitions of Â�constant of 3.
the same word, and total the number of words circled.
3. Estimate the square root of the total number of polysyllabic words Method C
counted. This can be done by finding the nearest perfect square and Perhaps the quickest way to perform the SMOG grading test is to use
taking its square root. the SMOG conversion table. Simply count the number of polysyllabic
4. Finally, add a constant of 3 to the square root. The resulting number is words in your set of 30 sentences and look up the approximate reading
the SMOG grade, or the reading grade level that a person must have grade level on the following chart.
achieved if he or she is to fully understand the text being assessed. SMOG CONVERSION TABLE
â•›
A few additional guidelines can help to clarify these directions: Total Polysyllabic Approximate Grade
• A sentence is defined as a string of words punctuated with a period Word Count Level (± 1.5)
(.), an exclamation point (!), or a question mark (?).
0-2 4
• Hyphenated words are considered as one word.
3-6 5
• Numbers that are written out should also be considered; if the num-
â•‡7-12 6
bers are in numerical form in the text, they should be pronounced to
13-20 7
determine whether they are polysyllabic.
â•›â•›21-30 8
• Proper nouns, if polysyllabic, should also be counted.
â•›â•›31-42 9
• Abbreviations should be read as if they were spelled out to determine
43-56 10
if they are polysyllabic.
57-72 11
Method B 73-90 12
Not all pamphlets, fact sheets, or other printed materials contain 30 sen- â•‡â•›91-110 13
tences. To test a text that has fewer than 30 sentences, do the following: â•›111-132 14
1. Count all of the polysyllabic words in the text. 133-156 15
2. Count the number of sentences. 157-182 16
3. Find the average number of polysyllabic words per sentence as follows: 183-210 17
Average = Total no. of polysyllabic words/Total no. of sentences 211-240 18
SMOG conversion table developed by Harold C. McGraw, Office of Educational Research, Baltimore County Schools, Towson, MD.
Sample Text: Quitting Smoking: Conversation starters

1 2
Most smokers want to quit. Support from a family member or friend can make all the difference.
3
Use these tips to start a conversation about quitting smoking.
4
• Be positive:
5 6
“You are important to me. I want you to live a long healthy life.”
7
“Your body will benefit right away. Twelve hours after you smoke your last cigarette, the carbon
monoxide level in your blood will drop to normal.” 8
9
“After a few months, you’ll breath easier and have more energy.”
10
“No more bad breath!”
11
“Think about how much money you’ll save.”
12
• Share steps to quitting.
13 14
“Make a list of reasons you want to quit. Keep the list where you’ll see it often.”
15 16
“Set a date to quit. Give yourself two weeks to plan for your quit date.”
17
“Talk to your doctor about medicines that can help you quit.”
18
“Call 1-800-QUIT-NOW (1-800-784-8669) for free support and coaching.”
19
“Throw away your cigarettes, matches, and ashtrays – at home, in the car, and at work.”
20
• Offer support.
21
“Tell me how I can help you quit.”
22
“I promise to understand if quitting makes you irritable and anxious.”
“Let’s go for a walk.” 23
“Let’s decide how to celebrate after you’ve been smoke-free for a month.” 24
Calculating the SMOG Readability Formula for this sample:
Number of polysyllabic words 16

Number of sentences 24
16/24 0.67 6 (the number of sentences short of 30) 4.02
4.02 10 14.02
Square root of 14 3.7 plus constant of 3 6.7

This sample is about a seventh grade reading level.
FIGUREÂ€20-2â•‡ Sample use of the SMOG formula for evaluating print materials: Using method B
for health materials with fewer than 30 sentences. (Health education material from Healthfinder.gov:
Quitting smoking: Conversation Starters. Retrieved August 2011 from http://www.healthfinder.gov/prevention/
ViewTool.aspx?toolId=40).
The inability to read can have dangerous implications if makes the print more difficult to read. Because capital letters
the client does not understand instructions for medications do not vary in size and shape, the eye has difficulty differentiat-
and treatments. BoxÂ€20-7 includes suggestions for health care ing between letters. Many researchers recommend using bold
Â�providers to alleviate some of the problems of low literacy. print to highlight important elements and using uppercase and
Â�lowercase letters for text. Serif-style type is also preferred over
Selecting Materials sans serif because serif type uses additional details on the ends
In addition to readability, other factors should be considered of some letters, making them easier to read.
when choosing print material. The selection process should Reading materials with a right margin that is “ragged” (i.e.,
include analysis of the content, format, and appropriateness of with equal space between all words so that lines are of Â�varying
the print material for the target group. lengths) are easier to read than materials in which the space
Content. Assess the content of the print material to determine between words is adjusted to ensure that all lines are the same
if it is accurate, up to date, and presents all of the information length. Headings should be used for paragraphs. Each para-
a learner needs to know to change behavior. The nurse should graph should present one idea and be about four sentences long.
discern whether too much unnecessary information is pre- Enough space should be inserted between paragraphs or sec-
sented that might confuse the learner. (Remember, print mate- tions of the print material so that it does not appear crowded.
rials are a supplement to, not a substitute for, education.) The Using white space is pleasing to the eye and can also be helpful
material should be organized in a logical manner, and resources for emphasis. Bullet lists are also easy to read.
for more information should be included. Use of the active voice and first person—such as “Do I Have
Format. Assess the format of the print material. The type Diabetes?” or “How Do I Choose Healthy Foods?”—makes
style and size of print are important, especially when work- materials readable and appealing. A consideration specific to
ing with groups such as older adults whose visual acuity may health-related materials is the inclusion of medical jargon and
be decreased. Although words written in all capital letters abbreviations. Even though the nurse understands these terms,
may appear larger and clearer, using all capital letters actually the general public needs definitions of words.
BOXÂ€20-7â•…â•‡FOUR STEPS FOR HELPING Nonprint Materials

LOW-LITERACY LEARNERS Purpose of Audiovisual Materials
INÂ€AÂ€HEALTH CARE SETTING Nonprint materials, often called audiovisuals, can take a vari-
ety of forms, including a simple diagram or picture, audiotape,
1. Create a shame-free environment.
videotape, radio, television, computer-assisted learning (CAL),
Offer to help, especially with paperwork. Many clients begin
their health care experience in a negative manner when they
or interactive websites. Audiovisuals enhance learning through
are handed a clipboard to complete a health history. If you see clarification and reinforcement; they are convenient and
an incomplete form, ask the questions yourself and fill in the Â�cost-effective because they can be used repeatedly with groups
answers without impatience or annoyance. of learners without using the nurse's time. Audiovisual materi-
Let the client know that many people have difficulty with medical als can often be adjusted to the learner's own educational pace
questions and that you can help. to meet individual learning needs.
2. Use simple and direct language, and give examples. Audiovisuals can be used to provide experiences that might
Speak in simple and direct language. Avoid medical jargon. not be possible otherwise. These experiences include bringing
Cover only two or three points at a time. Read written mate- an expert into the community via videotape, transporting the
rial to the client and emphasize the key points. learner to a new community and culture, or allowing the learner
Review your materials for readability at a fifth- or sixth-grade to experience a life event—such as what happens during a heart
reading level; include pictures or diagrams. Redesign or select attack or the birth of a baby—without actually being there.
different materials if necessary. Use graphs or tables instead
of too many numbers. Selection of Audiovisual Materials
3. Use the teach-back technique. The nurse should preview the audiovisual aid and determine if
Instead of asking the client if he or she understands, try to phrase use of the audiovisual aid meets the learning objectives and is
the question so you get more than a yes or no answer. Ask appropriate for the group. With current trends to limit health care
the client to explain how to take his or her Â�medications or costs, compare the cost to purchase or rent the video to the ben-
to show you a procedure as he or she will do it at home. efit. If the audiovisual is expensive, the nurse could probably teach
Consider that noncompliance might really be lack of the same information using less expensive charts or pictures.
understanding.
However, if a learning objective is for each learner to plan low-
4. Target your approach based on what you know about the
fat meals for a week while keeping within the family budget, then
population.
Be proactive, in a community with health disparities such as Â�poverty,
investing in an interactive computer-based learning program might
nonnative speakers of English, or refugees; make arrangements provide individual learner feedback while saving nursing time.
for a family member or an interpreter to be present during the As with print materials, the nurse should determine the
counseling part of the visit. appropriateness of the audiovisual aid based on the reading and
Consider that the patient might not be the only reader of written comprehension abilities of the target group. A DVD or televi-
information. sion program is not useful if the language or medical jargon is
Assess your organization and the educational materials and resources too difficult for the group to comprehend.
for low-literacy clients.
Use of Audiovisual Materials
Modified from Schwartzberg, J., & Lagay, F. (2001, June). Health
Use of audiovisual materials also depends on the equipment
literacy: What patients know when they leave your office or clinic.
American Medical Association, AMA Ethics. Retrieved 2001 from available. Nurses should practice using the equipment. When
http://www.ama-assn.org; and Safeer, R., & Keenan, J. (2005, March). practicing, the nurse should move about the room to be sure the
Health literacy: TheÂ€gap between physicians and patients. American audiovisual material can be seen and heard. Using audiovisual
Family Physician, 72(3), 463-468. equipment is not difficult, but the nurse should feel Â�comfortable
doing so and should be able to solve minor technical problems.
An essential point to remember is to bring a backup disk or flash
Selection of Materials for Target Groups. Selecting print drive to the presentation. Some of the Â�advantages, Â�disadvantages,
materials that are appropriate for diverse ethnic and cul- and uses of audiovisual aids are listed in BoxÂ€20-8.
tural groups is of particular concern to the community/
public health nurse. Photographs or sketches of people Sources of Educational Materials
should represent the ethnicity of the community. Simply Community/public health nurses who prepare educational pro-
substituting ethnic faces, Â�however, is not enough. Culture grams need to locate sources for class materials. The first place to
also includes the values, traditions, norms, and customs start is the nurse's own agency. Most community/public health
of a community. The assistance of a member of the target agencies keep collections of resource materials, often compiled
group is useful in selecting materials that are appropriate by the nurses themselves. Other possible sources are distributors
for the community. of educational materials, catalogues, and Â�community agencies.
The nurse must determine whether resources or com- Time on the telephone can bring great results. A specific
modities mentioned in the material are readily available in telephone directory of community services is sometimes avail-
the Â�community. For example, a nutrition pamphlet empha- able. The regular telephone book should not be overlooked as
sizing eating fresh fruits and vegetables is not useful if these a resource for finding educational materials. The front of the
foods are too expensive or are not available in the commu- book may provide listings of governmental or private agencies
nity. A better choice of pamphlet might be one that compares that offer health services. Other places to look in the telephone
the nutritional values of affordable and available frozen and book are in the government section or listings under “health
canned foods. services” or “health care.”
BOXÂ€20-8â•…â•‡AUDIOVISUAL TEACHING AIDS

FLIP CHARTS Disadvantages
Advantages 1. Trained support personnel required to create a local production
1. Very inexpensive 2. Not suitable for large auditorium presentations unless several Â�monitors
2. Encourages audience involvement and feedback or a projection system is used
3. Provides degree of informality
4. Useful for small- to medium-sized groups in informal settings COMPUTER PROJECTION
Advantages
Disadvantages 1. Does not require darkened room
1. Less dynamic and more limited in presenting information 2. Seamless presentation of ideas with rate controlled by presenter
2. Cannot be seen in large rooms 3. A variety of programs such as PowerPoint can be used to add visual
3. Impractical in terms of portability and storage interest
4. Presenter able to face audience
VIDEOTAPE/DVD
Advantages Disadvantages
1. Allows for easy replay 1. Needs detailed instruction on setup and operation
2. Equipment generally available 2. May be transported, but presentation site must be equipped with
3. Usually feasible to do some local production of reasonably high quality electricity, screen, etc.
4. Very useful with small groups 3. Use of “busy” pictures can distract from presentation; training in
5. Materials portable and easy to store development of presentations highly recommended
A special tip for the nurse using the telephone is to create a print materials. Internet users with limited literacy are Â�generally
personal resource telephone book. When a call is productive, willing to use the Web to access health information and are
make a brief note of the agency telephone number, services Â�successful when the website is well designed with easy naviga-
and materials available, and the name of the contact person. tion and clear communication. The health literacy website devel-
Networking with colleagues is a valuable tool for all aspects of oped by the Office of Disease Prevention and Health Promotion
nursing care delivery. (USDHHS, 2010b) (http://www.health.gov/healthliteracyonline/)
The internet is another option for locating local resources— includes characteristics of how low-literacy learners use the Web
often agencies may have merged or combined purposes and and guidelines for designing easy-to-use websites.
these newer resources usually have a web page. Opportunities Some specific sources of reliable health education informa-
are available to locate educational materials from private tion are listed in Community Resources for Practice at the end
sources. Businesses in the community such as pharmaceuti- of the chapter and are also referenced in ChapterÂ€18.
cal companies or manufacturers of medical devices sometimes
supply educational materials. However, good judgment must Preparation of Teaching Aids
be exercised before adopting these materials for use. These If nurses cannot find appropriate teaching materials, they can
materials are often beautifully illustrated, with photographs of design some. An advantage to designing teaching aids is the
people using specific products, and free samples such as dia- ability to make the teaching aid specific to the community.
pers or coupons are sometimes provided. The nurse should Nurses may choose to rewrite teaching aids that are too difficult
review the materials for appropriateness. The educational mes- for the target group to read or to supplement existing mate-
sage must not depend on using a specific product. For example, rials with culture-specific information. A comprehensive guide
cooking with a nonfat cooking spray is healthier than frying, to developing effective print materials including how to define
regardless of the brand of cooking spray. When reviewing the the target audience and develop content is available through the
pamphlet determine if the client is receiving the message to buy National Cancer Institute (2003).
only one brand. Community/public health nurses also use various methods
The nurse should also visit the community library and to develop their own resource files. Suggestions include cutting
the local video store. The library usually keeps catalogues of and saving articles and pictures from newspapers, Â�magazines,
Â�community resources. Many libraries and video stores loan professional journals, and pamphlets, being careful to note
videotapes or DVDs with health information at minimal or the source of each. These materials do not have to be from
no cost. Again, the nurse must review these materials before Â�professional publications. A simple picture with an easy-to-
Â�recommending them to learners. read Â�caption found in a lay magazine can be effective. However,
specific health information should be consistent with the most
Internet Resources recent professional standards. Use of this file when looking for
Use of the Internet by nurses and their clients is changing the an educational aid or when the need exists to create a Â�program
delivery of health care and accessibility of health-related infor- may save time and energy. As a note of caution, the nurse
mation. A client may bring new or conflicting information that should be aware of copyright issues, taking care not to repro-
was downloaded from the Internet to the health education set- duce materials that have been copyrighted without permission
ting. The nurse has the responsibility to help the client deter- from the author. Fortunately, federal government health-related
mine the quality of Internet materials (BoxÂ€20-9). In addition resources are abundant, and these materials are not copyrighted
to evaluating the Internet source, the nurse should also evaluate and are in the public domain for use by anyone. A Â�copyright-free
the site for readability using methods similar to those used for graphics library, NIDDK Image Library (n.d.), is Â�available from
BOXÂ€20-9â•…â•‡CRITERIA FOR EVALUATING INTERNET RESOURCES

Authorship Navigation, Links, and User Friendliness
• Are the author's name and credentials or a list of consultants on the • Is the site easy to use?
site? • Is the site consistently available? Does the site download and print
• Are the authors and/or consultants clinically reputable? without difficulty?
• Can the author be contacted? Can you give feedback to the site • Is the presentation logical?
administrator? • Does the site have a site map?
• Does the site have links to other sites? Do they work? Are the linked
Nature of Information and Resources sites credible and relevant?
• What is the purpose of the site? Is a mission statement provided? • Is client privacy protected? No registration should be needed to use
• Where does the information originate? Is it a reputable organization? the site. Be aware of sites that share user information for future
• Are health care journals cited? advertising.
• Is the information current? Does a date indicate recent updates?
Readability
Content Accuracy • What is the reading level of the material?
• Is the content complete? Is the information based on clinical evidence • Are there other special readability features such as diagrams or
or research? graphs?
• Does an advertiser sponsor the site? If yes, is there a distinction • Is there minimum redundancy?
between advertising and educational content? Is there an advertising • Is the site designed for patients or for professionals? Does the
policy indicating that the advertisers do not play a role in selection of site encourage you to share the information with your healthcare
health information? provider?
• Does the site appear to be biased? • Can the font be enlarged for use by visually impaired persons? Are
• Is the owner of the site trying to sell a product? there accommodations for other disabilities?
Data from Cader, R., Campbell, S., & Watson, D. (2003). Criteria used by nurses to evaluate practice-related information on the World Wide Web.
Computers, Informatics, Nursing: CIN, 21(2), 97–102; and U.S. National Library of Medicine, National Institutes of Health. MedlinePlus quality
guidelines. Accessed August 2011: http://www.nlm.nih.gov/medlineplus/criteria.html.
the National Institute of Diabetes and Digestive and Kidney Principles of

Diseases, National Institute of Health (NIDDK) website (http:// Teaching
catalog.niddk.nih.gov/ImageLibrary/).
EDUCATIONAL
PRINCIPLES OF TEACHING ENVIRONMENT
PHYSICAL — Communications and
We can now consider the teaching principles that the nurse ENVIRONMENT rapport
can use throughout the health education process. The nurse Support, participation,
— Convenient location clarifying, sharing
can think of these principles as an umbrella covering the entire — Size of room — Diversity
teaching–learning process. A little bit of coverage can make the — Chairs — Experience
experience more comfortable for the nurse and the learners — Equipment Valuing of life’s knowledge
— Lighting — Personalization
(FigureÂ€20-3). — Temperature Inclusion of culture and
home environment
Physical Environment
The location of the meeting is the initial consideration. A con-
venient location prevents transportation problems that prohibit Community learning needs Content and strategy selection
attendance. Health education often occurs in health centers or Learner assessment Evaluation
in public facilities, such as schools, libraries, senior centers, or Emotional readiness Evaluation outcomes
fire halls. In areas with public transportation, these places are Experiential readiness Teacher effectiveness
Factors in a group of learners Use of print or audiovisual
generally accessible during the day but may not be as accessible Behavioral objectives materials
during the evening, especially if bus routes change after busi- Problems of low literacy
ness hours. In rural areas or areas with no public transportation,
educational programs may be offered in conjunction with other
FIGUREÂ€20-3â•‡ Principles of teaching.
events, such as meetings of faith communities. The nurse also
needs to assess the location and make sure it is accessible and
appropriate for persons with disabilities or health problems. For The nurse might be able to make some security arrangements at
example, conducting an arthritis group-educational session on the facility if problems exist. Encouraging participants to “come
the upper floors of a building without an elevator or conducting with a friend” is another good suggestion to promote safety.
a session for clients who have hearing problems in a building The nurse should preview the physical environment to assess
in which renovation or construction is causing environmental the size of the room and ensure adequate seating for the num-
noise would be inappropriate. ber of people expected. Before the group arrives, the nurse
Another consideration is the safety of the neighborhood and should arrange seating to suit the educational plan. If small-
available lighting if the educational session is held in the Â�evening. group discussion is planned, chairs around a circular table are
ideal. For larger groups, just a circle of chairs is appropriate. If maintain eye contact and speak slowly so the client can use
lecture and demonstration are planned, placement of chairs in a lip Â�patterns and facial expression to help with comprehension.
semicircle allows everyone to see the demonstration. With very Good lighting is important for the client to obtain nonverbal
large groups, using several semicircular rows is still effective if cues. If a window is available, the hearing-impaired person
the chairs are not directly behind one another. should sit with his or her back to the window and the nurse
Two comfort factors are the lighting and temperature of the should face the learner. With this arrangement, the light is on
room. The ability to adjust the lighting is particularly impor- the face of the professional and not shining in the client's eyes.
tant when using projected visuals. The nurse should practice In addition, the nurse should be aware of daylight that provides
lighting adjustments before the group arrives. Temperature is an uncomfortable glare or exceptionally bright electric lights
important, because learners who are too cold or too warm may that put a glare on the nurse's face or shine in the client's eyes.
have difficulty concentrating.
Diverse Strategies
Educational Environment The nurse should plan the health education program to provide
In addition to assessing and altering the physical environment, a variety of learning experiences. Based on the assessment of
the nurse should adjust the educational environment to Â�promote learner needs, teaching strategies should be matched to learn-
the optimal learning experience. Using the following principles, ing styles. Some people learn by doing, some by hearing, oth-
the nurse can improve the response of the Â�participants to the ers by reading. Use of a variety of teaching strategies will retain
educational program. learner interest and meet group needs. The opportunity exists
to choose a strategy (see TableÂ€20-4) that meets the objectives
Communication and Rapport and also meets the needs of adult learners (see TableÂ€20-1) for
Learning should be a shared experience. The nurse's commu- self-Â�direction and control over the learning environment.
nication skills and ability to develop rapport with the learners
enhance education. When the nurse offers some initial informa- Experience
tion about credentials and experience, the group's confidence in Each learner brings his or her experiences, positive or negative,
the nurse as a resource is increased. The nurse should encourage into the educational setting. The nurse needs to consider indi-
group participation and communicate willingness to support vidual experiences when planning the content and strategies for
the learners, ensuring the freedom to ask questions and make health education. Listening carefully to the experiences of the
mistakes within the group until objectives are met. group gives the nurse the needed information. The learner who
The nurse needs to be flexible. Even when a lecture is planned, has had a negative experience with health education might be
allow time for group participation, especially with adult learn- reluctant to participate and should not be pressured to Â�participate.
ers who expect to share. The nurse needs to develop the Â�ability The nurse may need to have alternate activities or roles available
to summarize, paraphrase, then reinforce and clarify health for the reluctant participant. For example, if a person is unwilling
Â�information for the group. Rapport is enhanced as the nurse to participate in a role-playing exercise, the client might be the
Â�values member contributions to the group. designated note taker or observer of the exercise.
The nurse might not be able to answer all discussion ques-
tions. A candid statement such as, “I don't know the answer Personalization
to that, but I can look for it” or “Let me tell you some of the Learners will have differences in age, gender, experience, socio-
resources we could both use to find the answer” supports the economic status, culture, and other factors. Using cultural
learner's needs and creates a climate of shared responsibility for examples in the content can be useful for personalization.
learning. This response also reinforces the concept of Â�asking for Culturally appropriate teaching materials are essential, and the
help and using community resources to meet learning needs. nurse should have a list of resources that may help overcome
Nonverbal communication is of special importance when cultural barriers, such as a resource list for persons who speak
providing health education. Only a fraction of the meaning of English as a second language. Learning can also be personal-
communication is transmitted through the spoken word; the ized by using individual learning contracts and individually
rest is conveyed through nonverbal cues such as body language, Â�negotiated behavioral modifications.
facial expression, and tone and pitch of voice. Another way to personalize teaching is to ask the learners
Awareness of nonverbal communication is important when how they will apply the knowledge at home. Sharing applica-
working with clients who have hearing impairments, such as tion ideas in the group provides reinforcement of content and
older adults. In this situation, the nurse must establish and also stimulates learning by encouraging others to try new ideas.
KEY IDEAS
1. Delivery of health education is both a historic and an increas- Â�
process and how it can be applied in a variety of commu-
ingly important role of the community/public health nurse. nity settings with individuals, families, and groups.
The current public and professional emphasis on health and 4. Assessing the community and the learners is necessary
wellness provides the perfect opportunity for community/ before the content and strategies for health education are
public health nurses to use their teaching skills. planned.
2. Promoting a healthy lifestyle through health education is a 5. Behavioral objectives are a useful tool for planning and
vital aspect of community/public health nursing. evaluating learning experiences.
3. To plan and implement health education programs, the 6. Content and strategies of the educational program should
nurse must have an awareness of the teaching–learning be tailored to the needs of the community or group.
7. Evaluating the learner outcomes, the nurse, and the edu- 9. A variety of teaching techniques, personalized instruction,
cational session are necessary to maximize the value of the and interpersonal support promote lifestyle changes.
health education program. 10. Principles of teaching can be used to enhance the teaching–
8. Print, audiovisual, and Internet materials need to be care- learning process.
fully analyzed before use.
CASE STUDY
Planning a Health Education Program
Ginny is a community health nurse who has spent most of her career CONSTRUCTING THE LESSON PLANS
working in ambulatory care clinics. She decided she needed a change Overall Goal
and moved to a new community. She quickly found a challenging job The learners will participate in daily physical activities that promote
as an occupational health nurse in an electronics plant. Part of the job health and well-being.
description for her new job includes planning and implementing health Behavioral Objectives (Samples)
education programs. 1. Ninety percent of the learners will identify two times during the work-
After spending a few months in her new office, Ginny has begun to day when they might walk instead of using the elevator or shuttle bus.
see some trends in the type of assistance being sought and the indi- 2. Ninety percent of the learners will identify two enjoyable physical
viduals who are seeking it. Many of these people are young men, activities that can be integrated into the family lifestyle.
25 to 35â•›years old, who request blood pressure checkups. Most of the 3. Sixty percent of the learners will engage in physical activity for
men have normal blood pressure, and Ginny is not sure why they con- 30Â€minutes three times during the week.
tinue to come to her office. Ginny enjoys talking and begins to conduct 4. Ninety percent of the learners will explore their feelings about start-
informal assessments on the workers as they come to see her. Many of ing an exercise program.
them have young families to support and fear losing their jobs. Some
workers talk with her about the inability to cope with problems at home Content
and the inability to sleep at night. Few of them engage in any regu- • Health benefits of a regular exercise program
lar cardiovascular exercise, and when she sees them in the cafeteria, • Safety considerations for beginners (e.g., existing health problems)
Ginny observes them eating high-fat foods with little nutritional value. • Examples of how to fit exercise into daily life
When their weight and height are assessed, more than two-thirds of • Popular family activities that promote exercise and family togetherness
the men are found to be overweight. Ginny wants to begin her health- • How to choose an activity program that the individual will continue
teaching programs but cannot decide what content to include. She is • Examples of common excuses for not exercising
not sure whether she needs to do any more assessment of the group, • Benefits of support from others
given that she may already have more health teaching to do than she • List of community resources for low-cost activities
can handle. Teaching Strategies
Where should Ginny begin? Is her needs assessment complete? • Lecture
How should she prioritize the content of the teaching program? Does • Small-group discussion for generating more ideas and examples
she know enough about the learners to plan teaching strategies? • Flip chart/markers for listing group ideas
Will Â�anyone be interested in participating in a health education • A “buddy system” to offer support
program? • Role-playing of the sedentary worker and his or her support buddy
offering encouragement
NEEDS ASSESSMENT AND LEARNING DIAGNOSIS • Continued intervention by giving each participant a hang tag for the car
Ginny recognizes the need for health education on cardiovascular rear-view mirror with a reminder to park far away and walk to work
health, diet, and stress reduction. She also recognizes the importance • Brochures and websites from community recreation groups that offer
of continuing the establishment of rapport. To begin her health educa- organized activities for individuals and families
tion series, Ginny plans to combine a continued needs assessment with
a brief health-teaching session. EVALUATION METHODS AND RESULTS
The needs assessment will help Ginny clarify the priorities of the • Evaluation methods were planned when a lesson plan was developed.
learning needs. A brief teaching will help establish rapport and identify • Game-show–style questions were used to evaluate objectives 1 and 2;
her as a resource to the workers. all of the participants were able to meet the objectives during the class.
The health teaching will be “Think You Are Too Busy to Exercise?” • Objective 4 was measured by observing the participants verbally
Ginny has chosen exercise because daily exercise can positively affect sharing ideas in class and in small groups. All of the participants were
each of the identified health problems. able to meet this objective.
Ginny makes sure that the health education session is held at a • To evaluate objective 3, participants were asked to report their exer-
convenient time and that all workers are given paid time to attend cise patterns at 1â•›month. Seventy percent of the participants reported
if they desire. The needs assessment is accomplished by briefly increasing exercise to 30 minutes three times per week.
sharing her observations and requesting a show of hands to indi- Additional Evaluation
cate interest in the cardiovascular health topics. Ginny is also open • Evaluation of teacher effectiveness was accomplished by using (1) an
to discussion and suggestions for future topics and writes these evaluation tool (see TableÂ€20-5) and (2) peer evaluation.
on the overhead. Two index cards and a pencil are also given to • Evaluation of the need for additional health education sessions was
each participant to write additional ideas anonymously and put based on requests to repeat the session by workers who were unable
them in a suggestion box. She also invites another nurse educa- to attend and on attendance at subsequent sessions.
tor whom she knows professionally to attend and assist with the See Critical Thinking Questions for this Case Study on the book's
initial session. website.
1. Select a teaching aid such as a booklet or pamphlet that you constructive suggestions to one another on improving your
have used in the past for health education of a family or teaching techniques.
group. Analyze the teaching aid for readability, content, and 4. Participate as a learner in a nurse-coordinated health edu-
format. Noting your results, will you use the material again cation group in your community. How did you choose the
or look for something different? group that you attended? Were your learning needs met?
2. Talk with a community/public health nurse about some Did you experience a change in behavior? What made the
completed group health education sessions. Did the nurse Â�experience a positive or a negative one?
consider the education to be successful? What criteria were 5. Call some providers of health education in your area and
used to measure success? What would the nurse do differ- inquire about their registration procedures for health educa-
ently if he or she were repeating the program? Was the nurse tion classes. Is requiring participants to register for the program
reimbursed specifically for teaching or was it considered part a confidentiality issue, especially if the program deals with a
of the job? sensitive topic or chronic illness? Should attendance at educa-
3. Working with a peer group, develop a health education plan tional programs be monitored and reported to case managers
for implementation either with actual clients or with a group for clients who participate in a managed care organization?
Â�
of peers. Make a video recording of the implementation of Should attendance be mandatory for clients diagnosed with a
the program. With the group, review the video and offer controllable illness such as high blood pressure?

Information about each of the following organizations is on its National Cancer Institute Clear & simple: Developing effective
website. print materials for low-literate readers: http://www.cancer.gov/
cancertopics/cancerlibrary/clear-and-simple/page1
HEALTH-ORIENTED NATIONAL ORGANIZATIONS National Health Information Center: http://www.health.gov/nhic/
American Academy of Pediatrics: http://www.aap.org/ National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/
American Cancer Society: http://www.cancer.org/ National Institute for Occupational Safety and Health: http://
American Diabetes Association: http://www.diabetes.org/ www.cdc.gov/NIOSH/
American Heart Association: http://www.heart.org/HEARTORG/ National Institutes of Diabetes and Digestive and Kidney
American Lung Association: http://www.lungusa.org/ Disease NIDDK Image Library: http://www.catalog.niddk.nih.
gov/imagelibrary/
SELECTED FEDERAL GOVERNMENT RESOURCES National Institutes of Health: http://www.nih.gov/
Agency for Healthcare Research and Quality: http://www.ahrq.gov/ Office of Disease Prevention and Health Promotion National
Centers for Disease Control and Prevention: http://www.cdc.gov/ Action Plan to improve health literacy and Health literacy
Consumer Product Safety Commission: http://www.cpsc.gov/ online: A guide to writing and designing easy-to-use health
HealthFinder.gov: http://healthfinder.gov/ Web sites: http://www.health.gov/healthliteracyonline/
MedlinePlus: http://www.nlm.nih.gov/medlineplus/ Office of Minority Health: http://minorityhealth.hhs.gov/
WEBSITE
STUDY AIDS
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October 2011 from http://catalog.niddk.nih.gov/ Winters, J. M., & Winters, J. M. (2007). strategy for older audiences. Gerontological
ImageLibrary/. Videoconferencing and telehealth technologies can Nursing, 33(3), 45-52.
Office of Minority Health. (2011). Retrieved provide a reliable approach to remote assessment Van Servellen, G., Nyamathi, A., Carpio, F., etÂ€al.
October 2011 from http://minorityhealth.hhs.gov/. and teaching without compromising quality. (2005). Effects of a treatment adherence
Redman, B. K. (1984). The process of patient Journal of Cardiovascular Nursing, 22(1), 51-57. enhancement program on health literacy, patient-
education (5th ed.). St. Louis: Mosby. provider relationships, and adherence to HAART
Redman, B. K. (1997). The process of patient SUGGESTED READINGS among low-income HIV-positive Spanish-
education (8th ed.). St. Louis: Mosby. speaking Latinos. AIDS Patient Care and STDs,
Rosenstock, I. M. (1974). Historical origins of Cutilli, C. C., & Schaefer, C. (2011). Case studies 19(11), 745-759.
the health belief model. In M. Becker (Ed.), in geriatric health literacy. Orthopaedic Nursing, Wallace, A. S., Carlson, J. R., Malone, R. M.,
The health belief model and personal behavior. 4(30), 281-285. etÂ€al. (2010). The influence of literacy on
Thorofare, NJ: Slack. Huffman, M. (2007). Health coaching: A new and patient-reported experiences of diabetes self-
U.S. Department of Health and Human Services. exciting technique to enhance patient self- management support. Nursing Research, 59(5),
(2010a). Healthy People 2020. Washington, DC: management and improve outcomes. Home 356-363.
U.S. Government Printing Office. Healthcare, 25(4), 271-274. Wilson, L. D. (2011). Developing low-literacy health
U.S. Department of Health and Human Services, Koniak-Griffin, D., Lesser, J., Nyamathi, A., etÂ€al. education materials for women. Maternal Child
Office of Disease Prevention and Health (2003). Project CHARM: An HIV prevention Nursing, 36(4), 246-251.
U N I T
6
Contemporary Problems in
Community/Public Health
Nursing
21 Vulnerable Populations
22 Disaster Management: Caring for Communities in an
Emergency
23 Violence: A Social and Family Problem
24 Adolescent Sexual Activity and Teenage Pregnancy
25 Substance Use Disorders
526
CHAPTER
21
Vulnerable Populations
Frances A. Maurer
FOCUS QUESTIONS
Are there groups that are at greater risk for diminished or no What types of social services are available for vulnerable
access to health care services? groups?
What predisposing factors make some people more vulnerable Has cost containment affected services? If so, in what ways?
than others? How can community/public health nurses help vulnerable
What are some of the risks associated with vulnerable groups? groups access services?
What are some of the most common health problems for What actions can a community/public health nurse take to
vulnerable groups? reduce health problems associated with poverty and other
What impact does lack of health insurance have on people? risk factors?
CHAPTER OUTLINE
Vulnerable Populations Characteristics of the Homeless
Definition of Vulnerable Population Shelters and Food Assistance
Multiple Factors Increase Vulnerability Medical Problems Associated with Homelessness
Poverty Migrant/Seasonal Workers
Poverty Defined Characteristics of Migrant/Seasonal Workers
Effects of Socioeconomic Status on Health Vulnerability of Migrant/Seasonal Workers
Health Status Indicators and Poverty Special Health Concerns of Migrant/Seasonal Workers
Income Level and Access to Health Care The Prison Population
Race and Ethnicity and Their Relationship to Income Health Issues in the Prison Population
and Health Status Services Available for Vulnerable Populations
Mortality and Morbidity Welfare Reform—TANF/Medicaid
Other Factors That Impact Racial/Ethnic Health Disparities Medical Care
Diet, Health, Socioeconomic Status, and Racial/Ethnic Housing
Influences Government Budget Crisis and Availability of Services
The Uninsured Nursing Considerations for Vulnerable Populations
Number of Uninsured Knowledge of Available Programs
Employment Status and Health Insurance Assistance with Language Barriers and Cultural Concerns
Uninsured Children Primary and Secondary Prevention
Impact of No Health Insurance on Health Case Finding
Homelessness Advocacy for Improved Services
Definition of Homelessness Partnership with Community Groups
Number of Homeless Data Collection and Research
KEY TERMS
Extremely poor Migrant worker Runaways
Food insecurity National housing wage Seasonal worker
Homelessness Poverty Throwaways
In-kind payments Poverty index Vulnerable population
527
528 CHAPTER 21â•… Vulnerable Populations
Economic
VULNERABLE POPULATIONS Environment status
Within the population of the United States, there are aggregates Psychologic Genetic
or groups that run a disproportionately greater risk for poor impact of heredity
health than the remainder of the population. These groups have poverty
certain characteristics, traits, or experiences that increase their
vulnerability. All health care professionals, especially commu- Mental
nity health nurses, come in frequent contact with individuals Occupation health
and families at great risk.
Health Status
Definition of Vulnerable Population
Age
A vulnerable population is a group or groups that are more Gender
likely to develop health-related problems, have more difficulty
accessing health care to address those health problems, and are
more likely to experience a poor outcome or shorter life span Lifestyle
because of those health conditions. There are a number of char- Race/
behaviors
ethnicity
acteristics, traits, or circumstances that enhance the poten-
tial for poor health. Healthy People 2020 (U.S. Department of Culture Education
Health and Human Services [USDHHS], 2010) has identified FIGUREÂ€21-1â•‡ Multiple factors determine health status.
certain groups as more vulnerable to health risks, including the
poor, the homeless, the disabled, the severely mentally ill, the
very young, and the very old. See the Healthy People 2020 box on would be more likely to experience difficulties obtaining and
this page for more information. maintaining a relationship with a primary care provider, would
have problems accessing tests and procedures for diagnosis and
HEALTHY PEOPLE 2020 ongoing monitoring, and would have difficulty obtaining and
paying for the appropriate medications.
Objectives Relevant to Vulnerable Populations—
Improve Access to Care Multiple Factors Increase Vulnerability
1. Increase to 100% the proportion of persons with health insurance The more risk factors for poor health a person or group has, the
(baseline: 83.2% of persons under 65â•›years had health insurance in more likely that person or group will be vulnerable. FigureÂ€21-1
2008). illustrates the interrelationships among multiple factors that
2. Increase the proportion of persons who have a specific source of affect health status. Some of these factors include lower socio-
ongoing care. economic status, lifestyle behaviors, the psychological impact
of poverty, genetic inheritance, race, ethnicity, and gender, as
Age Group 2008 Baseline 2020 Target well as those factors previously mentioned in the discussion. As
Children under 17â•›years 94.3% 100% noted in ChapterÂ€7, a person or group can alter some but not
Adults 18â•›years and older 81.3% 89.4% all factors associated with health risks. For example, a person
who smokes can stop smoking and reduce his or her risk for
3. Increase to 83.9% the proportion of people with a usual primary lung cancer and heart disease, but a person cannot alter his or
care provider (baseline: 76.3% in 2007).
her genetic heritage. Some lifestyle situations are more resistant
4. Reduce the proportion of persons who delay or have difficulty in
to change and are not easily overcome. For example, someone
getting emergency medical care to 9% (baseline: 10% delayed or
had difficulty getting emergency care in 2007).
living in poverty might be there as a result of multigenera-
5. Reduce food insecurity among U.S. households to 6% and in so tional poverty, poor education, poor health, or sudden change
doing reduce hunger (baseline: 14% of households in 2008). in financial situation. Persons with sudden changes in financial
situation (e.g., as a result of a loss of employment or a downturn
Data from U.S. Department of Health and Human Services. (2010). in the economy) are more likely to easily improve their financial
Healthy People 2020. Washington, DC: Author. Available at http:// situations. Others in poverty face years of struggle and many
www.healthypeople.gov. Refer to ChaptersÂ€7, 8, 10, 23, 24, 25, 27, 28,
31, 32, and 33 for specific objectives related to specific vulnerable
roadblocks to improving their economic situations.
populations. Nurses are accustomed to identifying risks associated with
poor health and devising interventions to improve health status.
Not all people who are at risk for poor health would be Working with vulnerable populations, nurses must become adept
considered vulnerable. To be considered vulnerable, a person at identifying risks that are amenable to intervention as well as
or group generally has aggravating factors that place them at those that require greater effort to overcome and those that are
greater risk for ongoing poor health status than other at-risk per- not alterable. This chapter identifies some of the most important
sons. For example, a middle-aged obese man with a sedentary factors associated with increased vulnerability and their relation-
lifestyle and hypertension would be considered at risk for car- ship to poor health. Other chapters in this book address specific
diac problems. If that man also had an income below the pov- vulnerable groups, including Â�children (ChapterÂ€27), older adults
erty level, no health insurance, and stressors related to living (ChapterÂ€28), sexually active adolescents (ChapterÂ€24), indi-
conditions, he would be more likely to be vulnerable to ongoing viduals exposed to Â�violence (ChapterÂ€23), addicted individuals
poor health status than a man with similar risk factors but with (ChapterÂ€25), and the Â�mentally ill (ChapterÂ€33), and these groups
an adequate income and health insurance. The man in poverty are not discussed in detail in this chapter.
CHAPTER 21â•… Vulnerable Populations 529
POVERTY Â�
critics contend, the number of poor in the United States
would be substantially lower (Lewit etÂ€al., 1997). The National
The most important factor associated with health status is eco- Research Council performed an extensive review of the poverty
nomic status. Poverty drastically increases a person's or group's index in 1995. The council found that including certain omit-
vulnerability to poor health status. ted items (such as in-kind payments) would have lowered the
number of people categorized as living in poverty, but consider-
Poverty Defined ing other factors (such as adequate adjustment for inflation of
When we think of the poor, we think of people living in Â�poverty. basic goods, work-related expenses, child care expenses, medical
People who are poor have difficulty providing the basic neces- expenses) would have raised the poverty threshold. They rec-
sities of food, clothing, and shelter for themselves and their ommended that a new poverty measure be adopted, one that
families. The United States has chosen to set a living standard better reflects the actual value of benefits and income and is
it considers “adequate,” and persons who fall below this income more easily adjustable for changes in inflation and the cost of
are considered poor. This standard is called the poverty index living (Citro & Michael, 1995).
or threshold. The U.S. Census Bureau and the Bureau of Labor Statistics
The poverty index is derived by determining the costs of have developed a prototype index to be used in conjunction
purchasing specific goods and services. It incorporates the cost with the current poverty index. This index, the Supplemental
of food for a minimum adequate diet (called the Economy Food Poverty Measure, addresses many of the major concerns with
Plan) and multiplies that cost by a factor of three to arrive at a the poverty index. The federal budget for 2011 did not include
basic subsistence standard. Adjustments are made to that figure funding for this project (Census Bureau, 2011a). At present the
for family size and age of household members (TableÂ€21-1). In original index is still in use.
2010, the poverty index for a family of four was $22,113. Any The incomes of 15.1% of all persons in the United States fell
family of four whose income falls below this figure is consid- below the poverty level in 2010. This translates into 46.2 mil-
ered to be poor, and any family whose income is above this lion, an increase of 6.6 million from 2008 (DeNavas-Walt etÂ€al.,
level is considered not poor. However, the income standards 2011). Of that group, 20.4 million (44%) had incomes of less
used to set the poverty index are in dispute. Criticism of the than 50% of the poverty level. People with incomes at 50% or less
income standards centers around conceptual and measure- of the poverty level are considered the extremely poor.
ment issues.
Fluctuations in the Poverty Level
Criticisms of the Poverty Index The poverty level remained relatively stable from the 1970s
There are many specific concerns with the criteria used to through the mid-1980s. Since then, however, this country has
determine the poverty index (Citro & Michael, 1995; Short experienced at least one period of high inflation, four episodes
etÂ€al., 1999; U.S. Bureau of the Census [Census Bureau], 2010). of substantial economic recession, and high unemployment,
Website Resource 21A provides a summary of specific criti- which have pushed a large number of families closer to the pov-
cisms of poverty measurements. The major criticism of the cur- erty index ceiling. FigureÂ€21-2 provides an illustration of the
rent poverty index is that it is an inadequate measure of poverty fluctuations in poverty level and shows the impact of recession
and should include costs of food, clothing, and shelter. on the poverty level. According to the U.S. Census Bureau there
Another criticism centers on the issue of in-kind pay- are approximately 60.4 million people whose income is less than
ments. In-kind payments are governmental subsidies such as the poverty level or no more than 25% above the poverty level
food stamps, public housing assistance, and vouchers provided (DeNavas-Walt etÂ€al., 2011).
by the Women, Infants, and Children (WIC) program that are Proponents of changing the poverty index measures believe
not counted as income. Were these benefits counted as income, that the government's reluctance to revise them is tied to the
political implications of such a move. If the newer measures
were adopted or inflation adjustments were done yearly, a sub-
TABLEÂ€21-1â•…â•‡POVERTY THRESHOLD IN
stantial number of people might be added to the poverty rolls
2010 BY FAMILY SIZE AND (Betson & Michael, 1997). No one in government wants to be
NUMBER OF RELATED held responsible for policies that could increase the size of the
CHILDREN UNDER 18 YEARS impoverished population.
FAMILY UNIT* SIZE POVERTY THRESHOLD
Shrinking Middle Class at Risk for Poverty
1 $11,344
2 $14,602 The gap between rich and poor is widening, which leaves the
3 $17,552 poor relatively poorer in general terms. The middle class is
4 $22,113 shrinking, and some middle-class families have lost ground and
5 $26,023 slipped into a lower economic level. Although most Americans
6 $29,137 do not live in poverty, the trend toward increasing numbers of
7 $36,635 poor is a matter of concern. Americans who are relatively well
8 $35,879 off (median family income, $50,599) have become uneasy about
9 or more $43,845 their future status. In fact, the U.S. Census Bureau reports that
*One or more adults and all related children.
the distribution of income has become more unequal over time.
From U.S. Bureau of the Census. (2010). Poverty threshold 2010. In 2010, the mean income of those in the top 20% was 15 times
Washington, DC: Author. Retrieved September 7, 2011 http://www. greater than the income of families in the lowest 20%. That
census.gov/hhes/www/poverty/data/threshld/thresh10.xls same year the top 20% of households earned more than the
Numbers in millions, rates in percent Recession

50
45 46.2 million
Number in poverty
40
35
30
25
20
Poverty rate
15 15.1 percent
10
0
1959 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
FIGUREÂ€21-2â•‡ Number in poverty and poverty rate: 1959 to 2010. (Data from DeNavas-Walt, C., Proctor,
B., & Smith, J. C. [2011]. Income, poverty, and health insurance coverage in the United States: 2010. Current
Population Reports, P60-239. Washington, DC: U.S. Bureau of the Census.)
Â�
combined income of the other 80% of households (DeNavas- (Briody, 2010; USDHHS, 2006). Adults 45 to 64â•›years of age who
Walt etÂ€al., 2011). The nation's experience with economic are below the poverty level are two to three times more likely to have
slumps or recessions and the growing government budget defi- three or more chronic conditions than are people with incomes of
cit serve as uneasy reminders that many more American fami- 200% or more above the poverty level (KFF, 2010). They are also
lies could easily suffer economic reversals and join the poor. more likely to experience severe headaches, migraines, low back
pain, neck pain, and joint pain than are people in better economic
Effects of Socioeconomic Status on Health circumstances (Braverman, 2011; USDHHS, 2006).
Socioeconomic status influences health status in many differ-
ent ways. It is not sufficient to consider only access to health Impact on Health of Multiple Stressors
care; the general standard of living is also an important influ- Associated with Poverty
ence on a person's level of health. Poor families have a harder The poor and vulnerable groups live with inadequate resources
time acquiring the basic necessities of food, clothing, shelter, and ongoing crises as they attempt to meet their and their fami-
and transportation. Diet, living conditions, and occupational lies' needs for food, clothing, and shelter. Many worry about the
hazards, as well as access to health care and the time frame in safety of their neighborhoods. These multiple unrelenting stress-
which medical care is sought, are all affected by income and, ors can impact a person's health, mood, and sense of well-being
in turn, affect an individual's health. Because of cost, the poor (Evans & Kim, 2010). People in poverty are more likely to report
often have to make choices between medical care and other feeling hopeless, powerless, and unable to manage their prob-
basic needs. Persons at or below the poverty level are 5 times lems. Depression is a commonly reported problem in vulnerable
more likely than those better off to delay seeking care because people. Research has suggested that adverse changes in income
of cost and 3.5 times more likely not to get care at all (Kaiser are associated with depressive symptoms (Heflin & Iceland,
Family Foundation [KFF], 2010; USDHHS, 2006). People below 2009). The stresses associated with poverty have other adverse
the poverty level are twice as likely to use the emergency room effects on mental health. Adults with incomes at or below the
as those who are better off. Public health care practitioners must poverty level are seven times more likely to have serious psycho-
be aware of all the risks associated with poverty if they want to logical distresses than those with higher incomes (200% or more
improve health status in poor populations. of the poverty level) (Pratt & Brody, 2008; USDHHS, 2006).
Health Status Indicators and Poverty Personal Perceptions of Individual Health

Mortality figures are used as one means of measuring health The poor are more likely than the nonpoor to see themselves as
status. The effects of income on mortality are measured directly physically unwell. Health interview surveys are used to Â�measure
and indirectly. Studies suggest a link between very poor eco- an individual's perception of health status. In these surveys
nomic status and early death (Hadley, 2005; Institute of lower-income persons have consistently reported greater disabil-
Medicine [IOM], 2001) ity in terms of impairment of activities or confinement to bed,
Certain illnesses have been identified as being more com- more worry and discomfort from illness, and higher dissatisfac-
mon among people living in poverty than in middle-income and tion with their health status (Brooks-Gunn & Duncan, 1997;
high-income groups (Braverman, 2011; USDHHS, 2006). These Cantor etÂ€al., 1998). About 72.3% of the poor report at least one
include anemia, arthritis, asthma, diabetes, hearing impairments, limitation in activity, whereas only 44.1% of the persons with
influenza, pneumonia, tuberculosis, and certain eye abnormalities incomes at 400% of the poverty level do so. The poor perceive
their health as poor or fair (21.8%) at almost three times the rate Mortality and Morbidity
reported by the nonpoor (8.6%) (USDHHS, 2011). Two important indirect measures of the influence of income
on health are (1) comparison of mortality rates for white and
Income Level and Access to Health Care minority populations in the United States and (2) examination
People who are poor are less likely to have health insurance, of the total mortality rates from illnesses that affect the poor to a
even if employed. Many do not qualify for health assistance pro- greater degree than other income groups. Examining the differ-
grams. Because of their income level and uninsured status, many ences between whites and minorities is an appropriate indirect
are asked to provide immediate payment when seeking health measure of the effect of income on health because minorities
care services. These factors influence an individual's ability to are at greater risk for poverty. Approximately 15.1% of the pop-
obtain health care when the need arises. TableÂ€21-2 compares ulation is classified as poor. When this group is broken down by
the use of various health care services by the poor, near poor, racial composition, white Americans are found to bear less risk
and nonpoor. Note that the poor make use of primary preven- for poverty than other racial and ethnic groups (FigureÂ€21-3).
tion services, such as dental care, childhood immunizations, Blacks and Hispanics have double the risk for poverty than do
and mammograms, less often than those with more economic white Americans (DeNavas-Walt etÂ€al., 2011).
resources. Acute care services, such as care in hospital emergency The mortality rate for blacks is approximately 23% higher
departments and hospitalization in short-stay facilities, are more than that for whites. The death rate is 9.8 per 1000 persons for
commonly used by the poor, because they often delay seeking blacks and 7.6 per 1000 for whites (USDHHS, 2011). Mortality
treatment until their condition requires more intensive care. rates for the three leading causes of death show the same trend
in racial disparity. Deaths from heart disease, stroke, and can-
RACE AND ETHNICITY AND THEIR RELATIONSHIP cer are all higher in blacks than in whites. The severity of ill-
TO INCOME AND HEALTH STATUS ness is also different. Blacks have a greater chance of high
health care expenditures, a measure of more severe illness (see
In the United States, ethnic and racial minorities are more ChapterÂ€10).
Â�vulnerable to poor health status than the remainder of the Some other racial/ethnic groups also have greater rates of
population. They are also more likely to be poor, which illus- poverty than the white population, and most experience health
trates the relationship between poverty and health. Healthy disparities. The life expectancy of African Americans is 4â•›years
People 2020 is stressing the social determinants of health in less than that of white Americans (USDHHS, 2011). American
order to reduce health disparities between subgroups of the Indians, blacks, and Hispanics have a higher rate of diabetes than
U.S. population. the white population (see ChapterÂ€7, FigureÂ€7-5). Other, more
TABLEÂ€21-2â•…â•‡TYPES OF HEALTH CARE SERVICES USED BY SOCIOECONOMIC STATUS

POOR NEAR POOR NONPOOR
One to three health care visits to doctor's office orÂ€ 39.3% 41.4% 47.3%
emergency department, or home visits
No health care visits to office or clinic (children 13.7% 14.4% 9.8-5.6%**
under 18â•›years)
Vaccination rate, combined series (children 19 to 35â•›months) 41% 46%* *
No usual source of health care (children under 18â•›years) 8.6% 8.3% 4.6-2.1%**
No usual source of health care (adults 18 to 64â•›years) 32.7% 30.3% 19.7-10.6%**
One emergency department visit during past 32.3% 23.8% 18.9-16%**
12â•›months (children under 18â•›years)
Dental visits in past year (children 2 to 17â•›years) 71.7% 75.2% 77.1-87.8%**
Dental visits in past year (adults 18 to 64â•›years) 42.7% 45.3% 59.1-77.9 %**
Untreated dental caries
â•…â•… Children 6 to 19â•›years 25.3% 18.3% 14.2-9.3%**
â•…â•… Adults 20 to 64â•›years 41.7% 22.2% 16.2-11.5%
Mammogram (women over 40â•›years) 51.4% 55.8% 64.4-79%**
One or more hospital stays in the past year 8.9% 6.9% 5.6-4.5%**
Reduced access, did not get or delayed care
due to cost during last 12â•›months
â•…â•…Medical care 24.8% 24% 16.8-7.2%**
â•…â•…Prescription drugs 20.5% 18.8% 12.2-4.1%**
â•…â•…Dental care 30% 27.8% 17.9-6.8%**
“Poor” is defined as having an income below 100% of the poverty level. “Near poor” is defined as having an income of more than 100% but less
than 200% of the poverty level. “Nonpoor” is defined as having an income of 200% or more of the poverty level.
*Combined data for near poor and nonpoor in these categories.
**First rate is for 200 to 399% of poverty level; second rate for 400% or more of poverty level.
Data from U.S. Department of Health and Human Services. (2011). Health, United States, 2010. Washington, DC: U.S. Government Printing Office.
30 Â�
specific health behaviors and beliefs of individuals and groups
also affect health status. Research indicates that racial and eth-
nic minorities receive a lower quality of health care than non-
25
minorities, even when conditions are comparable (insurance
Percentage in Poverty
status, income, age, and severity of condition) (Russell, 2011;

20 Smedley etÂ€al., 2002). Health behaviors and beliefs influence
health because, among other things, they dictate how and when
15 people seek health care services, what health practices they
employ, and their diet and exercise behaviors.
10
Diet, Health, Socioeconomic Status,
5
and Racial/Ethnic Influences
Income and nutritional status are positively correlated. Studies
indicate that American Indians, Alaska Natives, Mexican
Â�
0
White White, not Black Asian Hispanic Americans, and African Americans—all populations with greater
Hispanic Any Race levels of poverty than whites—have a significantly greater risk
FIGUREÂ€21-3â•‡ Percentage in poverty by race and Hispanic origin. for nutritionally related diseases. Although some dietary choices
(Data from DeNavas-Walt, C., Proctor, B., & Smith, J.C. [2011]. Income, are the result of cultural influences, income-related restrictions
poverty, and health insurance coverage in the United States: 2010. Current on diet choices play a greater role in nutritional deficiencies in all
Population Reports, P60-239. Washington, DC: U.S. Bureau of the Census.) groups, especially minorities.
In studies of minority children, vitamin and mineral defi-
affluent racial/ethnic groups—for example, Chinese Americans ciencies are found to be relatively commonplace. Growth
and Japanese Americans—experience less health disparity and retardation in preschool children is a health indicator and
sometimes exhibit more favorable scores on health status mea- might reflect the inadequacy of a child's diet (USDHHS,
sures than do white Americans (see ChapterÂ€8). 2000). In American Indian and Hispanic children, there is
Infant mortality is another indicator of health status. Infant an increased incidence of linear growth stunting (Lewit &
death rates are higher for blacks and some other minorities Kerrebrock, 1997; Trowbridge, 1984). Some studies find that
(FigureÂ€21-4). In 2006, the black infant mortality rate was 13.5 all children in poverty show a greater incidence of growth
per 1000 live births, which is 2.5 times higher than the white stunting than do children from other economic environ-
infant mortality rate (5.7 per 1000) (Morbidity and Mortality ments (Brooks-Gunn & Duncan, 1997; USDHHS, 2000).
Weekly Report [MMWR], 2011). Note that FigureÂ€21-4 illus- Diet and weight relationships in minority children indi-
trates different infant mortality rates for subsets within a cer- cate greater deviation from average weights, either above or
tain racial/ethnic minority. For example, Puerto Ricans have below the norm. Classic studies of minority populations in
a higher infant mortality rate, whereas Mexicans have a lower America found that many more children were either under-
infant mortality rate. weight or overweight with unbalanced diets (USDHHS,
2000; Yanochik-Owen & White, 1977). In 2008 the obesity
Other Factors That Impact Racial/Ethnic Health rate for black and Mexican children was higher than for
Disparities white children, and those children at or below the poverty
Many factors contribute to health disparities. Poverty is per- level had a higher rate of obesity than children whose fam-
haps the most important factor, but other factors also play a ilies had more income (USDHHS, 2011). Ogden and col-
role. Discrimination, the health care environment, and the leagues (2010) compared children between 2 and 19â•›years
and found a higher rate of high body mass index among
Hispanics, Mexican Americans, and African Americans as
White, not Hispanic compared to white children of the same ages.
Black, not Hispanic Obesity is at epidemic proportions in the United States. New
studies indicate that adults of all economic levels have a simi-
American Indian lar risk for obesity. However, obesity is more common among
or Alaskan Native
Asian or Pacific Hispanic and African American men and women than among
Islander (total) whites (USDHHS, 2011). First Lady Michelle Obama has made
Hispanic (total) it her campaign to reduce obesity and improve healthy eating in
the American population.
Puerto Rican
Diet-related health issues are more common in the poor.
Mexican Adults below the poverty level have a greater risk of hav-
ing high serum cholesterol levels than those whose income is
Cuban above the poverty level (USDHHS, 2011). Anemia is a frequent
0 5 10 15
health problem in low-income persons. Studies have found
Infant Deaths per 1000 Live Births anemia to be especially prevalent in blacks, American Indians,
FIGUREÂ€21-4â•‡Infant mortality by race and Hispanic origin:
and Mexican American children in poverty (Chong, 2007;
United States, 2006. (Data from CDC health disparities and inequal- USDHHS, 2000). Anemia and concomitant low weight gain in
ities report – United States, 2011. Morbidity and Mortality Weekly pregnancy are also more prevalent in minorities (USDHHS,
Reports 60 [Supplement], 1-50.) 2000; Ural, 2011). Poverty doubles the risk of low weight gain
during pregnancy (Ural, 2011). Several governmental pro- 2009). No newer data are available, although the cost of insur-
grams have been designed specifically to support the health ance has continued to rise every year since that report. About
and diet needs of poor pregnant women and their children (see 53% of adults who do not have health insurance cite cost as
ChapterÂ€24). the major reason they are uninsured (Insurance Information
Poverty is correlated with food scarcity and hunger. Some Institute, 2007).
people in this country still experience hunger and lack access to
needed food. The federal government uses the term food inse- Employment Status and Health Insurance
curity to describe the condition of people who do not consis- It is a misconception that most of the uninsured are unem-
tently have access to enough food to allow for active and healthy ployed (FigureÂ€21-5). Most of the uninsured are workers or
living (Children's Defense Fund [CDF], 2005a, p. 18). In 2010, the dependents of employed persons. Low-income workers are
17.2 million people were food insecure. Twenty-three percent three times less likely to have health insurance (26.9%) than
of people with incomes below 130% of the poverty index expe- those with higher incomes (8% of those with incomes over
rience food scarcity while only 7.4% with incomes at or above $75,000). Most workers without health insurance are employed
185% of the poverty index experience food scarcity (Coleman- in lower-paying jobs with few or no benefits. Many of the unin-
Jensen etÂ€al., 2011). Healthy People 2020 is committed to elimi- sured work in service industry positions, such as food or jani-
nating hunger in the American population. torial services. Many have to work two or three jobs to support
their families. Unlike nonworkers in poverty, low-income work-
THE UNINSURED ers are not covered by the Medicaid program.
Lack of health insurance increases a person's risk for poor Uninsured Children
health and premature death (Hadley, 2005; IOM, 2001; Health care is especially important for children because delayed
Trossman, 2011; USDHHS, 2011). The uninsured are less able treatment or missed opportunities for health care services have
to access health care services and are more likely to forgo needed lifelong consequences. Poor health in children also affects their
health care because of cost concerns (Hadley & Holahan, 2004). educational progress. There are 7.3 million uninsured children
Uninsured Americans get about 55% of the medical care of peo- in the United States (DeNavas-Walt etÂ€al., 2011). Expansion of
ple with insurance. People in poverty, the homeless, racial and health insurance for children has been a major goal of govern-
ethnic minorities, and migrant populations are all at greater risk ment. In fact, the uninsured rate among children dropped from
for no health insurance coverage, which increases their vulner- 25% in 1997 to 12% in 2000 and to 9.8% in 2010. The rate
ability to poor health. decline is attributed to the State Children's Health Insurance
Program (CHIP) begun in 1997 (see ChaptersÂ€4 and 27).
Number of Uninsured
More than 49.9 million people, or 16.3% of the population,
do not have health insurance (DeNavas-Walt etÂ€al., 2011).
Did not work at
Others are without health insurance for some time during least one week
the calendar year. For example, adolescents over 18 and new
unemployed college graduates might lose coverage under their
Less than full time
parents' plan. The U.S. Department of Health and Human
Services (USDHHS, 2011) reports that 37% of the popula-
tion younger than 65â•›years of age is uninsured at some point Worked full time
during a given year and 17.5% are uninsured throughout the
year. The new health care reform legislation includes condi- 0 5 10 15 20 25 30
tions that allow children to continue on their parents’ health A Percentage
plan until age 25.
The number of uninsured has increased as our economy—
with large numbers of low-level entry jobs and fewer blue collar Less than $25,000
high-paying job opportunities—has left more people unem-
ployed or underemployed and without employer-provided
$25,000-$49,999
insurance. Even workers with health insurance plans are vul-
nerable to loss of coverage. An increasing number of employ-
ers are eliminating or reducing health insurance coverage to $50,000-$74,999
employees and their families (see ChapterÂ€4). Workers who are
between jobs and workers whose employers do not offer health
insurance coverage are also at risk for having no insurance $75,000 or more
coverage. The Consolidated Omnibus Budget Reconciliation
Act (COBRA) provides health insurance portability for work- 0 5 10 15 20 25 30
ers who change jobs, but many find the premiums too costly. B Percentage
Only approximately 9% of eligible workers participate in the
FIGUREÂ€21-5â•‡ People without health insurance by work experi-
COBRA program. Individuals with no health insurance who ence (A) and income level (B). (Data from DeNavas-Walt, C., Proctor,
try to find individual insurance plans find the costs too high. In B., & Smith, J. C. [2011]. Income, poverty, and health insurance cover-
2007, the estimated cost of COBRA family health insurance was age in the United States: 2010. Current Population Reports, P60-239.
between $4704 (individual) and $12,680 (family) (Doty etÂ€al., Washington, DC: U.S. Bureau of the Census.)
Despite the success of CHIP, eligible children have been missed. situation for most people. A national study reported that as
Approximately 28% of the 7.3 million uninsured children many as 13.5 million adults have been homeless at some time
are eligible for CHIP (Georgetown University Health Policy in their lives (HUD, 2007). The growing shortage of affordable
Institute, 2009). housing, declines in public assistance, and increase in poverty
are largely responsible for increases in homelessness (National
Impact of No Health Insurance on Health Coalition for the Homeless [NCH], July 2009a).
The uninsured are more likely to be hospitalized for prevent-
able conditions and to have no usual source of care (Hadley &
Characteristics of the Homeless
Holahan, 2004; USDHHS, 2011). Because of delays in seeking Homelessness is both an urban and a rural problem, but rural
health care, the uninsured are sicker when they seek treatment homelessness is harder to document. In rural areas, white, single or
(Hadley, 2005; IOM, 2002a). For example, uninsured women married women and their children are the largest groups of home-
delay regular screening for mammography (60%) and Pap less persons (Fisher, 2005; NCH, 2009b). In urban areas, single
smears (33%). Women with breast cancer who are uninsured men and single females with children are the two largest groups of
have a 30% to 50% greater risk of dying than women with health homeless persons (FigureÂ€21-6). It is always difficult to categorize
insurance (IOM, 2007). The uninsured are less likely to receive homeless people, because each person might have several charac-
early treatment for heart disease and diabetes. Even when diag- teristics that place them in more than one risk group. For example,
nosed with heart disease or diabetes, they are less likely to use a veteran with a history of substance abuse and mental illness could
appropriate medications and follow-up services. Delayed care is be included in at least three subgroups of the homeless.
expensive care. The estimated cost of uncompensated care pro- The racial and ethnic makeup of the homeless varies accord-
vided to the uninsured by hospitals and other service providers ing to geographical location. Approximately 80% of urban
is between $42.7 and $61 billion per year (Clemens-Cope etÂ€al., homeless shelter users are white or African American (HUD,
2010; Families USA, 2009). The Institute of Medicine (IOM) 2011) (FigureÂ€21-7). Rural homeless people are more likely
(2003) estimated the actual economic costs of not having health to be white, American Indian, or migrant workers (National
insurance to be between $65 and $130 billion per year in health American Indian Housing Council, 2007; NCH, 2009b). People
care costs, lost wages, and increased spending burdens on other in poverty, people with serious mental illness, and substance
public welfare programs. Many argue that money would be bet- abusers are more likely to be homeless.
ter spent in providing some kind of insurance coverage for the
The Poor
uninsured. That strategy would improve the health status of a
vulnerable group and have an added benefit in reducing costs Persons living at or below the poverty level are more vulnerable
associated with delayed care. and more likely to become homeless than are those living above
the poverty level. Between 7% and 9% of all poor people are
homeless, but nearly all homeless people are poor. Any financial
HOMELESSNESS emergency, major illness, or job loss may result in homelessness.
Homeless people include persons from all walks of life: very Because African American, Hispanic, and American Indian
poor men, women, and children, unskilled workers, farmers, populations are at greater risk for poverty, they are also at
housewives, social workers, health care professionals, and scien- greater risk for homelessness. The National American Indian
tists. Some become homeless because of poverty or a failure of Housing Council (2007) reports that more than 90,000
their family support systems. Others become homeless through American Indian families are homeless or in extremely poor
loss of employment, abandonment, domestic violence, alcohol- living arrangements. The council states that there is an imme-
ism, mental illness, social deviance, mental retardation, physical diate need for 200,000 housing units. The council estimates
illness, or disability. Whatever the cause, the homeless are more
vulnerable to health problems and reduced access to health care
Unaccompanied youth &
services. multiple child households (1.4%)
Multiple adult households
Definition of Homelessness (2.6%)
Homelessness describes the existence of a person who has no
fixed nighttime residence or who has a nighttime residence that
is designed to provide temporary shelter or is a public or pri-
Single
vate place not intended to provide sleeping accommodations female
for human beings. This definition encompasses those persons households
who are literally homeless but does not include those who are (26.9%)
living with relatives or in substandard housing. Homeless fami- Single males
lies who have had to move in with relatives or friends and rural (69.1%)
homeless persons are not nearly as visible and are more likely
to be omitted from federal programs designed to address issues
relating to homelessness.
Number of Homeless
FIGUREÂ€21-6â•‡ Estimated composition of urban sheltered home-
There are approximately 1.6 million people who are homeless: United States. (Data from U.S. Department of Housing and
less in a given year (U.S. Department of Housing and Urban Urban Development. [2011]. The 2010 annual homeless assessment
Development [HUD], 2011). Homelessness is not a permanent report to Congress. Washington, DC: Author.)
30
25
20
Percentage
15
10
0
Severely Physically Employed Victim of HIV
Mentally Disabled Domestic Positive
A ill Violence
45
40
35
30
Percentage
25
20
15
10
5
0
White, Non African White, Other Single Multiple
B Hispanic American Hispanic Race Races
FIGUREÂ€21-7â•‡ A, Selected characteristics of homeless adults. B,
Racial composition of urban homeless shelter users. (Data from
U.S. Conference of Mayors. [2010]. Status report on hunger and home-
lessness. Washington, DC: Author; and U.S. Department of Housing
and Urban Development. [2010]. The 2010 annual homeless assess-
ment report to Congress. Washington, DC: Author, Office of Community
Planning and Development.) A homeless man who has lived on the streets for several years.
What sort of life does this man experience? How does he feel
that American Indians have a rate of substandard housing about his situation?
that is six times that of the general population. For example,
approximately 60% of the houses on the Pine Ridge Indian
reservation are infested with black mold (Pine Ridge Fact (emotionally and mentally separated from society) and socially
Sheet, 2009). Overcrowding is a major issue; some homes have decompensated (unable to interact with other people).
as many as 25 people living in one dwelling. Many families live
in cars, tents, or makeshift shelters. Homeless Families and Children
An increase in the number of homeless families has been
Homeless Men reported in all areas of the United States. Families with chil-
Single homeless men still make up the largest and most vis- dren are the Â�fastest growing group among the homeless population
ible subgroup of the homeless population. Veterans com- (NCH, 2009b). Families comprise the largest group of homeless
prise at least 10% of the homeless population (Homelessness in rural areas. Although some homeless families are two-parent
Resource Center [HRC], 2010a). Homeless veterans have high units, most consist of one parent with an average of two or three
rates of mental illness (45%) and substance abuse (70%); many young children.
confront both issues (HRC, 2010a). For some, homelessness Homeless mothers tend to be young, have less education,
becomes a long-term condition, with a few men reporting that and have low employment rates. Domestic abuse has been cited
they have been homeless for 30 to 50â•›years. Older homeless men as the primary cause of homelessness for mothers with chil-
are more likely to have been married at some time in their lives, dren. The U.S. Conference of Mayors (2010) reports that half
whereas many younger homeless men have never been married. of the cities surveyed cited domestic violence as the primary
cause of homelessness in that population. In San Diego, 50%
Homeless Women of Â�homeless women are victims of domestic violence (HRC,
Homeless women are not as visible and are more difficult to 2010b). Pregnant homeless women are especially vulnerable to
count than men. Women with dependent children are the multiple risk factors. They lack prenatal care, adequate nutri-
Â�largest group of homeless women, followed by single women tion, and basic necessities of life, which places both them and
with substance abuse and/or domestic violence histories, and their unborn children at risk.
“bag ladies” (HUD, 2007;NCH, 2009a). Homeless families tend to seek shelter, and women with small
Bag ladies are alienated from the mainstream of society children receive priority for temporary housing. Two-parent
and use few resources. They are psychologically decompensated families might “double up” with other families, live in tents in
parks, or live in the family car. Once homeless, families have a WoodsÂ€etÂ€al.,Â€2003). They are also at higher risk of mood disor-
difficult time finding a place to live because of the lack of avail- ders, suicide attempts, and conduct disorders (Paquette, 2010a).
able housing and the substantial down payments demanded for
rental units. One or both parents might be employed on a full- Shelters and Food Assistance
or part-time basis, but their income is not sufficient to meet the Many religious organizations and advocacy groups have worked
minimal needs of their family members. to help homeless people, but these efforts have not kept pace
Data on homelessness indicate that 59% of the total homeless with the growing numbers and changing needs. In 2010 fam-
shelter population is youths under the age of 18. Most home- ily homelessness rose 9% in urban areas in part fueled by home
less children are preschoolers between infancy and 5â•›years of foreclosure rates. During 2011, most cities (77%) estimated the
age (HRC, 2010b). Developmental testing of preschool children number of homeless would remain steady or increase (USCM,
indicates that preschool homeless children exhibit significant 2010). Despite a dramatic increase in shelter beds during the
developmental delay in all areas (NCH, 2006a). Many home- 1980s and 1990s, there are not enough shelters and transitional
less children have attended preschool and school programs on housing spaces for the homeless population (USCM, 2010). In
a sporadic basis. They often have deficiencies in learning read- almost all major cities, the estimated number of homeless peo-
iness, have reading and math delays, lack social interaction ple exceeds the available spaces. Twenty-seven percent of home-
skills, and they experience long intervals between school atten- less families are turned away from shelters because there is no
dance (National Center on Family Homelessness [NCOFH], space. The majority of surveyed cities (62.5%) report that they
2009; U.S. Department of Education, 2006). Lost school time have to issue vouchers for hotels because of a lack of shelter
results in academic underachievement and gaps in learning and beds. Although rates of homelessness in rural areas are similar
experience. to rates in urban areas, there are few or no shelters in rural com-
munities (NCH, 2009b).
Homeless Teenagers In 2010, the requests for emergency food assistance increased
Approximately 1.6 million teenagers are homeless (Toro etÂ€al., by 24%. More than 43% of cities report that they have to turn
2007). HUD (2011) reports that unaccompanied minors com- away people due to lack of adequate food supplies (USCM,
prise 1.1% of the urban sheltered population. Since most unac- 2010). Cities report that the resources and budgets to meet
companied teens shun shelters, the actual number of homeless those needs decreased at the same time that the need for
youth is difficult to quantify. Some are runaways, and others are food supplies increased. A majority of cities expect their bud-
“throwaways.” Runaway teens have significant psychological dis- get for emergency food assistance to be reduced in the com-
turbances and a higher rate of drug abuse and contacts with the ing year, despite the increase in demand. Budget reductions and
legal system than other youths. Studies of runaway youths reveal a increased demand are tied to the current recession and state/city
high incidence of family violence and physical abuse. These home- fiscal crisis (USCM, 2010).
less teenagers reported being victims of chronic, severe abuse, both
physical and sexual, beginning at an early age (Paquette, 2010a). Medical Problems Associated with Homelessness
Throwaway children have parents who have severed all relation- Homelessness has a severe impact on a person's health and
ships with them; usually, rejection is preceded by months or years Â�well-being. Rates of acute and chronic health problems among
of failed relationships. Divorce, incestuous behaviors, or scape- the homeless are high (BoxÂ€21-1).
goating might contribute to the desertion of the child.
Some homeless youths are separated from their fami- Physical Health Problems
lies because shelter policies prohibit the admission of teenag- Homeless people are exposed to extreme weather conditions,
ers, especially older boys, in family shelters. Over 55% of cities the common cold and influenza, and minor injuries, as well as
report families had to break up to enter emergency shelters (U.S. diseases such as tuberculosis and HIV/AIDS. Chronic diseases
Conference of Mayors [USCM], 2010). Some youth are home- are often exacerbated because health care services are not con-
less because they have been discharged from residential or insti- sistently available. Colds and influenza are the most common
tutional placements or have become too old for foster care acute health problem. The second most common acute prob-
(Paquette, 2010a). lem is accidents or trauma. Scabies and lice infestations not only
Homeless youths adapt quickly to life on the street, where are troublesome but also can contribute to dangerous second-
they are subject to criminal victimization, such as learning ary infections.
to solicit money and drugs through prostitution. They gravi- Hypertension, diabetes, respiratory illnesses, and car-
tate toward neighborhoods where they are tolerated, such as diovascular diseases are the most common chronic medical
areas frequented by intravenous drug users and prostitutes. problems among the homeless population (Baty etÂ€al., 2010;
They engage in substance abuse and risky sexual practices Kerker etÂ€al., 2011; NCH, 2006b). Chronic alcoholics are sub-
(NCH, 2008). ject to gastrointestinal disorders, esophageal hemorrhage,
Homeless youths, especially unaccompanied homeless pancreatitis, and cirrhosis. Cancer is not generally detected
youths, have more serious and complex health problems but until the disease is advanced and the person is debilitated.
are the most difficult population to reach. Their distrust and Homeless women have the same illnesses as homeless men,
fear of persons in authority make it harder to provide health may be subjected to rape, and may have one or more sexually
care and other services. They often have poor hygiene prac- transmitted diseases.
tices, receive inadequate nutrition, and are vulnerable to poor Homeless children are more likely to have a variety of
health, human immunodeficiency virus and acquired immu- physical illnesses, including higher rates of asthma, ane-
Â�
nodeficiency syndrome (HIV/AIDS), other sexually transmit- mia, diarrhea, and poor nutrition (NCOFH, 2011). Homeless
ted diseases, substance abuse, and premature death (Rew, 2003; Â�children have ear infection rates that are 50% higher than the
BOXÂ€21-1â•…â•‡HEALTH PROBLEMS OF THE HOMELESS

Acute Physical Disorders Mental Health Problems
• Upper respiratory tract conditions • Schizophrenia
• Trauma, including major and minor injuries • Bipolar disorder
• Minor skin ailments • Depression
• Infestations (mites and lice) • Panic disorder
• Nutritional deficiencies • Borderline personality disorder
• Tuberculosis • Antisocial personality disorder
Chronic Physical Disorders Health Problems in Children

• Alcoholism and other substance addictions • Anxiety
• Hypertension • Incomplete or no immunizations
• Gastrointestinal disorders • Speech and language problems
• Peripheral vascular disorders • Upper respiratory tract illnesses and asthma
• Dental problems • Minor skin ailments
• Diabetes • Ear infections
• Human immunodeficiency virus infection/acquired immunodeficiency • Gastrointestinal disorders
syndrome • Trauma
• Neurological disorders • Eye disorders
• Lice infestations
Problems Associated with Pregnancy
• Lack of prenatal care
• Inadequate nutrition
• Obstetric complications
Data from Lindsey, A. (1995). Physical health of homeless adults. Annual Review of Nursing Research, 13, 31-61; Wright, J. D., & Weber, E.
(1987). Homelessness and health. New York: McGraw-Hill; Better Homes Fund. (1999). Homeless children: America's new outcasts. Newton
Centre, MA: Author; National Health Care for the Homeless Council. (2004). People need health care. Retrieved January 9, 2004 from http://www.
nationalhomeless.org/facts/health.html; and New York City Department of Health and Mental Hygiene. (2005). The health of homeless adults in New
York City: Homeless Services December 2005. New York: Author.
national Â�
average. Many homeless children are subjected to Substance abuse is a significant risk for homeless popula-
physical abuse. Immunizations might not be started or may be tions. Of homeless substance abusers, many are alcoholics
incomplete, which places children at risk for preventable com- (see ChapterÂ€25). A review of studies of homeless populations
municable diseases. In New York City, 61% of children without indicated that alcoholism is six to seven times more prevalent
housing have not completed the recommended immunization in homeless men than in the general population. In one sur-
series for their age. Homeless children are more vulnerable to vey 38% of homeless clients reported alcohol problems and
mental health problems, such as anxiety, depression, and with- 26% reported other substance abuse (Congressional Research
drawal (NCOFH, 2011). Service, 2005).
Drug addiction includes dependence on drugs such as
cocaine, crack, heroin, and a variety of prescription medica-
Mental Illness and Substance Abuse tions and inhalants (Kerker etÂ€al., 2011). Runaway and home-
Mental illness, low self-esteem related to past neglect or abuse, less youths who live on the streets have higher rates of illicit
and substance abuse are some of the intrinsic factors that drug use than do youths living in shelters or households
predispose people to homelessness. Approximately 26% of (National Runaway Switchboard, 2010). Many of the people
the homeless are mentally ill, and 35% are substance abusers with Â�substance abuse problems might also have one or more
(Paquette, 2010b). Severely mentally ill persons have difficulty mental disorders (see ChapterÂ€25).
carrying out activities of daily living, managing themselves, Depression is one of the most frequent and most serious
engaging in interpersonal relationships, and going to work. mood disorders among homeless individuals. One study of
The mentally ill homeless are homeless for longer periods than homeless women with families found that 50% experienced a
are homeless persons who are not mentally ill. The chances major depression (Weinreb, 2006). Community health nurses
for the severely mentally ill to escape homelessness are limited working with the homeless should routinely evaluate clients for
because of the disruption they experience in personal judg- signs of depression. Both homeless men and women have higher
ment, motivation, and social skills (Greenberg & Rosenheck, rates of suicide or suicide attempts than the general population
2010; NCH, 2006c). Only 5% to 7% of the homeless with men- (Arangua & Gelberg, 2007). Nurses working in clinics that serve
tal illness need to be institutionalized (see ChapterÂ€33). Most the homeless population should assess clients for depression
can live in the community with appropriate support services and suicidal ideation. Some clients might freely tell the nurse
(NCH, 2006c). The problem is that the chronically mentally ill that they are depressed; others might withhold the information
often do not seek help. unless they are asked.
Willie came to the walk-in health clinic in an inner-city soup Vulnerability of Migrant/Seasonal Workers
kitchen. It was past time to see clients, and the nurses were pre- Agricultural workers have multiple risk factors, which
paring to leave. A community health nurse asked Willie why he increase their chances of poor health and premature death.
had come to the clinic. He said, “I'm going to kill myself today.” Their low wages place them at the very bottom of the impov-
When the nurse asked if he had a plan, he told her that he had erished population. The majority of farmworkers earn
a loaded gun under his mattress. When he left the clinic, he was between $10,000 and $12,500 per year and 30% have total
going to go to his room and shoot himself in the head at 4:00â•›PM. family incomes below the poverty level. Most do not have
When asked why he planned to kill himself, he said that he was health insurance and 22% have used some government-
so depressed he could not stand it anymore. “I'm an alcoholic. funded program for low-income people such as WIC or food
I'm all alone. I have no friends, and my family won't speak to me. stamps (NCFH, 2009). Because they have no health insur-
I haven't had a job in over 10â•›years. What's the point? Life is just ance and low income, they are subject to the health problems
not worth living.” The nurse told Willie that arrangements had and risks associated with these two conditions, as identified
been made for an emergency evaluation at a psychiatric hospital. earlier in this chapter.
He was transported to the hospital and arrived at the emergency Many migrant/seasonal workers are undocumented and
department within an hour after he had come to the clinic. therefore at special risk. Because they risk discovery and deporta-
tion, these workers have little recourse when working Â�conditions
and housing are not adequate. Workers are often housed in
MIGRANT/SEASONAL WORKERS overcrowded barracks, trailers, buses, or sheds with poor sani-
tation (Villarejo etÂ€al., 2011). Heating and cooling, utilities, and
Migrant and seasonal workers are vulnerable to health risks, plumbing are substandard or not available (NCFH, 2007a). One
and many lack access to health care services. A migrant study found 66% of residences have Â�exterior Â�problems and 82%
worker is someone who moves from state to state with the sea- had between 1 to 5 interior problems. Only 11% of units met
sons in search of employment. A seasonal worker is someone camp housing standards (Villarejo etÂ€al., 2011). Many use com-
who lives and works in one geographical area. Seasonal work- munal bathing and toilet facilities.
ers might travel to work, but they usually limit that travel to Working conditions are poor. Agricultural workers in gen-
a single state or area. Some workers travel with their families, eral are exposed to pesticides and have a high rate of work-
and the whole family, including children, might work. Other related injuries (see ChaptersÂ€9 and 32). The Environmental
workers travel without families in small groups. For example, Protection Agency (EPA) estimates that 300,000 farmwork-
a group of men might travel from job to job together and send ers have pesticide-related health problems each year (NCFH,
money home to their families, rather than have their families 2007b). Additionally, farmworker children are exposed. There
travel with them. is also pesticide spillover into the surrounding communities
Most migrant/seasonal workers are employed in agricul- (Steinberg & Steinberg, 2008).
tural work in nurseries, orchards, canneries, or farm fields. Agricultural workers are excluded from the protections of
For example, they may do planting, potting, or trimming in the Fair Standards Act and the National Labor Relations Act,
nurseries; pick apples or oranges in orchards; prepare and and workers on small farms are excluded from the protec-
pack fruits, vegetables, and fish in canneries; or harvest corn tions of the Occupational Safety and Health Administration
or wheat in the field. (OSHA) (NCFH, 2007a). They are exempt from overtime pay
provisions and have no collective bargaining rights. Children
Characteristics of Migrant/Seasonal Workers as young as 12 are allowed to work in agriculture, and there
Estimates of the number of migrant/seasonal workers vary and are no age restrictions for children working on family farms
might not be very accurate. Migratory populations are difficult (Association of Farmworker Opportunity Programs, 2007;
to count. Undocumented workers, those without visas or work NCFH, 2007b; U.S. Department of Labor, 2011). Oversight of
papers, do not cooperate with data collectors. Many are involved what few protections the law provides is sporadic and ineffec-
in agriculture and other seasonal work. An estimated 11 to 12 tive. For example, the EPA and OSHA mandate that workers be
million undocumented migrants live in the United States (Pew educated and trained regarding the safe handling and applica-
Hispanic Center, 2011). An estimated 3 million migrant/sea- tion of pesticides. However, a large number of migrant work-
sonal workers are in the United States (National Center for ers are still without that training (NCFH, 2007a; Levine, 2010).
Farmworker Health [NCFH], 2009). Approximately 60% of
the migrant workers in California are undocumented workers
(University of California, 2005). Many more work in states such Jason and José are migrant workers who travel with sev-
as Texas, Arizona, Florida, Georgia, Washington, Oregon, and eral other men to different states seeking work. They have
other states with agricultural businesses. contracted with a crew boss to work in the fields of a Mr.
Most agricultural workers are foreign born. They are pre- Samuels. The farmer owns 700 acres of orchards and
dominantly Hispanic of Mexican origin, but include people employs 22 workers, and his enterprise is therefore cov-
from Central America, African Americans, American Indians, ered by OSHA regulations. Today the two men are picking
and Asians. The most recent surveys indicate that Â�migrant/sea- and packing peaches. They have been working for 8 hours
sonal workers are mostly young males (median age 31), who and are expected to continue for another 2 to 4 hours or
are married (58%). Most have little schooling; 38% have com- longer. The crew boss supplied them with sandwiches and
pleted between four to seven grades (NCFH, 2009). Most do not soda at lunchtime. The temperature is over 90 degrees. Both
speak English well, cannot read Spanish well, and have a very men are suffering from dehydration. Today, Â�representatives
low income.
receive little preventive health care, have poor schooling, and

of the local health department are visiting Mr. Samuels
experience exposure to environmental Â�pesticides. All family
because there have been complaints in the past. The health
members are exposed to the problems associated with poor
department personnel note that there are no toilets or water
housing conditions, such as lice, rats, roaches, lead paint, poor
sources in the fields. In the past, they have reminded the
sanitation, no heat, and poor ventilation (NCFH, 2007a, 2007b).
farmer that he is required by OSHA regulations to pro-
vide sanitation and fresh water to workers. Mr. Samuels
has responded by spacing his workers in the fields in such THE PRISON POPULATION
a way that they are not concentrated enough to be covered
Vulnerable populations are overrepresented in the juvenile
by OSHA regulations. Today the health department person-
justice and adult prison systems. Prisoners are more likely to
nel notice that the workers are concentrated enough to be
come from poverty. They have lower levels of education than
covered by OSHA regulations and, after a half hour of dis-
the general public. They are more likely to come from single-Â�
pute, Mr. Samuels agrees to provide water and toilet facil-
parent homes (see ChapterÂ€24). They are more likely to have
ities. Jason and José note that this pattern of compliance/
been exposed to drug trafficking, weapons, and gang violence in
noncompliance is a regular occurrence and have no faith
their neighborhoods (CDF, 2011).
that their working conditions will improve.
There is a disproportionate representation of racial
Â�minorities in the prison population. For example, Â�minority
youths comprise 56% of the population in the juvenile Â�justice
Special Health Concerns of Migrant/Seasonal Workers system (CDF, 2011). The number of girls arrested has grown
For many migrant/seasonal workers, English is a second by 50% since 1980. In 2007 girls comprised 14% of all youth
Â�language, and others speak little or no English. This makes Â�placements in juvenile justice (CDF, 2011). In 2010 the adult
it doubly hard for them to negotiate the health care system population in jails and state and federal prisons was 1.6
when they are ill (see ChapterÂ€10). Many feel uncomfortable Â�million, most of whom were males (Pew Center on the States,
seeking care in the United States. Workers feel intimidated 2010). Those numbers represent the first state decrease in the
by health care professionals and have different expectations prison population in 38â•›years. Females comprised only 7%
of service. For example, many expect their problems to be of the total prison population (West & Sabol, 2010). Persons
treated immediately. They do not expect to have to come to from racial minority groups are at significantly greater risk of
the clinic several times before the problem is pinpointed and imprisonment than are whites. Blacks are 6 times more likely
dealt with. Those with undocumented immigration status are and Hispanics 2.6 times more likely to be incarcerated than are
less likely to attempt to see a health care worker. Forty-three whites (West, 2010).
percent of undocumented workers have never visited a doc- Racial minorities comprise a larger portion of the adult
tor or clinic since entering the United States (Lighthall, 2004). prison population that would be expected from their num-
Many are reluctant to seek care because they run the risk of bers in the general U.S. population. For example, whites
losing their jobs. comprise 34%, blacks 39.4%, and Hispanics 20.6% of the
Extreme poverty, lack of insurance, and difficulty accessing prison population. However, whites are 70%, blacks are
health care create additional risks above and beyond the nor- 13.2%, and Hispanics are 16.7% of the total U.S. popula-
mal risks associated with language barriers, immigration issues, tion (Census Bureau, 2011b). Prisoners have more health
and the other factors discussed earlier. Migrant workers' health risks and poorer health status than members of the general
problems include the following (Mines etÂ€al., 2001; University population. This is to be expected given the characteristics
of California, 2005; Villarejo etÂ€al., 2000): of the prisoner population with regard to poverty, minority
• Twenty-five percent have a diagnosed chronic condition status, poor education, exposure to violence and substance
(e.g., high blood pressure, diabetes). abuse, and single-parent home environments, all of which
• Eighty percent report that they suffer from stress and have been noted previously in this chapter or in ChapterÂ€24
anxiety. to be risks for poor health.
• More than 75% of men and women are overweight.
• Rates of iron deficiency anemia, leukemia, high serum cho- Health Issues in the Prison Population
lesterol level, and stomach, uterine, and cervical cancer are Prisoners report more—and more chronic—health problems
higher than in the general population. than would be expected in their age group. Approximately 40%
• Twenty-seven percent have had a work-related injury. report a chronic medical problem such as diabetes, asthma, or
• Prenatal care is delayed, with 30% of pregnant women wait- heart disease (Wilper etÂ€al., 2009). The U.S. Department of Justice
ing until the second trimester and 14% waiting until the reported more than 50% of inmates were found to have a mental
third trimester to seek care. problem. Inmates are at risk of injury because of their exposure
• The infant mortality rate is 25% higher than the national to violence within the prison system. Approximately 13% report
average. being injured, and the risk of injury increases with time served.
• Rates of infectious diseases, including tuberculosis, are One in three inmates who served 1â•›year or more reports being
higher than in the general population. injured while in prison. They have poor access to care; less than
More than 40% of farmworkers who visit migrant health 14% of prisoners have seen an RN or doctor since being jailed
clinics have multiple and complex health problems. They also (Wilper etÂ€al., 2009).
experience the usual problems associated with vulnerable Prisoners are more likely to be substance dependent or sub-
Â�populations: poor nutrition, poor dental care, poor vision care, stance abusers. Forty-two percent of all federal inmates were
and little or no prenatal care. Children of migrant Â�farmworkers using drugs before incarceration and 45% report a history of
alcohol dependence (Maruschak, 2008). Drug use has increased largest federal-state programs, Temporary Assistance for Needy
among prisoners over the past 20â•›years. Marijuana is the most Families (TANF) and Supplemental Security Income (SSI), cov-
commonly used substance, followed by crack/cocaine, heroin, ered 6.8 million people in 2008 and had a combined budget of
barbiturates, stimulants, and hallucinogens. Many committed $72.1 billion (Census Bureau, 2011c). Both programs covered
crimes to pay for drugs. The U.S. Department of Justice (2011) only 20% of the 39.8 million people below the poverty line in
reported that 30% of offenders committed their crimes while 2008. Voluntary and charitable organizations also provide assis-
using drugs. Inmates do have access to some drug treatment tance to needy groups. Services are sporadic, are seldom com-
programs. The most common methods are peer counseling, prehensive, and are not available in every area of the country.
drug education, and self-help programs. Only 14% of inmates
are in a treatment program run by a trained professional. Welfare Reform—TANF/Medicaid
Because prisoners have a higher rate of risky behaviors, In 1996, Congress passed the Personal Responsibility and Work
they have a greater risk of HIV/AIDS. In 2008, 22,000 state and Opportunity Reconciliation Act, known as welfare reform.
Â�federal prisoners were HIV positive, more than five times the This act, and related legislation designed to balance the bud-
rate in the U.S. population. Testing for HIV is sporadic. Twenty- get, disproportionately affected the poorest and most vulner-
four states test all inmates on admission (Maruschak, 2009). able groups in this country. The act created TANF, which put
Almost all states will test an inmate if the inmate has potentially tight limitations on the length of time a family could receive
HIV-related symptoms or requests testing. A more uniform HIV welfare assistance (5-year lifetime limit). Each family had to
testing policy is appropriate given the higher risk of the prison develop a plan to improve its independence. Families could be
population. punished for noncompliance, including having health benefits
canceled. Benefits are very meager. The current median TANF
SERVICES AVAILABLE FOR VULNERABLE benefit and food stamp allotment combined provide the equiv-
POPULATIONS alent of approximately 55% of the poverty-level income (Schott
& Finch, 2010). ConseÂ�quently, families on these two programs
There are a number of governmental and private assistance pro- do not receive adequate relief. The eligibility requirements for
grams that help selected vulnerable groups (BoxÂ€21-2). The two Medicaid were also altered.
BOXÂ€21-2â•…â•‡PROGRAMS PROVIDING ASSISTANCE TO VULNERABLE POPULATIONS

Temporary Assistance for Needy Families (TANF) Low-Income Housing Units
Replaced Aid to Families with Dependent Children (AFDC) in 1996. Also known as public housing. These units are built with governmental
Provides temporary financial assistance to needy families with dependent funding, and persons who qualify based on income may live in the units.
children. Places a time limit on benefits; most recipients must have a job
within 2â•›years of starting the program. Monthly payment of $300 to $500 Supplemental Security Income (SSI)
per month intended to pay for low-cost rental housing, food, and cloth- Provides cash supplements for qualified individuals who cannot work
ing. Persons enrolled in the TANF program generally qualify for Medicaid. because of physical or mental problems, including the blind, aged, and
disabled. Persons receiving SSI benefits qualify for Medicare after a
Medicaid selected period of SSI eligibility.
Federal and state-funded assistance program to provide health care ser-
vices to certain people in need (see ChapterÂ€4). Medicaid increasingly Migrant Health Centers
relies on managed care programs to provide care to qualified individu- Established as part of the Migrant Health Act of 1962. The centers provide
als and families. primary and selected preventive health care to migrant/seasonal workers
and their families. In 2007 the centers served 826,000 people at 157 sites.
Children's Health Insurance Program (CHIP) Rural health centers (see ChapterÂ€32) also provide selected health care
Designed to enroll children who would not be covered under the services to migrants, the homeless, and other vulnerable groups.
Medicaid program, for example, children in one- or two-parent families
whose income is more than the qualifying income for Medicaid but who McKinney Homeless Assistance Act, 1987
are still needy (see ChapterÂ€27). Provided for outpatient health care services and attempted to ensure home-
less children access to the same educational opportunities as children living
Women, Infants, and Children (WIC) Program in homes. Services of 16 federal agencies are coordinated under the act.
Provides supplemental food and formula for infants, young children, and
pregnant and new mothers (see ChaptersÂ€3 and 27). USDHHS-Funded Nurse-Managed Clinics
Certain nurse-managed health centers are funded under grants from the
Supplemental Nutrition Assistance Program (SNAP) U.S. Department of Health and Human Services to provide health care
Provides debit cards that can be used to purchase a restricted list of gro- services to vulnerable populations, including the homeless.
ceries and food items at participating food stores.
Voluntary Organizations
SectionÂ€8 Rental Assistance Program/Voucher Church programs, charitable organizations, and foundations offer selected
Programs programs in selected geographical areas. These include soup kitchens,
Provide rental subsidies designed to help low-income people pay for overnight shelters, temporary housing, medical care either in clinics or
low-rent housing. Recipients pay 30% of their income and the federal on site, transportation, translation assistance, and advocates to assist
government pays 70%. persons attempting to navigate the governmental assistance programs.
From Hawkins, D. (2001). Migrant health issues: Introduction. Buda, TX: National Center for Farmworker Health, Inc.
(Jenkins, 2007). CHIP has similar but less restrictive crite-

Edith Wilson and her four children are newly enrolled in the
ria than Medicaid. Children who have been in this country
TANF and food stamp programs. Sally Haines, a community
for fewer than 5â•›years are prohibited from coverage under
health nurse, visits with Edith to review her children's eligi-
federal funding, but states can use their own funds to pro-
bility for CHIP or Medicaid. Edith reports that she receives
vide care (Guttmacher Institute, 2009). After 5â•›years of resi-
$574 per month in TANF benefits. She is paying 40% ($219)
dency, children are mandated care under CHIP with both
of her TANF allotment for rent. She is being asked to partici-
federal and state monies.
pate in a welfare-to-work program to improve her chances of
employment. Edith reports that she has no one to watch her Effects of Welfare Reform on Families
two preschool children for free during the day. Her neighbor
One of the effects of welfare reform is a drop in the number
will watch her two youngest children for $200 a month ($50
of households receiving welfare assistance. In 1991 over half of
a week). That leaves her with $155 to see her four children
Â�
all low-income families received benefits under Aid to Families
through all other expenses for the month. She receives food
with Dependent Children (AFDC), the precursor to TANF. In
stamp assistance, but despite very hard budgeting, she is
2010, only 20% of families received TANF assistance (Women's
unable to stretch the food stamps to pay for all her grocer-
Legal Defense and Education Fund, 2011). In addition, the aver-
ies and other subsistence products (soap, food wrap, etc.)
age TANF payment ($5204 in 2010) is approximately 30% of the
for the month. Edith shares with Sally her frustration at the
poverty threshold ($17,098) for that year. TANF payments have
demands of the program. She feels that the program admin-
not kept pace with inflation and in one-third of states TANF
istrators do not understand her predicament and have done
benefits have remained the same as in 1996 (Schott & Finch,
nothing to help her with her situation.
2010). The net effect has been to push many families deeper
into poverty.
At the same time, the WIC program was sharply curtailed. To make up for these deficits, the federal government is
Homeless mothers housed with others can use the supple- using the Earned Income Tax Credit (EITC), which is a tax
mental feeding program to feed their children for only 1â•›year. credit for low-income households that pay taxes on wages.
Women in prison or teenaged mothers in detention centers are The intent of the EITC is to encourage workplace partici-
denied benefits for their children. Adults without children can pation, and the credit helps to keep 5 million people above
use the program for 3â•›months over a period of 3â•›years. the poverty threshold (Institute on Taxation and Economic
Policy, 2011). The tax credits make up approximately 11% of
Effects of Welfare Reform on Immigrants the income of eligible low-income households (Congressional
Welfare reform had a particularly strong effect on immigrants. Budget Office [CBO], 2007). While the EITC helped some
Legal immigrants who entered the country after August 22, people, there were still 46.2 million others below the poverty
1996, were barred from receiving benefits from SSI, Medicaid, level in 2010.
TANF, or state block grants. Medicaid coverage was provided TANF time limitations (5â•›years) started to impact families in
only in emergencies. For example, prenatal care is not consid- 2001, when a quarter of a million families lost benefits (Bloom
ered an emergency, but labor and delivery are. States have the etÂ€al., 2002). Research studies suggest that one-third of those
option to resume services to immigrants after they have been who leave the TANF program each year do so because they have
in the United States for 5â•›years. If immigrants become U.S. reached the specified time limits (CDF, 2005b). The impact of
citizens, they are eligible for services. Undocumented or ille- TANF changes has become apparent. Most federally funded
gal immigrants are barred from all federal public benefits, and studies of families who have left TANF found that their earn-
all states are required to bar illegal immigrants from state and ings were below the poverty level (Lower-Basch & Greenberg,
locally funded programs (Dreweke & Wind, 2007). This has cre- 2008). Most individuals, including those who are doing all right,
ated a dilemma for health care workers, who feel that they have are employed in low-wage jobs that pay below the poverty level
been asked to operate as agents of the Immigration Service. ($7 to $8 per hour). They have no health care benefits, sick leave,
Many facilities simply do not ask immigration status when pro- pensions, or vacations (Women's Legal Defense and Education
viding care to individuals and families. The American Nurses Fund, 2011).
Association (ANA, 2010) supports this position and also sup- Most TANF recipients live in crowded conditions; 40%
ports access to care for both documented and undocumented are unable to regularly pay rent or utilities and more than
immigrants. half experience food insecurities (Loprest & Zedlewski,
In 2006, Congress required states to demand proof of 2006). Only 25% of TANF families live in public housing or
citizenship for all Medicaid recipients. This has resulted in receive housing vouchers (Schott & Finch, 2010). Most fam-
an additional administrative burden for states and a delay ilies leaving welfare do not receive subsidized housing and
in Medicaid coverage for families. For example, in 2006 the have problems maintaining housing as well as other issues.
state of Maryland spent $12 million in administrative costs Families report having to move or being evicted, utility shut
to comply with the new regulation that requires a pass- offs, and needing medical care but being unable to get it
port or two types of identification as proof of citizenship (Lower-Basch & Greenberg, 2008). The recession and sub-
(Epstein, 2007). This requirement places additional bur- sequent housing foreclosures have further stressed this vul-
dens on poor people, many of whom do not have passports nerable population.
and/or driver's licenses or birth certificates. In Virginia, TANF imposed new limitations on the number of wel-
6 out of 10 legitimately eligible children went without fare recipients eligible to continue schooling. Before welfare
Medicaid coverage for weeks to months because their par- reform, educational pursuits were considered a work activity.
ents had difficulty providing the necessary documentation Under TANF states may have only 20% of their caseloads in
eÂ� ducational activities, which leaves 80% at a disadvantage. Forty 3.1 million units (National Council of State Housing Agencies,
Â�percent of TANF recipients do not have a high school diploma, 2010). Rent has increased faster than inflation or wages. Federal
and 76% are considered to have low literacy levels (Tally, 2005; financing for public housing has decreased by 30% since 1991,
Women's Legal Defense and Education Fund, 2011). Further and the average wait for SectionÂ€8 rental assistance vouchers is 3
education would have beneficial results on individuals' earning or more years (Gorenstein, 2009; Husock, 2009). Because of this
capacity and job attainment, and assist them in gaining employ- backlog, families spend more time in shelters or remain home-
ment stability with the possibility of advancement into better- less for longer periods, creating further stress on the available
paying jobs. shelter spaces.
Limitations in state budgets (see ChapterÂ€4) have eroded the In almost every locality, the minimum wage is not adequate
ability of states to provide families using TANF benefits with to afford an unsubsidized one- or two-bedroom apartment.
support services such as child care and transportation (Schott The combined earnings of two full-time (40 hour per week)
& Finch, 2010). These limitations, coupled with the TANF minimum-wage workers will not pay the rent in most parts of
term limits, have created a pool of people who are at great the United States (National Low Income Housing Coalition
risk. The subset
Â� of extremely poor is increasing. In 2010, 20.4 [NLIHC], 2011). FigureÂ€21-8 shows the difference between
Â�million people and 7.4 million children were in extreme poverty minimum-wage income and the actual income (national hous-
(DeNavas-Walt etÂ€al., 2011). Without changes to the current ing wage) needed to afford the rent for one- or two-bedroom
Â�welfare program, the expectation is that an increasing number units. The national housing wage assumes that individuals
of vulnerable families and individuals might experience a loss will use 30% of their total income for housing costs. An esti-
of benefits, work at poorly paying jobs, or remain unemployed. mated 7.1 million households earn less than the lowest median
For individuals and families in such circumstances, there will be income and spend more than 50% of their income on hous-
an even greater risk for poor health and limited access to health ing with no help from public assistance housing programs
care services. (NLIHC, 2011). All of these households are one paycheck away
from being homeless.
Medical Care
In addition to the services provided under the Medicaid pro- Government Budget Crisis and Availability of Services
gram, medical services are available for free or at a reduced The current fiscal crisis affects funding for programs at both the
rate from various private and publicly funded health care ser- national and state levels. States are especially stressed because
vices. For example, many metropolitan cities allocate public they have borne increasing responsibility for publicly funded
monies to provide part of the budgets for medical clinics for programs as a result of the federal change to a block grant sys-
the homeless. These clinics may receive other funds through tem (see ChapterÂ€4). The federal government has been reduc-
private charities or fund-raising. These services are errati- ing the proportion of the budget spent on welfare programs.
cally located and often are not available to some vulnerable Many of these cuts have been made by changing to block grants
people. for federal contributions to state-run programs. Current efforts
The most numerous sources of medical services are com- involve a combination of continuing block grants and/or
munity health centers (CHCs). CHCs originated in the 1960s reduced funding to programs.
and offer medical care in both urban and rural areas. They
have been proven to be cost-effective vehicles of quality
health care (Ku etÂ€al., 2010). There are more than 1200 CHCs 20
providing services at 8000 sites in the United States and 250
of those are nurse-managed health centers (Hansen-Turton
etÂ€al., 2010). CHCs serve approximately 24 million people
Hourly Wage Dollars per Hour
per year (National Association of Community Health Centers 15

[NACHC], 2011). Their clients are poor, may be uninsured or
on Medicaid, and are usually sicker—often chronically ill—
and comprised of more minorities than the general popula- 10
tion (NACHC, 2009). Almost all CHC patients have incomes
at or below 200% of the poverty level; 38% are uninsured,
with most of the remainder on Medicaid or CHIP (NACHC,
2011). CHCs rely heavily on nurse practitioners and other 5
nursing staff to provide much of the care. CHCs have been
supported by both the Bush and Obama administrations.
These centers are expected to receive $11 billion in new fund- 0
ing over 5â•›years under the new health care reform legislation Hourly Income: Hourly Income:
and to double the number of new clients for a total of 40 mil- two minimum National Housing
lion clients by 2015. wage jobs Wage
($7.25 per hour
per job)
Housing
FIGUREÂ€21-8â•‡Comparison of minimum-wage income and
This country's lack of affordable housing and limited avail- national housing wage (income needed to afford rent for a
ability of housing assistance places many in poverty at risk for one- or two-bedroom unit). (Data from Bravve, E., DeCappeo, M.,
homelessness. Rent increases and availability of only a few units Pelletiere, D. etÂ€al. [2011]. Out of reach 2011. Washington, DC: National
have exacerbated the situation. The estimated shortage is at least Low Income Coalition.)
Starting in 2002, states have had to contend with shrinking stopped enrolling children in CHIP, and by 2005, 39 states
revenues and increased program responsibilities. The current had added cost-sharing co-pays to CHIP (CBO, 2007). You
economic recession only exacerbates the stress on state budgets. can expect to see further such actions by states if federal
No states have responded by raising income taxes. Some states funding is reduced further.
have made efforts to increase fees, such as the cost for renewing To date, state funding cuts would have been deeper if not
driver's licenses or car registrations. Others have increased or for the federal government's recognition of the economic crisis
are in the process of increasing property taxes, tuition at state- and input of emergency funding. These emergency funds were
funded colleges and universities, sales taxes, cigarette taxes, and meant to be a stopgap measure to help states until their budget
other revenue sources. crises were over. The American Recovery and Reinvestment Act
Many states have used program cuts as the primary method provided $140 billion in emergency Medicaid, safety, and educa-
for balancing the budget. Funding cuts in 46 states have been tion funds. Without this input many more families would have
especially heavy in programs serving low-income families—for seen benefits cut or reduced. Emergency funding will expire at
example, TANF, CHIP, Medicaid, and other welfare programs the end of 2011 and there is no indication that additional fed-
(Johnson etÂ€al., 2011; Shannon, 2010). The following are some eral funds will be available to prop up state budgets. If no action
examples of these cuts: is taken in the future there will be additional budget cuts to state
• Thirty-one states have cut health care programs by restrict- services.
ing eligibility for either health insurance or health services.
• Twenty-nine states have cut services to the elderly and dis- NURSING CONSIDERATIONS FOR VULNERABLE
abled by restricting medical, rehabilitative, home care and POPULATIONS
other services and by increasing the cost of those services to
the poor families served. Community/public health nurses frequently care for individu-
• Thirty-four states and the District of Columbia have cut als and families with many health risks and limited access to
K-12 education budgets. care. The health needs of these individuals are often complex
• Forty-three states have cut higher education budgets. and linked to social and financial conditions. Nurses need to
• Monthly cash benefits for TANF have been reduced in some develop expertise in a broad range of areas to best serve this
states and time limits for TANF benefits have been short- population.
ened. Other states are considering similar actions.
These cuts have drastic effects on low-income people. Knowledge of Available Programs
Funding cuts are expected to continue and to be more com- For vulnerable individuals, poor health is often exacerbated
prehensive. States are experiencing shortfalls (revenues lower by the lack or limited availability of health care services.
than expenditures) of approximately $112 billion for fiscal Knowledge of the primary assistance programs, their ben-
year 2011 (Brewer, 2011). These shortfalls will require addi- efits, and their scope of coverage is important to community
tional cuts in programs for vulnerable populations, and the health nursing. Nurses need this information so that they can
cuts might extend to other programs as well. Some states refer families to these programs and assist them in applying
have made changes to the Medicaid application process that for the benefits for which they are eligible. In Jacksonville,
require more reverifications at shorter time intervals. This Florida, for example, there was a high rate of infant mor-
requirement may create an additional difficulty for recipi- tality. An outreach program was implemented that educated
ents, resulting in lower Medicaid enrollments. In Arizona community groups about the problem and the available
one million low-income people were cut from the Medicaid resources, which led to a drop in the infant mortality rate
program and in California the state cut funding for almost (Pope, 2010). Nurses should become familiar with additional
all services to HIV/AIDS patients and eliminated funding for programs and services that might be unique in their com-
maternal, child, and adolescent health programs (Johnson munities. They should develop contacts at each agency and
etÂ€al., 2011). be aware of the eligibility criteria to avoid sending clients on
Current funding levels do not allow adequate coverage of futile appointments.
all those in need of the services provided by the programs. An extensive application process is required for most gov-
With additional stresses on state and federal budgets, little ernmental assistance programs. Clients often require help in
effort will be made to expand those programs to include per- gathering the necessary data (proof of income, bills, etc.) and
sons already eligible for their services. For example, funding filling out the forms. Nurses can either help with the application
and services are a critical issue for migrant health centers. process or refer clients to others they know who are capable of
Service expansion is not possible without additional fund- performing that task.
ing. CHIP is one program that does not provide services to People enrolled in many of these programs must undergo
all eligible children. Approximately 2 million eligible chil- periodic review of their cases to renew their eligibility. If
dren are not enrolled in CHIP (Georgetown University their financial situation has changed, there is always the
Health Policy Institute, 2009). There are proposals to lower possibility that payments will not continue. If they fail to
federal payments to states for Medicaid and CHIP in an attend a review appointment, their benefits or cash pay-
effort to reduce federal spending at the same time states are ments might be stopped. Nurses should be familiar with the
being pressured to increase enrollment of eligible children renewal criteria for programs and be prepared to remind cli-
(Kaiser Health News, 2011). States have no incentive to con- ents and encourage compliance with the schedule. It is also
tinue outreach enrollment efforts when their budgets are possible to find assistance for people having trouble with
already stressed and they have considered or are consider- transportation to appointments or problems with complet-
ing cuts to CHIP (Health Affairs, 2011). In 2004, six states ing paperwork.
Assistance with Language Barriers and In this case, the nurse could have ignored other family
CulturalÂ€Concerns members and simply done the job she was sent to do, which
Many migrant/seasonal workers have difficulty reading or is perform a prenatal check on Jackie. Instead, she took the
speaking English. Other minorities might have similar prob- time to discover another family member in need. Although
lems. Interpreter services should be available so that every effort the program in which she was employed could provide ser-
is made to interpret their concerns accurately. Sensitivity to dif- vices only to Jackie, the nurse was knowledgeable about other
ferences in cultural values and health care practices should also types of community services that would fit the needs of the
be part of quality care (see ChapterÂ€10). grandmother, Sammy Allen. She took the time to initiate
care, and in so doing, reduced Sammy's chances of additional
Primary and Secondary Prevention complications.
Nurses should take every opportunity to screen for poten- Advocacy for Improved Services
tial problems and provide health education on appropriate
health issues. Because many vulnerable children and adults Community nurses are in a position to know the problems
have incomplete vaccination records, all should be screened associated with specific service programs. They have a unique
for immunization status. Areas such as adequate nutrition, the body of information to share with others in efforts to improve
importance of prenatal care and vitamins, the need for den- Â�funding and program effectiveness. Nurses can advocate by
tal and eye examinations, good dental hygiene, safe food stor- becoming involved as members of special interest groups, tes-
age, and the importance of ensuring safe water supplies are all tifying before governmental agencies, advocating changes from
appropriate to address in health education. within their current employing agencies, and providing infor-
Screening to identify health problems and reduce further mation to other community groups and organizations. Many
complications is also a concern. This chapter has identified people are truly not aware of the problems experienced by vul-
numerous health problems that tend to occur in vulnerable nerable groups. Speaking out helps put an issue in the forefront
populations. Nurses should be aware of and screen for these of public consciousness. The IOM (2004) determined that the
health conditions. They include hypertension, diabetes, obe- best means of improving health status for vulnerable popula-
sity, poor foot care, infectious diseases, anemia, high choles- tions is to adopt some type of universal health insurance (see
terol level, dental caries, and substance abuse. Every encounter ChapterÂ€4).
should be used as an opportunity to check for other health Partnership with Community Groups
problems or concerns. This is not only good nursing care but
is cost-effective. For example, people in poor health are less One of the recommendations of the IOM (2002b) is that public
able to work and provide for their families. If early screening health organizations partner with other community groups to
and treatment improve a person's health so that the person provide needed services. This is a relatively new role for com-
can work, not only is the cost of care reduced (delayed care is munity health nurses, but one that could improve services to
more expensive), but the family's financial resources are also needy populations. Nurses should become active in identifying
improved. potential community partners to help address specific health
needs for at-risk groups. For example, a community might have
Case Finding a high rate of HIV/AIDS among the teenaged population. The
Nurses should consider every client contact as an opportunity community health nurse could form a work group to coordi-
to search for other family members in need of health services. nate a response. Community participants might include rep-
resentatives of the nurse's employer (the local health agency),
leaders of youth groups (e.g., Boy Scouts or Girl Scouts), local
Karen Boggs is a community health nurse doing prenatal
area church leaders, leaders of local sports associations, and rep-
home visiting. She visits Jackie Allen, a 16-year-old expect-
resentatives of the local HIV/AIDS activist group (if present in
ing her first baby. Jackie lives with her mother (Doris Jones),
the community).
her mother's boyfriend, several siblings, and her grand-
mother (Sammy Allen). During the visit, Karen reviews the Data Collection and Research
usual prenatal concerns and addresses Jackie's questions
One of the most important ways nurses can help improve ser-
about dieting during pregnancy. She notices that Jackie's
vices for vulnerable populations is to document the effects
grandmother, Sammy, is sitting in a chair with her right foot
of poor, improved, or good service. To do this, nurses must
propped up on two pillows. After Karen has completed her
develop accurate data collection systems. They must conduct
visit with Jackie, she asks Sammy about her foot. Sammy tells
well-designed research studies with established outcome mea-
the nurse that she has diabetes and her foot is causing her
sures. Different types of intervention programs can be tested
problems. Karen examines Sammy's foot and finds it swol-
for effectiveness. Collaboration with other health professionals
len, hot to the touch, and with reduced pain sensation. The
should strengthen these research endeavors.
nurse discovers that Sammy has no primary care provider
In the current climate of economic retrenchment, cost
and has not been taking her prescribed medication because
concerns must be addressed as part of any intervention strat-
she cannot afford it. The nurse, with Sammy's permission,
egy. All studies should include cost-benefit measures as part
arranges for an appointment that afternoon at the local
of the research design. All nurses involved in research study
nurse-centered clinic. During subsequent visits to her pri-
and design need to remember that interventions that produce
mary client, she continues to monitor Sammy's health and
improved health results and save money or cost no more than
assist her in acquiring needed services, including a source of
current services are more likely to be favorably received by
prescription medication.
decision makers.
ETHICS IN PRACTICE
Refusing to Provide Care Gail Ann DeLuca Havens, Ph.D., RN
The emergency department (ED) is remarkably quiet for a Friday evening. chance to work. The ED care providers on duty that evening express bit-
As Maureen, the registered nurse manager for the evening shift, passes ter resentment at having to continue to provide services to someone who,
the doorway to the waiting room, she catches a glimpse of a dusky face judging from his behavior, really doesn't want to be well.
and hands; a man is huddled in a corner at the far end of the room. She Do health care providers have a right to refuse to provide care to an
wonders why the person is not in one of the examining rooms being individual who continuously consumes health care resources by know-
evaluated. However, before she has the opportunity to find out why this ingly and repeatedly placing himself or herself at risk for disease and
man is in the waiting room, she is called to assist in calming down an injury? What should Maureen's course of action be? How much of the
8-year-old. response of the center personnel is attributable to a difference between
Two hours later, activity has increased in the ED. Maureen is headed their values and Horace's values as a homeless person? In exploring
down the hallway adjacent to the waiting room to retrieve some sup- the health care experiences of homeless individuals, every person inter-
plies from a seldom-used cabinet. Her attention is drawn to the same viewed described health care providers as lacking compassion for the
figure in the corner of the waiting room. He doesn't seem to have moved homeless (Nickasch & Marnocha, 2009). Specifically, health care provid-
since she noticed him earlier. There is something vaguely familiar about ers were depicted as lacking respect, sensitivity, insight, and compas-
the huddled figure, but what draws Maureen into the waiting room and sion in their interactions with homeless persons.
to the corner is her intuition that something is amiss here. She realizes One approach to the dilemma is simply to consider the staff's reaction
that the person in the waiting room is experiencing respiratory distress that evening as a manifestation of their job-related stress and frustra-
at about the same time that she recognizes the person as Horace, a tion and to believe that it was a single aberrant incident that will not be
homeless alcoholic who is a frequent visitor to the ED. repeated. However, this strategy would not acknowledge Horace's right
“Thanks for finally coming to get me, Miss Maureen. I was beginning to be treated with respect as a person. This is the fundamental principle
to feel mighty poorly.” of the Code of Ethics for Nurses (American Nurses Association, 2001),
“No problem, Horace,” replies Maureen, as she starts to wheel him which was breached the evening in question. This strategy also does not
from the waiting room into the treatment area. “What seems to be the address the underlying reason for the staff's refusal to treat Horace. Thus,
problem?” there remains the potential for an incident of this nature to be repeated.
“Trouble breathing. When I take a deep breath it hurts right around The potential to inflict grave harm—namely, to act with maleficence—in
where the doctors listen to my heart.” the process is a real possibility as well. Finally, Maureen recalls that the
“How long have you been waiting to see the doctor, Horace?” ED was relatively quiet the evening of the incident involving Horace, so it
“Since one o'clock.” is doubtful that situation-induced stress was a factor.
Maureen notes that was 8 hours ago. “Horace, did the admitting clerk Maureen completes an incident report. This process will lead to noti-
register you when you arrived?” fication of all appropriate nursing and medical administrative personnel,
“It seemed like she did,” he replied. who will be responsible for follow-up with the individuals involved. Still,
Maureen situates Horace on a gurney in an examining bay and goes Maureen is left with grave concern. Nursing and medicine have a cov-
to retrieve his chart from the admitting clerk's area while the physician enant with society to provide competent care to its members. Personnel
is evaluating him. Maureen is summoned back into the treatment area are bound by the principle of fidelity to remain faithful to the trust and
by a code call. Returning, she finds that Horace has stopped breathing, responsibility placed on nursing (and medicine) by society to provide
and the physician is slow to respond. She notices that no one but herself care that is not limited by personal beliefs and attitudes (American
seems particularly committed to responding appropriately in this emer- Nurses Association, 2001).
gency situation. She says, “Folks, you'd better move quickly and effec- Maureen is particularly concerned about the nurses involved in this
tively, because if this man dies it will be your fault!” incident. Conflicting obligations of fidelity have been characterized as
Horace is swiftly and competently resuscitated and several minutes more pervasive and morally troubling in nursing than they are in any other
later is responding appropriately to verbal cues. His assessment reveals area of health care. This is due primarily to the role of nursing in health
bilateral pneumonia that is compromising respiratory functions. Horace care, which means that a nurse often must choose between responsibili-
is admitted and placed on mechanical ventilation for a brief period so ties to the employing institution, on the one hand, and responsibilities to
that he can be oxygenated properly and suctioned as needed. Horace patients, on the other (Beauchamp & Childress, 2009).
recovers from his pneumonia without complications and is discharged Maureen decides to convene a consultants group comprised of peers,
in several days. a social worker, a representative from the institution's ethics committee,
Meanwhile, Maureen questions why she didn't anticipate this kind and a psychiatrist who specializes in problems professionals encoun-
of reaction to Horace from the ED staff. She had observed and been ter in their practice. Her goal is to have the group meet with the ED
informed about the growing reluctance of the staff to treat Horace, yet nurses and physicians on duty the evening of the incident with Horace
she never considered the possibility that nurses and physicians would to engage them in ongoing dialogue and to offer continuing support for
collectively refuse to care for a patient. What alternatives do you per- future problems of this nature.
ceive as responses to this problem?
Over the next several days after Horace's admission, Maureen meets References
with each of the nurses, physicians, and support personnel on duty the American Nurses Association. (2001). Code of ethics for nurses with inter-
evening that Horace experienced respiratory arrest. Their anger and frus- pretive statements. Washington, DC: American Nurses Publishing.
tration overwhelm her at times. They no longer feel obliged to care for Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics
Horace. He doesn't care for himself, so why should they feel any moral (6th ed.). New York: Oxford University Press.
obligation to care for him? He consumes precious resources with each Nickasch, B., & Marnocha, S. K. (2009). Healthcare experiences of the
almost weekly visit to the ED. Even when he agrees to be admitted to the homeless. Journal of the American Academy of Nurse Practitioners,
detoxification unit, he signs himself out before he gives the treatment a 21(1), 39-46.
KEY IDEAS
1. Poverty is linked to poor health, limited access to health care 5. Cost-containment measures that result in less access are not
services, and delay in seeking such services. cost-effective. Acute and delayed care is ultimately more
2. Certain groups are at greater risk for limited access to costly than preventive services and immediate treatment.
health care services because of cost. Groups at greatest 6. The community/public health nurse can serve as a vital link
risk include people in poverty, the uninsured, low-income to resources and health care services for vulnerable groups.
children, the homeless, migrant/seasonal workers, and the 7. Community/public health nurses can help break down the
elderly. barriers to health care through public and professional edu-
3. Multiple factors contribute to vulnerability. Some factors are cation and research in effective intervention strategies.
easily rectified; many others are not. 8. Community/public health nurses can advocate on behalf of
4. The homeless, migrant/seasonal workers, their families, and vulnerable groups by writing and calling government repre-
others in poverty live in desolate conditions in cities, towns, sentatives and speaking to professional and community orga-
and rural areas across the United States. nizations about the problems and needs of high-risk groups.
â•…â•‡THE NURSING PROCESS IN PRACTICE

A Homeless Man at Risk for Acquired Immunodeficiency Syndrome by Jennifer Maurer Kliphouse
Mr. J. is a 37-year-old man who has been homeless for 2â•›years in a large • Assess the degree of family and social supports available to assist
city. He completed the tenth grade in school and has worked episodi- the client through prolonged homelessness (e.g., shelter, legal assis-
cally in food service occupations. He has come to the health care clinic tance, transportation, job training, advocacy, financial aid).
on several occasions for treatment of a cold or to “have my blood pres- • Assess for neglect because of ineffective individual coping.
sure checked.” He was dependent on intravenous cocaine before he was • Assess the potential for injury because of the client's lifestyle and
imprisoned 5â•›years ago for drug-related activities. He did not use drugs exposure to multiple risk factors.
for 3â•›years, but since his release from prison, he says he has “gotten • Assess the potential need for legal services.
high every chance I get. I don't have much money, so I only use cocaine
about once a week. If I have a little money I may drink beer. When I don't Nursing Diagnoses
have any money, I do without. It's too embarrassing to beg.” Mr. J. has • Hopelessness related to long-term stress of homelessness as evi-
expressed interest in a drug treatment program, but there is a long waiting denced by despondent mood of conversation, e.g., “This is a terrible
period for inpatient programs that accept persons without any insurance. way to live”; “I don't see the point in going on.”
Mr. J. states that he is aware of behaviors that place him at risk • Risk for suicide related to depression as evidenced by his statement,
for HIV infection. He carries condoms with him and says that he uses "One way or another, this has got to stop. Life hurts too much to keep
them. He is not as careful with his needles. Sometimes he forgets and going on."
borrows a friend's needle when using cocaine. Mr. J. has no steady • Diarrhea related to undetermined process as evidenced by loose
relationships but stays with girlfriends for a few weeks at a time. He stools lasting at least 1â•›week.
has a 10-year-old son whom he has not seen in 2â•›years. Two years ago, • Deficient fluid volume related to loss of body fluids, as evidenced by
Mr.Â€J. tested negative for HIV and tuberculosis. He has refused tests diarrhea, concentrated urine, and night sweats.
since that time. • Imbalanced nutrition: less than body requirements related to inability
Mr. J.'s blood pressure is 160/94â•›mm Hg. He reports that his grandmother to absorb nutrients as evidenced by clothes that have become too big.
died of a stroke 2â•›years ago. He has refused a complete physical examina- • Ineffective health maintenance related to ineffective individual cop-
tion, insisting, “What you don't know can't hurt you.” On his last two visits, ing as evidenced by hypertension and absence of HIV and tuberculo-
Mr. J. expressed concern about whether his situation will ever get better. sis testing.
He said, “This is a terrible way to live. No place to call your own. No one • Deficient knowledge of HIV and associated symptoms related to lack
wants to look at me or talk to me. I just don't see the point in going on. One of interest in learning HIV status by refusal of HIV testing and state-
way or another, this has got to stop. Life hurts too much to keep going on.” ment “What you don't know can't hurt you.”
During this visit, Mr. J. tells the nurse that his cold does not seem to • Risk for infection related to lack of knowledge about the modes of
be getting better, saying, “I cough at night, and lately it seems that I transmission of HIV as evidenced by sharing of intravenous needles.
wake up in the night sweating a lot. I don't really understand it, because • Ineffective individual coping related to situational crises as evidenced
the mission is pretty cold.” As the nurse continues to talk with him, she by substance abuse (cocaine and alcohol abuse).
learns that he has begun having diarrhea in the past week. Mr. J. also • Powerlessness related to homelessness as evidenced by inability to
asks about a change of clothes, because the clothes he is wearing seem get a job.
to be getting too big for him. • Social isolation related to unacceptable social behavior as evidenced
Based on a thorough assessment of the client, the nurse might begin by exclusion from his family and perceived rejection by others.
to develop a mutually acceptable plan of care for Mr. J. • Chronic low self-esteem as evidenced by denial of problems, self-
neglect, and self-destructive behaviors.
Assessment • Ineffective sexual patterns related to ineffective individual coping as
• Assess the physical, psychological, social, spiritual, and environmen- evidenced by short-term relationships.
tal needs of the client. • Ineffective denial related to lack of control of life situation as evi-
• Assess for the presence of depression, suicidal intentions, social iso- denced by refusal to have a medical evaluation.
lation, ability to meet nutritional needs, self-care behaviors, and com- • Spiritual distress related to homelessness as manifested by question-
pliance with health regimen. ing the meaning of life.

A Homeless Man at Risk for Acquired Immunodeficiency Syndrome

Hopelessness related to long-term Client will describe an improved sense Arrange referral for psychiatric Mr. J. missed the first scheduled
stress of homelessness as of well-being and control over his evaluation for antidepressant appointment with a psychiatrist.
evidenced by despondent mood of personal circumstances. therapy and psychotherapy. A second appointment was made,
conversation (see above for detail) which he kept. The clinic provides free
weekly dispensing of the medication,
and at each dispensing, Mr. J. attends
a 1-hour therapy session.
Explore available self-help options, Mr. J. states that it is hard enough to
such as psychiatric outpatient attend one weekly session and shows
groups. no interest in group therapy.
Risk for suicide related to depression Client will verbalize a decreased level Make a verbal contract with the client Mr. J. completes the verbal contract,
as evidenced by his statement, of hopelessness and despair. that he will not harm himself. which is renewed with each weekly
“One way or another, this has got to session. He states that he has still
stop. Life hurts too much to keep thought of “ending it,” but he has not
going on.” created a plan to harm himself.
Support the client through this period The nurse continues to offer Mr. J. a
of distress by accepting his behavior, chance to voice his feelings with each
avoiding judgmental evaluations, visit. He is thankful, stating, “It's nice
and reinforcing positive statements to know there is someone to listen to
and behaviors. me.”
Diarrhea related to undetermined Client will report less diarrhea. Consult with a primary care provider A prescription is written for atropine/
process as evidenced by loose stools about the use of antidiarrheal diphenoxylate (Lomotil), which is
lasting at least 1â•›week medication. provided free to Mr. J. He reports no
further episodes of diarrhea at this time.
Explain the effects of diarrhea on Mr. J. verbalizes dehydration as a
hydration. possible effect of diarrhea. “I've been
trying to drink more water, but I forget
sometimes.” As diarrhea is absent
after treatment, there is a decreased
risk of dehydration.
1. Determine your state's income cap for Medicaid eligibility to support on the starting salary before that amount would
for a family of three. What percentage of the current pov- put you below the poverty index (if it ever would)?
erty level is your state's eligibility cap—30%, 50%, 70%, 3. For 2â•›weeks, clip items from newspapers and magazines con-
or some other percentage? Plan a 1-month budget for a cerning poverty, homelessness, and vulnerable groups, and
family of three for minimally adequate food, clothing, federal and state policies that directly or indirectly affect the
and safe shelter. Include the cost of a telephone, electric- very poor. What examples, if any, relate to inequities of access
ity, and fuel. Compare your state's Medicaid cap for this to health care? What examples, if any, relate to injustices of
fictional family with your monthly budget. Is the capped health status or health care based on race or income level?
income more or less than your expected monthly costs? If 4. Volunteer to work in a soup kitchen or shelter for at least
less, consider what you might be willing to forego paying 4 hours. What did you feel when you first arrived? How
for or purchasing. What if you had additional expenses, approachable were you to the clients you encountered? What
including medical costs? How would you restructure was significant for you in this experience?
your budget to meet these unexpected expenses? Is this 5. Visit an emergency department and interview staff nurses
achievable? about methods of working with vulnerable populations.
2. Research the starting salary for registered nurses in your geo- Observe the pattern of interaction with patients in the wait-
graphical area. Look up the monetary payments under TANF ing room or treatment room. Do you note differences that
in your state. Does the TANF allotment received by anyone might be related to the patient's condition? How do nurses
match the nurse starting salary amount? If so, how many respond when you ask them about caring for the poor, the
people does TANF expect you to support on that allotment? homeless, migrants/seasonal workers, and those without
Look up the current poverty index and compare that with health insurance? What problems do they perceive and how
the nurse starting salary. How many people are you expected do they deal with them?

Children's Defense Fund: http://www.childrensdefense.org/home. Salvation Army National Headquarters: http://www.Â�salvationarmyusa.
html org/usn/www_usn_2.nsf
Coalition for the Homeless: http://www.coalitionforthehomeless.org/ Streetkid-L Resource Page (a global discussion list about the
Homeless Initiative Office, Department of Veterans Affairs: plight of homeless children): http://www.pampetty.com/
http://www.va.gov/HOMELESS/Programs.asp homelessness.htm
Homelessness Resource Center: http://homeless.samhsa.gov/ University of California at San Francisco student-run Students'
Interagency Council on Homelessness: http://www.usich.gov/ Homeless Clinic: http://medschool.ucsf.edu/homeless/
National Center for Children in Poverty: http://www.nccp.org/ pubClinic/about.asp
National Center for Farmworker Health: http://www.ncfh.org/ Local agencies (check the local phone book for specific
National Coalition for the Homeless: http://www.nationalhome- organizations):
less.org/ Local food and clothing banks
National Health Care for the Homeless Council: http://www. Church-sponsored health and social services
nhchc.org/ Local public health agencies
National Law Center on Homelessness and Poverty: http://www. Community mental health centers
nlchp.org/ Local shelters
National Low Income Housing Coalition: http://www.nlihc.org/ Many states have a Coalition for the Homeless or similar orga-
template/index.cfm nization. Check websites for the selected state and request
National Runaway Switchboard: http://www.1800runaway.org/ information about homeless programs in that state.
WEBSITE

• NCLEX Review Questions 21A: Criticisms of the Poverty Index
• Care Plans
• Glossary
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United States household population 2005- population.html. Bureau of Justice Statistics Bulletin NCJ 231675.
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Brief No. 7, September 2008. Washington, DC: Abstract of the United States (2010). TablesÂ€538, Wilper, A. P., Woolhandler, S., Boyd, J. W., etÂ€al.
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Nursing Research, 52(4), 234-239. hunger and homelessness. Retrieved September 2, 666-672.
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people of color. Center for American Progress. uploads/2010_Hunger-Homelessness_Report- etÂ€al. (2003). Boston HAPPENS Program: HIV-
Washington, DC: Author, Retrieved from http:// final%20Dec%2021%202010.pdf. positive, homeless, and at-risk youth can access
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minorities.html. President and Congress on the implementation Seminars in Pediatric Infectious Diseases, 14(1),
Schott, L., & Finch, I. (2010). TANF benefits are low of the education for homeless children and 43-53.
and have not kept pace with inflation: Benefits youth program under the McKinney-Vento Women's Legal Defense and Education Fund.
are not enough to meet families’ basic needs. Homeless Assistance Act. Washington, DC: U.S. (2011). Welfare reform at age 15: A vanishing
Washington, DC: Center on Budget and Policy Department of Education, Office of Elementary safety net for women and children. New York:
Priorities. and Secondary Education. Available at http:// Author.
Shannon, B. (2010, August 13). $51M in www.ed.gov. Yanochik-Owen, A., & White, M. (1977). Nutrition
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SUGGESTED READINGS
Children's Defense Fund. (2011). The state of Harrington, C., & Estes, C. L. (2008). Health Agriculture, Food Assistance and Nutrition
America's children: 2011. Washington, DC: Author. policy: Crisis and reform in the U.S. health care Research Program.
Institute of Medicine. (2002). Care without coverage, delivery system (5th ed.). Sudbury, MA: Jones U.S. Bureau of the Census. (2011). Poverty, income
too little, too late. Washington, DC: Author. & Bartlett. and health insurance coverage in the United States:
Flaskerud, J. H., Lesser, J., Dixon, E., etÂ€al. Marmot, M. (2005). Social determinants of health 2010 (Current Population Reports, P60-239).
(2002). Health disparities among vulnerable inequalities. The Lancet, 365(9464), 1099-2005. Washington, DC: U.S. Government Printing
populations: Evolution of knowledge over fire Nord, M., Andrews, M., & Carlson, S. (2006). Office.
decades in Nursing Research publications. Household food security in the United States, U.S. Conference of Mayors. (2010). Status report on
Nursing Research 51(2), 74-85. 2005. Washington, DC: U.S. Department of hunger and homelessness. Washington, DC: Author.
CHAPTER
22
Disaster Management: Caring for
Communities in an Emergency
Christina Hughes and Frances A. Maurer*
FOCUS QUESTIONS
What are the different types of disasters? What impact has terrorism had on disaster planning efforts?
What happens when a disaster occurs? Who is in charge? What are the responsibilities of community/public health
What are the common physical and psychosocial effects on nurses in disaster nursing?
disaster victims and workers? What is your emergency preparedness plan? Your family's
What are the agencies that might be involved in predisaster plan?
planning?
CHAPTER OUTLINE
Definition of Disaster Local Governments, Communities, and Volunteer Groups
Types of Disasters American Red Cross
Agents of Harm or Damage in a Disaster Emergency Response Network
Factors Affecting the Scope and Severity of Disasters Incident Command System
Vulnerability of a Population or Individual Emergency Operations Center and Emergency Medical System
Environmental Factors and Type of Impact Principles of Disaster Management
Warning Time and Proximity to Disaster Prevention and Mitigation
Individual Perception and Response Rescue and Emergency Medical Care
Dimensions of a Disaster Evacuation and Definitive Medical Care
Predictability Reconstruction and Recovery
Frequency Stages of Emotional Response
Controllability Psychological Reactions after Disaster
Time Long-Term Effects of the Disaster Experience
Scope and Intensity New Challenges for Disaster Planning and Response
Phases of a Disaster Bioterrorism
Preimpact Phase Chemical and Hazardous Materials
Impact Phase Nursing's Responsibilities in Disaster Management
Postimpact Phase Preplanning: Developing a Response Plan
Effects of Disaster on the Community Impact of Domestic Disasters on Disaster Planning
Disaster Management: Responsibilities of Agencies and Community Preparedness
Organizations Emergency Response
Planning Recovery
Federal Government Personal Response of Care Providers to Disaster
State Governments Ethical and Legal Implications
KEY TERMS
Biological terrorism (bioterrorism) Man-made disasters Natural disasters
Chemical terrorism Mass casualty incident Posttraumatic stress disorder (PTSD)
Disaster Multiple casualty incident
Disaster nursing Mitigation
*This chapter incorporates material written for the 4th edition by Mary L. Beachley and John W. Young.
552
CHAPTER 22â•… Disaster Management: Caring for Communities in an Emergency 553
Disaster occurs in many forms: floods, wind, fire, explosions, 2001, which caused mass casualties and major property damage
extreme range of environmental temperatures, epidemics, multiple in New York City and at the Pentagon in Washington, DC. These
car crashes with many casualties, school shootings, and environ- attacks were followed by a bioterrorist act involving the mailing
mental contamination from chemical agents and/or bioterrorism. of anthrax-contaminated letters to locations on the East Coast.
The Louisiana Gulf Oil Spill of 2010 and the resulting environmen- Successful efforts to address these and other disaster situ-
tal damage is one example of disaster. In the past 10â•›years, many ations demand sophisticated preplanning measures and a
natural and man-made disasters have occurred in the United States well-coordinated emergency response during the actual disas-
(TableÂ€22-1). Flooding is the most common natural disaster world- ter situation. Comprehensive planning requires the combined
wide and is the third leading cause of weather-related deaths in the efforts of all levels of government, academia, health care pro-
United States (National Oceanic and Atmospheric Administration fessionals, business, and voluntary organizations cooperating to
[NOAA], 2011). Major floods in the Northwest, the Midwest, develop contingency plans to meet situations that might arise
North Dakota, and the Southeast cost billions of dollars in lost during and after the occurrence of the actual disaster.
homes, businesses, and crops and created long-term shelter needs
for thousands of people. The Japanese tsunami of 2011 caused an DEFINITION OF DISASTER
estimated $309 billion in damages to personal property and public
infrastructure (Voice of America [VOA] News, 2011). The American Red Cross (ARC) defines a disaster as “a threat-
Frequently occurring natural and man-made disasters during ening or occurring event,” either natural or man-made, “that
the past 30â•›years have brought the need for emergency preparedness causes human suffering and creates human needs that vic-
to the attention of the American public. Hurricanes, earthquakes, tims cannot alleviate without assistance” (ARC, 2008). The
brush and forest fires, and terrorism have created a concern across Robert T. Stafford Disaster Relief and Emergency Assistance
the country for preparedness. In the 1990s and in 2001, Americans Act (Public Law 93-288) defines a major disaster as “any natu-
experienced terrorist acts that pointed to an urgent need for spe- ral catastrophe (including any hurricane, tornado, storm, high
cial planning, training, and organization to treat mass casualties water, wind-driven water, tidal wave, tsunami, earthquake, vol-
and address the threat of chemical and biological terrorism. These canic eruption, landslide, mudslide, snowstorm, or drought), or,
threats require more coordinated disaster planning and response regardless of cause, any fire, flood, or explosion, in any part of
from a broader team of emergency responders and agencies. the United States which in the determination of the President
Worldwide, there has been an increase in terrorist activi- causes damage of sufficient severity and magnitude to warrant
ties. In 2005, terrorists bombed the London transit system, major disaster assistance under this Act to supplement the efforts
killing 56 people and injuring another 700. In the United States, and available resources of States, local governments, and disas-
bombings of public buildings have targeted abortion clinics, ter relief organizations in alleviating the damages, loss, hardship,
the World Trade Center in New York City, a federal building or suffering caused thereby” (Federal Emergency Management
in Oklahoma City, and Olympic Park in Atlanta during the Agency [FEMA], 2007, p. 2). There have been more than 1998
1996 Summer Olympics. Almost 11,000 incidents of terror- presidential disaster declarations since 1953. Website Resource
ism occurred worldwide in 2009, most in South Asia. These 22A provides a map showing the types and distributions of
incidents claimed over 58,000 lives (U.S. Department of State, these disasters.
2010). In the United States, the most egregious example of a A major disaster can create a mass casualty incident or a multi-
man-made disaster was the terrorist attacks of September 11, ple casualty incident. A multiple casualty incident is one in which
TABLEÂ€22-1â•…â•‡EXAMPLES OF DISASTERS—UNITED STATES

PLACE DATE CASUALTIES
Man-Made Disasters
Bombing of Murrah Federal Oklahoma City, OK April 19, 1995 168 deaths
Building
Train accident Bourbonnais, IL March 15, 1999 11 deaths, 122 injuries
Terrorist plane crashes New York (World Trade Center), September 11, 2001 3025 deaths
Washington, DC (Pentagon), and
Shanksville, PA
Anthrax mailings United States October–December 2001 5 deaths
Chlorine leak Graniteville, SC January 2005 9 deaths
Train accident Washington, DC June 22, 2009 9 deaths
Oil spill Louisiana April 2010 11 deaths
Natural Disasters
Earthquake Northridge, CA January 17, 1994 60 deaths
Tornado Tuscaloosa, AL April 1998 32 deaths, 256 injuries
Tornadoes Oklahoma May 1999 41 deaths, 748 injuries
Hurricane Isabel Virginia, NC, Delaware, and September 2003 40 deaths
Washington, DC
Wildfires Los Angeles and San Diego, CA, area October 2003 20 deaths
Hurricane Katrina Gulf Coast August 2005 1330 deaths, 2096 missing
Tornadoes Joplin, MO, Springfield, MA May/June 2011 145 deaths
554 CHAPTER 22â•… Disaster Management: Caring for Communities in an Emergency
more than 2 but fewer than 100 persons are injured. Multiple leaving the area quickly; young children whose immune systems
casualties generally strain and, in some situations, might over- are not fully developed; and persons with respiratory or car-
whelm the available emergency medical services (EMS) and diac problems. For example, a fire in a nursing home, a more
resources. A mass casualty incident is a situation in which there vulnerable community, is potentially more lethal than a fire in
are a large number of casualties, usually 100 or more, that sig- a college dormitory. Nursing home residents are at greater risk
nificantly overwhelm the available EMS, facilities, and resources. because they are less physically fit and more susceptible to the
When there are mass casualties, a community or region consequences of smoke inhalation and other consequences than
usually requires the assistance of emergency personnel and are young college students.
resources from surrounding communities or states. The
September 11, 2001, plane crashes in Manhattan; Washington, Environmental Factors and Type of Impact
DC; and Pennsylvania and the 2011 earthquake in Haiti are In a disaster situation, physical, chemical, biological, and social
examples of mass casualty incidents in which the affected com- factors influence the scope and severity of the outcomes. Physical
munities required outside assistance. factors include the time when the disaster occurs, weather con-
ditions, the availability of food and water, and the function-
Types of Disasters ing of utilities such as electricity and telephone services. For
Essentially, there are two types of disasters: natural and man- example as a result of Hurricane Katrina in 2005, residents of
made. Both types vary in intensity, severity, and impact. Natural New Orleans were without drinking water due to broken water
disasters include hurricanes, tornadoes, flash floods, blizzards, mains and approximately three million homes or facilities were
slow-rising floods, typhoons, earthquakes, avalanches, epidem- without power (NOAA, 2005). Some communities were with-
ics, and volcanic eruptions. Man-made disasters include war, out power for a short period (1 to 2â•›days), whereas others were
chemical and biological terrorism, transportation accidents, without power for weeks or months. In general, those without
food or water contamination, and building collapse. Fire can electricity for longer periods have a more difficult time coping
be either man made or naturally occurring. Both the California with the disaster than those who are without power for a day or
fires of 2003 and the New Mexico fire of 2011 resulted from a so. In Japan, the Tokyo Power Company initiated rolling black-
combination of man-made and natural causes: arson/accident outs (3–6 hours) on a rotating basis to avoid a complete power
and weather conditions (i.e., a dry summer season and high shut down in the affected areas (National, 2011).
winds). The New Mexico fire was started by a tree collapsing on Chemical, biological, and social factors impact the scope and
a power line and burned almost 120,000 acres (KKTV, 2011). severity of a disaster. Leaks of stored chemicals into the air, soil,
groundwater, or food supplies are examples of chemical factors.
Agents of Harm or Damage in a Disaster Biological factors are those that occur or increase as a result of
The agent is the physical entity that actually causes the injury water contamination, improper waste disposal, insect or rodent
or destruction. Primary agents include falling buildings, heat, proliferation, improper food storage, or lack of refrigeration
wind, rising water, chemical and biological agents, and smoke. owing to interrupted electricity service. Some social factors to
Secondary agents include bacteria and viruses that produce consider are those related to an individual's support systems.
contamination or infection after the primary agent has caused Loss of family members, changes in roles, and the questioning
injury or destruction. of religious beliefs are social factors to be examined after a disas-
Primary and secondary agents vary according to the type of ter. In general, individuals and families with ample social sup-
disaster. For example, a hurricane with rising water can cause port do better in coping with emergencies than do individuals
flooding and high winds; these are primary agents. Secondary with little or no social support.
agents include damaged buildings and bacteria or viruses that
thrive as a result of the disaster. In an epidemic, the bacteria or Warning Time and Proximity to Disaster
virus causing a disease is the primary agent rather than the sec- Demi and Miles (1983) identified both situational and per-
ondary agent. sonal factors that influence an individual's response to a disas-
ter. Situational variables include the amount of warning time
FACTORS AFFECTING THE SCOPE AND SEVERITY before disaster occurs, the nature and severity of the disaster,
OF DISASTERS physical proximity to the disaster, and the availability of emer-
gency response systems. An individual's reaction to a disaster
A number of factors affect the degree of impact that disasters will be greater if there is little or no warning and the victim is
will have on individuals, families, and communities. These fac- in physical proximity to the disaster site. For example, the loss
tors are addressed in the following section. of life in tornadoes is often affected by warning systems. When
towns have warning sirens and a planned system of monitoring
Vulnerability of a Population or Individual for potential tornadoes, more people are able to take shelter. In
Certain characteristics of humans influence the severity of the these instances, even with substantial damage to buildings and
disaster's effect on individuals and communities. For exam- personal property, personal injuries and deaths are limited.
ple, the age of a person, preexisting health problems, degree of The closer an individual is to the actual site of the disaster
mobility, and emotional stability all play a part in how someone and the longer the individual is exposed to the immediate site of
responds in a disaster situation. Those most severely affected the disaster, the greater the psychological distress that the indi-
by a disaster are the physically handicapped who have limited vidual experiences. A research study of residents in Manhattan
mobility or are wheelchair dependent; people who are venti- conducted 5 to 8â•›weeks after the September 11, 2001, terror-
lator dependent or attached to other life-support equipment; ist attacks found a high risk for depression and posttraumatic
the mentally challenged; older persons, who might have trouble stress disorder in this population (Galea etÂ€al., 2002).
Individual Perception and Response Weather Fatalities

Personal variables influence an individual's reaction to a disas- 200
ter. Psychological proximity, coping ability, personal losses, role Weather Fatalities for 2010
overload, and previous disaster experience all influence indi- 180 10 Year Average (2001–2010)
vidual response. An individual's risk for developing severe psy- 30 Year Average (1981–2010)
160
chological consequences is greater if that person is emotionally 138
140
close to the individuals affected, has compromised coping abili-
116
ties, has experienced many losses, feels overloaded in her or his 120 71 115
role, or has never before experienced a disaster. Psychological 103
100
reactions in the aftermath of disasters are addressed in greater 92
detail later in this chapter. 80

64
An individual who perceives a disaster to be less severe than 55 56 56
60
it is will probably have a less severe psychological reaction than 45 47
42 41 43*
39 34 37
a person who perceives the situation as catastrophic (Richtsmeir 40 33
29 25
& Miller, 1985). An individual's perception of an emergency or
20
disaster might evolve over time as the person begins to acknowl-
0
edge the full impact of the disaster. The human mind is capable 0
of allowing perceptions to be only as disastrous as the mind can Flood Tornado Heat Winter Rip
currents
cope with at a given time.
Lightning Hurricane Cold Wind
Doris Jones is in her backyard when she hears her neigh- FIGUREÂ€22-1â•‡Average number of fatalities per weather-related
bor, Alice Alvarez, calling for help. She runs next door to incident in the United States, Puerto Rico, Guam, and the Virgin
Islands. (From National Weather Service. [2011]. Natural hazard statis-
find Alice holding her 3-year-old daughter, who is bleeding tics: Weather fatalities. Birmingham, AL: Author. Retrieved July 6, 2011
profusely from numerous large cuts on her left arm. Blood from http://www.nws.noaa.gov/om/hazstats.shtml.)
is all over the concrete patio and extends into the kitchen.
Ms. Jones grabs the toddler and applies pressure to the cut residents are at greater risk for earthquakes, and people who
area with kitchen towels. She has Ms. Alvarez call 911. After live near large river systems are at greater risk for flooding than
the paramedics arrive and transport the child and her mother people who live elsewhere. The National Weather Service calcu-
to the hospital, Doris gathers with several neighbors and lates that average annual fatalities for hurricanes and tornados
learns how the injury occurred. The toddler had climbed onto have increased (FigureÂ€22-1). Most deaths are from heat-related
the kitchen counter, dislodging several glasses. The glasses fell causes, which were not calculated until recently. However, the
to the floor and broke. The girl then fell from the counter greater frequency and intensity of natural disasters may or may
into the pile of glasses. During the conversation, Doris starts not prepare citizens for their occurrence. Some citizens become
to tremble and cry. Another neighbor takes her home and immune to repeated warnings and are less likely to seek shelter
cares for her. Doris cannot understand why she got so upset to protect themselves and their property when warned. Other
after the emergency was over instead of during the emergency. citizens take each warning seriously and regularly take appro-
priate safety precautions.
DIMENSIONS OF A DISASTER Controllability
Disasters can differ along a number of dimensions: predictabil- Some situations allow prewarning and control measures that
ity, frequency, controllability, time, and scope or intensity. These can reduce the impact of the disaster; others do not. Mitigation
dimensions influence the nature and possibility of preparation is a term used in disaster planning that describes actions and/
planning as well as the response to the actual event. or processes that can be used to prevent or reduce the dam-
age caused by a specific disaster event. In the Midwest floods
Predictability of 2011, for example, some control and mitigating actions were
Some events are more easily predicted than others. Advances possible. Emergency planners were able to control some of the
in meteorology, for example, have made it more feasible to effects of the flooding by sandbagging levees and riverbanks to
accurately predict the probability of certain types of natural, reduce the effects of water damage and by deliberately blasting
weather-related disasters (e.g., tornadoes, floods, and hurri- dikes and dams to divert flood waters to less populated areas.
canes), whereas other disasters such as earthquakes are not as The immediate impact on people was reduced by the ability
easily predicted. Man-made disasters such as explosions or vehi- of emergency personnel to organize evacuations and decrease
cle crashes are also less predictable. Authorities and emergency the risk of injury and death. Sometimes the scope of a disas-
personnel have more time to prepare for the situation when an ter can overwhelm resources available to mitigate the effects
event is predictable than when an event is not foreseeable. (FigureÂ€22-2). After Hurricane Katrina, many citizens of New
Orleans who were poor and disabled were stranded because
Frequency there were inadequate resources to aid with evacuation. The
Although natural disasters are infrequent, they appear more Gulf Oil Spill leaked over 205 million gallons of crude oil, which
often in certain geographical locations. Residents of the Gulf has resulted in a long-term cleanup effort.
Coast of the United States live in what is commonly referred to The Los Angeles earthquake of 1994 did not allow prewarn-
as “hurricane alley.” These people are at greater risk for experi- ing and immediate precautionary actions, but other types of
encing a hurricane than someone who lives in Alaska. California control measures were available. Mitigating measures can be
A B
FIGUREÂ€22-2â•‡A, Flooding in New Orleans, Louisiana, in the aftermath of Hurricane Katrina in
2005. B, Rescued pelican. Many oil soaked birds and dolphins were found in the aftermath of the
Louisiana Gulf Oil Spill. (A, From Federal Emergency Management Agency, Washington, DC. Retrieved
July 7, 2011 from http://www.photolibrary.fema.gov/photolibrary/photo_details.do?id=19208; B, From U.S.
Fish and Wildlife Service, Washington, DC. Retrieved July 9, 2011 from http://digitalmedia.fws.gov/cdm4/
item_viewer.php?CICOROOT=/natdiglib&CISOPTR=10504&CISOBOX=1&REC=9.)
implemented well in advance of potential disasters. The enact- Scope and intensity should be considered separately in disas-
ment of building standards and codes intended to reduce the ter planning. For example, in the case of a building explosion,
harmful effects of a disaster are one example. More stringent the scope is small, with a limited area of a community affected,
fire safety measures (e.g., smoke detectors, sprinkler systems, but the intensity is great. The explosive forces are highly destruc-
improved fire doors) have made more newly constructed build- tive to the building and cause death and injury to people within
ings safer in the event of an actual fire. Newer buildings that the building and in the immediate vicinity. A tornado is another
complied with more stringent construction codes survived example of a high-intensity and small-scope disaster; in con-
the most recent San Francisco earthquake with less structural trast, a hurricane can have a high intensity and a large scope of
damage than did older buildings built before these codes were impact. The area of damage from a specific hurricane can cover
implemented. Los Angeles was in the process of retrofitting its several states and involve many communities. An explosion at a
freeway system to strengthen highway resistance to earthquake water-purifying plant might cause minimal injury to property
damage when the last big earthquake hit the area in 1994. and personnel at the plant but might reduce or eliminate the
water supply for an entire community for days or even weeks.
Time
Time factors that relate to disaster impact include the speed of PHASES OF A DISASTER
onset of the disaster, the time available for warning the popu-
lation, and the actual length of time of the impact phase. It is There are three phases to any disaster: preimpact, impact, and
more difficult to prepare for very sudden events. A flash flood, postimpact phases. The actions of emergency personnel and
for instance, might catch many unaware, whereas gradual flood- other health care professionals depend on which phase of the
ing allows more time for preparation. When there is a lengthy disaster is at hand.
period of warning, more protective measures can be intro-
duced. For example, several days’ warning allows authorities Preimpact Phase
in low coastal areas to evacuate vulnerable communities before The preimpact phase is the phase before a disaster. This is the
a hurricane hits. Tornadoes do not offer such lengthy warning time for disaster planning and mitigation before the actual
periods. The impact phase of the disaster might last for minutes, occurrence. Disaster planning activities have a critical influ-
hours, or even days. The most damage is generally caused by the ence on how a disaster will affect a region, state, and commu-
worst possible combination of time factors: a rapid onset, no nity. This is the time for assessment of probabilities and risks
opportunity for warning the populace, and a lengthy duration of occurrence of certain types of disasters. Based on risk assess-
of the impact phase. ment and hazard vulnerability analyses, specific action plans
should be designed to reduce the effects of predicted disasters.
Scope and Intensity Mitigation might involve legislating specific building codes and
Scope refers to the geographical area and social space dimension land-use restrictions. Assessment and inventory of resources for
impacted by the disaster agent. A disaster might be concentrated special equipment, supplies, and personnel necessary to sup-
in a very small area or involve a very large geographical region. A port an emergency response is essential. Planning activities
disastrous event might affect a small segment or a large percent- should be coordinated by the emergency management agency
age of the population in a geographical area. Intensity refers to and should involve all appropriate governmental agencies, pub-
a disaster agent's ability to inflict damage and injury. A disaster lic safety organizations, private organizations, and health care
can be very intense and highly destructive, causing many inju- entities. Disaster plans and personnel training must be reviewed
ries and deaths and much property damage, or be less intense, and tested on a regular basis. A critical component of the predi-
with relatively little damage done to property or individuals. saster phase preparation is education of the public to Â�encourage
individual preparedness. Examples of public education are the the shelters. During the impact phase, injured persons undergo
hurricane watch preparation and evacuation procedures for triage, morgue facilities are established and coordinated, and
communities in the Southeast hurricane belt. search and rescue activities are organized.
An important part of the preimpact phase is the warning
opportunity. A warning is given to a community at the first pos- Postimpact Phase
sible sign of danger. For some disasters, no warning is possible. The postimpact phase has two components: emergency and
However, with the aid of weather networks, satellites, and new recovery. The emergency phase begins at the end of the impact
weather-monitoring technology, many meteorological disasters phase and ends when there is no longer any immediate threat
can be predicted. of injury or destruction. The emergency phase is the time of
Giving the earliest possible warning is crucial to preventing rescue and first aid. Incident command is established if it was
loss of life and minimizing damage. This is the period when the not established in the warning phase. An assessment is made to
emergency operations plan is put into effect. Emergency opera- establish the extent and types of emergency resources needed.
tions centers (EOCs) are opened by the state or local emergency Recovery begins during the emergency phase and ends with
management agency. Communication is a key factor during this the return of normal community order and functioning. The
phase. Disaster personnel will call on amateur radios, radio and disaster planning cycle should begin again during the recov-
television stations, and any other available sources to alert the ery phase. Evaluation of the current disaster plan and com-
community and keep citizens informed. The community must munity response should be done based on the recent disaster.
be educated to heed warnings and to recognize threats as seri- Debriefing should occur for all disaster response agencies and
ous. When communities experience several false alarms, mem- personnel. The disaster plans should be modified in keeping
bers may not take future warnings very seriously. with the lessons learned from the most recent event. For sur-
The role of the nurse during the warning period will vary vivors of a disaster, the impact phase might last a lifetime (e.g.,
depending on her or his employer's role in disaster response. victims of the September 11, 2001, terrorist attacks).
Nurses should be informed of their specific roles and respon-
sibilities for disaster response. Community health nurses might Effects of Disaster on the Community
be assigned to assist the ARC in preparing shelters, to assist Not only are individuals affected physically and emotionally
with emergency aid stations, and to establish contact with other by a disaster, but the entire community is also affected. Local
emergency service groups. and regional economies can be devastated by a disaster and
Nurses should establish their own family disaster response require years of recovery. By 2006, the federal government had
plans to protect their families and homes while still being able committed over $110 billion, and citizens had donated almost
to respond to their communities’ need. The nurse's personal $3.5 billion in cash and in-kind services to ongoing Gulf Coast
plan should address options for emergency communication rebuilding efforts (White House, 2006). The most important
with family members and employer as well as child care, pet disruptions to the community are the following:
care, and transportation options. • Public service personnel are overworked.
• Lifelines, including telephone systems, television and radio
Impact Phase broadcasting, transportation, and water and sanitation ser-
The impact phase occurs when the disaster actually happens. It vices, are interrupted.
is a time of enduring hardship or injury and of trying to sur- • Resources such as food and medical supplies are depleted.
vive. This is a time when individuals help neighbors and fami- • Rumors run rampant and are hard to check.
lies at the scene, a time of holding on until outside help arrives. • Public and private buildings might be damaged.
The impact phase might last for several minutes (e.g., during In a disaster, the social and psychological reactions of indi-
an earthquake, plane crash, or explosion) or for hours, days, or viduals are closely interwoven with those of the community.
weeks (e.g., in a flood, famine, or epidemic). Usually, there are four phases of a community's reaction to a
During this phase, there should be a preliminary assess- disaster:
ment of the nature, extent, and geographical area of the disas- 1. Heroic phase: strong, direct emotions focusing on helping
ter. The number of persons requiring shelter, the type and people to survive and recover
number of anticipated disaster health care services, and the 2. Honeymoon phase: a drawing together of people who simul-
general health status and needs of the community must be taneously experienced the catastrophic event
determined. It is important to have an estimate of the needed 3. Disillusionment phase: feelings of disappointment because of
emergency resources as soon as possible after a disaster event delays or failures when promises of aid are not fulfilled (peo-
to activate mutual aid plans and ensure a timely response ple seek help to solve their own personal problems rather
from emergency medical services and other vital community than community problems)
support services. 4. Reconstruction phase: a reaffirmation of belief in the com-
The impact phase continues until the threat of further munity when new buildings are constructed (delays in this
destruction has passed and the emergency plan is in effect. If phase might cause intense emotional response)
there has been no warning, this is the time when the EOC is
established and put in operation. The structure and functions DISASTER MANAGEMENT: RESPONSIBILITIES OF
of the EOC are addressed in more detail later in this chapter. AGENCIES AND ORGANIZATIONS
The ARC oversees the opening of shelters in many communi-
ties. Every shelter has a nurse as a member of the ARC disaster Governments bear the primary responsibility for designing and
action team. The nurse is responsible for assessing health needs implementing disaster relief. All planning begins at the local
and providing physical and psychological support to victims in level. Private and voluntary agencies contribute expertise and
efforts to selected areas as designated by government plans. The emergency management of existing emergency response sys-
key to effective disaster management is predisaster planning and tems, medical and mental health care providers, public health
preparation. departments, law enforcement agencies, fire departments, EMS,
and the National Guard (local MMRS) to provide an integrated,
Planning unified response to a mass casualty event.
The purpose of disaster planning is to provide the policies, pro-
cedures, and guidelines necessary to protect lives, limit injury, Department of Homeland Security
and protect property immediately before, during, and after The President created the DHS as a response to the terrorist
a disaster event. A comprehensive emergency management attacks in 2001. A Presidential Directive (HSPD-5) in 2003
plan addresses four areas: (1) mitigation, (2) preparedness, (3) ordered the creation of a National Response Plan (NRP). The
response, and (4) recovery. NRP was periodically updated to incorporate lessons learned
A comprehensive plan demands a coordinated, coopera- from exercises and real-world events. In 2008, the NRP was
tive effort among many different people, agencies, and levels superseded by the National Response Framework (NRF).
of government. Planning should use valid assumptions about The NRF establishes a comprehensive, national, all-hazards
possible disaster agents based on previous community, state, approach to domestic incidence response. The Framework
and regional experiences, as well as experiences from other identifies the key response principles, as well as the roles and
regions. The United Nations (UN) General Assembly has iden- structures that organize a coordinated and effective national
tified disaster events as a major threat to the global community response by communities, states, the federal government, and
and declared the 1990s as the International Decade of Natural private-sector and nongovernmental partners. In addition, it
Disaster Reduction. The UN called for a worldwide plan- describes special circumstances in which the federal govern-
ning effort to reduce loss of life and property. As part of the ment exercises a larger role, including incidents in which fed-
UN effort, the World Health Organization (WHO) developed eral interests are involved and catastrophic incidents in which
a planning guide for community emergency preparedness to a state would require significant support. An important ele-
assists countries in preplanning efforts, personnel training, and ment of the NRF is the National Incident Management System
post disaster recovery (WHO, 2010). (NIMS), a consistent nationwide system that standardizes inci-
Planning requires technology to forecast events; engineer- dent management practices and procedures. Under the NRF,
ing to reduce risks; public education about potential hazards; the DHS is responsible for mass care; that is, the coordination
surveillance systems to detect environmental hazards; a coor- of nonmedical services such as shelter, food, emergency first
dinated emergency response; and a systematic assessment of aid, search and rescue, and efforts to reunite displaced family
the effects of a disaster to better prepare for future disasters. members (USDHS, 2011).
Responsibility for addressing these five areas of disaster plan-
ning is shared by federal, state, local, and voluntary agencies. Department of Health and Human Services
Some of the organizations involved in disaster planning and The U.S. Department of Health and Human Services (USDHHS)
relief are listed in Community Resources for Practice at the end partners with the Departments of Agriculture, Defense, Energy,
of this chapter. Justice, and Transportation; the Environmental Protection
Agency (EPA); the DHS; the National Communications System;
Federal Government and the U.S. Postal Service and serves as the lead federal
The federal government generally enacts laws and provides agency for public health and medical services under the NRF.
funds to support state and local governments. The Public The USDHHS also directs and manages the National Disaster
Disaster Act of 1974 (Public Law 93-288) provided for consoli- Medical System (NDMS). The NDMS is designed to deal with
dation of federal disaster relief activities and funding under a medical care needs in disasters of great intensity and scope that
single agency. overwhelm the local health care system (USDHHS, 2010). It has
three main objectives:
Federal Emergency Management Agency 1. Provide medical assistance to a disaster area in the form of
The Federal Emergency Management Agency (FEMA) was medical assistance teams, medical supplies, and equipment
established in 1979 as the coordinating agency for all avail- 2. Evacuate patients who cannot be cared for in the affected
able federal disaster assistance. The agency works closely with area to other predetermined locations
state and local governments by funding emergency programs 3. Provide a national network of hospitals that are designated
and providing technical guidance and training. The scope and to accept patients in the event of a national emergency
intensity of FEMA's response to a disaster is influenced by the Other agencies supporting the NDMS include the DHS and
severity of the disaster's impact on the community. If damage the Departments of Defense and Veterans Affairs.
is limited and the existing local, state, and regional resources
can handle the problems, FEMA's services might not be needed. Centers for Disease Control and Prevention, Department
FEMA responds to all moderate (level II) and massive (level I) of Health and Human Services
disasters. FEMA provides both direct aid (supplies and person- The emphasis in disaster planning at the Centers for Disease
nel) and indirect services (funding and coordination efforts). Control and Prevention (CDC) is prevention and/or mitiga-
FEMA oversees long-term recovery efforts as those still under- tion of epidemics and biochemical hazards (both natural and
way in the Gulf states. In 2003 FEMA was consolidated into the deliberate terror). The CDC has updated and refined its surveil-
Department of Homeland Security (DHS). lance system to rapidly identify health threats to the population.
FEMA manages and helps develop local metropolitan med- Educating health care professionals to recognize and treat bio-
ical response systems (MMRS). That system contracts with chemical hazards is a priority (CDC, 2011). There is a concern
that biological agents, such as those causing smallpox, anthrax, relief (FigureÂ€22-3). Most states also have a state coordinator to
and influenza, can be used as weapons. The CDC has devel- manage fire department resources and personnel.
oped recommendations for preevent smallpox vaccinations and The state emergency management agency advises the gov-
plans for mass immunization of health care workers and other ernor when the state has exhausted its resources or the disas-
emergency personnel if the need arises (CDC, 2003a). In 2003, ter is predicted to be of such magnitude that the state does not
the CDC mailed an informational packet about smallpox to all have the resources to respond and manage the disaster event.
health care providers and encouraged health care professionals The governor then notifies the FEMA that federal disaster relief
to register online to receive updated information (CDC, 2003b). assistance is needed. Timely assessment and evaluation of the
Other CDC activities are addressed later in the chapter. local and state resources and their ability to respond to any
The federal government has other agencies involved in disas- disaster event is critical to activate the appropriate communica-
ter relief. Website Resource 22B lists most agencies and their tion channels to obtain federal assistance and mutual aid from
responsibilities during disaster. A few examples are mentioned surrounding states in a timely manner during a disaster event.
here. The National Guard provides transportation, assistance
with evacuations, and police services when local or area police Local Governments, Communities, and Volunteer Groups
resources are strained or overwhelmed by disaster needs. The Local governments are responsible for the safety and welfare of
temporary housing program of the U.S. Department of Housing their citizens. They act to protect the lives, health, and prop-
and Urban Development helps families either relocate or repair erty of their citizens; carry out evacuation rescues; and main-
their homes. The EPA coordinates oil and hazardous materials tain public works. Local disaster response organizations should
removal and mitigation. The FEMA oversees long-term com- include local area governmental agencies such as fire depart-
munity recovery. ments, police departments, public health departments, public
works departments, emergency services, and the local branch
State Governments of the ARC.
State governments coordinate the development of the state Communities must have an emergency operations plan.
emergency operations plan and establish an emergency man- Local planning efforts include contingency action plans for var-
agement agency to coordinate the state response to a disaster ious types of disaster situations, designation of an overall inci-
event. For disaster planning purposes, if the disaster involves dent commander, and identification of community resources
more than one local jurisdiction, the state might coordinate that can be used in a disaster. The plan is developed and tested
response services. in mock-disaster exercises and then revised and refined. The
Usually, there is one state agency designated as the emergency local emergency management agency has communication links
management agency for all state-coordinated disaster efforts. with the state's EOC and with the FEMA and the DHS.
When a disaster happens, the state governor will open the state's Area hospitals develop their own action plans for handling
EOC, in which some state agencies (e.g., state police; National small community disasters such as a school bus accident or a
Guard; state emergency medical services; and state health, wel- large apartment fire. They are also involved in community plan-
fare, and social service agencies) will work together at the same ning preparation for larger-scale disasters that require a coor-
location to direct their specific agency's functions for disaster dinated community effort. Local hospitals play an important
Federal assistance
Governor President
DHS
DHHS
Incident Commander
at state EOC Other agencies
as needed
Operations Finance Logistics Planning
Dept. of Transportation
State police
Dept. of Public Health
Emergency medical
response system
Dept. of General Services/

Public Works
FIGUREÂ€22-3â•‡ Organizational chart of a state emergency operating system and avenue for federal
assistance, if needed. (Adapted from Federal Emergency Management Agency. [2011]. Incident Command
System. Retrieved July 6, 2011 from http://www.fema.gov.)
role in the NRF. Local volunteer organizations such as the Boy courses on first aid and disaster preparedness, and are involved
Scouts, Girl Scouts, Jaycees, veterans associations, community in management and supervisory positions.
emergency response teams, and church groups, can be consid-
ered additional resources to be used as the need arises. Local EMERGENCY RESPONSE NETWORK
health care professionals who do not participate in commu-
nity organizations that are officially involved in disaster plan- The primary goals of disaster management are to prevent or
ning might be called on to volunteer their services during an minimize death, disability, suffering, and loss on the part of
emergency. disaster victims. How these goals are achieved varies with the
type of disaster and the type of rescue worker. Police officers
American Red Cross and firefighters will have an entirely different focus from that
The ARC was founded in 1881 by Clara Barton. It is a voluntary of health care workers. It is vital that efforts be directed in a
agency that was granted a charter on January 5, 1905, by the well-designed and coordinated manner to ensure the most
U.S. Congress. The charter gives the ARC the authority to act efficient and timely response to disaster needs. The NIMS
as the primary voluntary national disaster relief agency for the encourages the use of two strategies to facilitate coordination
American people and to be ready for immediate action in every and reduce duplication of services at all levels of emergency
part of the United States. The federal statute allows the ARC to response: (1)Â€the incident command system and (2) the EOC.
coordinate efforts with other federal agencies. This federal leg-
islation applies only to those emergencies and major disasters Incident Command System
that have been declared as such by the President. On a national Established organizations provide many of the community ser-
level and in many communities, the ARC acts to coordinate vices needed in a disaster (TableÂ€22-2). The incident command
the disaster relief efforts of a variety of voluntary agencies. The system (ICS) was adopted by the FEMA to coordinate responses
ARC has created five programs to meet the human needs of a to a disaster at the scene of the disaster. The most important fea-
disaster (BoxÂ€22-1). ture of the ICS is a common organizational structure in which
Today, approximately 40,000 nurses are involved in the ARC, all community and local governmental agencies are represented
either as employees or as volunteers (ARC, 2011). Nurses pro- (FigureÂ€22-4).These agencies are woven into a response sys-
vide direct services to persons in a disaster, develop and teach tem in which each organization maintains its own autonomy
while being integrated into the central organization and incor-
porates MMRS systems if they are available to the locality. For
BOXÂ€22-1â•…â•‡AMERICAN RED CROSS example, emergency management personnel are not mixed
PROGRAMS FOR DISASTER with people from the public works department. Each organi-
RELIEF zation can concentrate on its assignment and not be distracted
by other responsibilities. For example, EMS personnel do not
1. Damage assessment: The first task after a disaster strikes is to have to be concerned with organizing shelters or providing
gather immediate and accurate information about the physical dam care in the shelters. That responsibility typically belongs to the
age resulting from the disaster.
ARC and local community service groups. Hospitals organize
2. Mass care: Shelter and food are provided to the affected commu
their efforts in the same manner, utilizing the Hospital Incident
nity or communities, including:
Command System (HICS) (California Emergency Medical
• Food provision: Food is provided at shelters or feeding stations
or might be taken by mobile units to disaster areas. Services Authority, 2007). Only if a disaster overwhelms the
• Shelter provision: Mass shelters are organized in schools, public state response will federal agencies assist (see FigureÂ€22-3).
buildings, hotels, motels, or churches.
• Supply provision: Personal hygiene articles, toilet articles, and/
or cleaning supplies are provided. TABLEÂ€22-2â•…â•‡EXISTING AGENCIES
3. Health services: Medical, nursing, and health care is provided in INVOLVED IN INCIDENT
shelters and emergency aid stations. Services include provision of COMMAND SYSTEM
blood and blood products; provision of emergency medical and hos
pital supplies; assistance to public health officials; and assistance AGENCY RESOURCE/FUNCTION
to families in finding available health care services. Government Administration Logistics, resource management,
4. Family services: Emergency assistance helps families resume communications and information
living by providing food, clothing, and shelter. Shelter assistance management
includes funding of temporary hotel stays, rent payments, secu Electric company Repair personnel, trucks, repair
rity deposits, utility deposits, and temporary home repairs. Help equipment, communications
in obtaining household items such as furniture, cooking and eat equipment
ing utensils, linens, and necessary appliances, and/or occupational Emergency management Emergency Operating Center,
supplies and equipment, such as tools or uniforms, is another poten equipment
tial area of assistance. The American Red Cross (ARC) assistance is Fire Firefighters, fire equipment
free and is provided through funds donated by the American people. Law enforcement Police officers, flares, blockades,
5. Disaster welfare inquiry service: Disasters frequently disrupt communication equipment
communication. The ARC disaster welfare inquiry service gathers Public health Surveillance systems, public health
information about the disaster area (what and who were affected, personnel
and individuals killed or injured) and makes this information avail Public works/highway Repair personnel and equipment,
able to concerned relatives through their local ARC chapters. department trucks, communication equipment
Incident Command
Operations Logistics
Section Section
Staging Law Enforcement Service Branch

Area • Perimeter Control • Communications
• Bomb Disposal • Triage
• Investigation Group • Medical Treatment
Fire Support
• Fire Suppression
• Hazardous Materials
EMS
Public Works
• Electric
• Gas
• Water and Sewer
FIGUREÂ€22-4â•‡ Sample organizational chart for an incident command system (at the scene of a
disaster). (Adapted from Federal Emergency Management Agency. [1998]. Basic incident command system
[IS-195]. Washington, DC: Author.)
Emergency Operations Center and Emergency representing the local emergency medical system, public health
Medical System department, and, usually, representatives from hospitals in
The EOC is the command center for coordination of the the community. The hospitals establish their command in a
Â�community-wide response to a disaster. The EOC coordinates place known as the Hospital Command Center (HCC). Joint
interactions among various response personnel involved in the Information Centers (JIC) may also be established to ensure
ICS at the scene as well as services provided at other locations. It accurate information dissemination in the community.
serves as the center for communication with other governmen-
tal agencies, local EMS, the ARC, and public safety agencies. In PRINCIPLES OF DISASTER MANAGEMENT
conjunction with other partners, the EOC forms an Â�emergency
management partnership. FigureÂ€22-5 illustrates how the EOC According to Garb and Eng (1969), there are eight fundamental
operates with other agencies and organizations not under its principles that should be followed by all who have a responsibil-
authority. Each community determines the locale and person- ity for helping the victims of a disaster. It is critical that rescue
nel involved in its EOC. The EOC includes health care Â�personnel workers apply these principles in proper sequence, or they will
be ineffective and possibly detrimental to disaster victims. The
eight basic principles are as follows:
1. Prevent the occurrence of the disaster, whenever possible.
State 2. Minimize the number of casualties if the disaster cannot be
Departments
prevented.
3. Prevent further casualties from occurring after the initial
Local impact of the disaster.
Other States
Jurisdictions
4. Rescue the victims.
5. Provide first aid to the injured.
State Emergency 6. Evacuate the injured to medical facilities.
Operations Center 7. Provide definitive medical care.
8. Promote reconstruction of lives.
Prevention and Mitigation

Federal Disaster Relief
Government Organizations The first three principles address prevention and mitigation of
the impact of a disaster. Certain types of disasters, particularly
FIGUREÂ€22-5â•‡ The Emergency Operation Center and its relation- man-made ones, might be preventable. Disasters have been pre-
ship to emergency management partners. vented by the enforcement of good building codes or by proper
land and water management. Other disasters are not prevent- BOXÂ€22-2â•…â•‡FIVE-CATEGORY CODING
able, but their impact might be mitigated. Public education can FOR TRIAGE
be used to reduce the impact of dangerous situations. In areas
that are prone to certain types of disaster situations, public edu- 1. Red—Most urgent; first priority
cation can alert the community on how best to prepare for such First-priority patients have life-threatening injuries and are experienc
situations in advance of an actual event. Community health ing hypoxia or nearing hypoxia. Examples of injuries of patients in this
nurses might be involved in such efforts, including providing category are shock, chest wounds, internal hemorrhage, head injuries
instruction regarding proper safety precautions and proper stor- producing increased loss of consciousness, partial- or full-thickness
age of emergency supplies, and giving first aid courses to prepare burns over 20% to 60% of the body surface, and chest pain.
the public to care for injuries in the event of an actual emergency. 2. Yellow—Urgent; second priority
Second-priority patients have injuries with systemic effects and
Public communication systems such as radio and television rou-
complications but are not yet hypoxic or in shock. Patients appear
tinely broadcast information about how people can obtain infor-
stable enough to withstand up to a 2-hour wait without immediate
mation in the event of an actual disaster situation.
risk. Examples of injuries of patients in this category are multiple
Early warning systems alert the public to the probability fractures, open fractures, spinal injuries, large lacerations, partial-
of immediate danger and help reduce the impact of predict- or full-thickness burns over 10% to 20% of the body surface, and
able disasters such as hurricanes or tornadoes. They might also medical emergencies such as diabetic coma, insulin shock, and epi
provide information on an evacuation plan or other immedi- leptic seizure. Patients with second-priority status might need to be
ate actions that improve the chance of survival and reduce the observed closely for signs of shock, at which time they would be
probability of injuries. recategorized to first priority.
Preventing further casualties after initial impact depends on 3. Green—Third priority
evaluating and lessening any unsafe conditions present immedi- Third-priority patients have minimal injuries unaccompanied by sys
ately after the disaster. For example, access to unstable buildings temic complications. Usually, these patients can wait longer than 2
and washed-out bridges must be prevented, and contamina- hours for treatment without danger. Examples of injuries of patients
tion of water and food supplies must be averted or corrected. in this category are closed fractures, minor burns, minor lacerations,
Periodic physical assessments of the disaster scene are essential sprains, contusions, and abrasions.
to make certain the area continues to be safe. These activities 4. Black—Dying or dead
are generally carried out by local utility personnel, firemen, and Dying or dead patients are hopelessly injured patients or dead vic
other individuals trained in structural assessment. tims. These patients have catastrophic injuries (e.g., crushing injuries
to the head or chest) and would not survive under the best of circum
Rescue and Emergency Medical Care stances. These patients present the greatest difficulty because fail
Rescue involves locating and freeing trapped victims and ure to treat patients conflicts with nursing philosophy. In a disaster,
then evacuating them to a safe place. In the event of a disas- triage must give the chance of survival to the greatest number of vic
tims rather than to one individual. Personnel and equipment must be
ter, the EOC becomes operational. Disaster service person-
reserved to treat the greatest number of viable patients.
nel, including EMS personnel, are called to respond. These
5. Contaminated—Might have a color code or a hazardous material
personnel will be involved in treating people at the scene of
(hazmat) triangle tag
the disaster as well as at other designated locations, including These patients are contaminated with hazardous bacteriological or
local hospitals. chemical substances. They will be routed to a decontamination sec
tor to eliminate hazards before additional treatment is provided.
Triage
Several times during the emergency response, triage might be
necessary to best determine the needs of injured victims. Triage of a coding system is presented in BoxÂ€22-2. Rapid systems for
is a French word meaning “sorting” or “categorizing.” During mass casualty triage such as Simple Triage and Rapid Treatment
a disaster, the goal is to maximize the number of survivors by (START) can also be used.
sorting the treatable from the untreatable victims. In a disas- Ideally, triage leads to appropriate and definitive care for all
ter, the potential for survival and the availability of resources victims. However, this can occur only if the cause of the multi-
are the primary criteria used to determine which clients receive ple casualties is quickly controlled so that rescue teams can care
immediate treatment. In a disaster situation, saving the great- for the injured in an organized manner. If the disaster condi-
est number of lives is the most important goal. Triage might tions continue or if secondary events such as fires or building
take place during the rescue operation at the scene of the disas- collapses occur, the rescue effort will be disrupted, and the treat-
ter and again at each stage of transport of the disaster victims. ment of victims will be hindered.
Many different personnel are involved in the triage operation.
Each person must know her or his exact role. Nurses and other Evacuation and Definitive Medical Care
emergency personnel, rather than physicians, are often used as Evacuation of victims must be done in an orderly but timely
triage officers because physicians are administering emergency fashion. Many factors will affect evacuation and must be con-
care to the more critical victims. sidered by the nurse. These include availability of transport
Prioritizing of victims for treatment can be done in many vehicles, specialized evacuation equipment, current weather
ways. Some communities use color coding. Probably the best conditions, condition of the roads leading to advanced care
and most easily understood is the category color-coding system. facilities, and time between disaster impact and arrival at the
Colored tags quickly identified the priority of care. A new concern hospital. Consideration must be given to the development of
is the need to identify people who might be contaminated with systems to track evacuated patients as well as well-thought-out
biochemical agents (Eckert, 2006; USDHS, 2004). An example policies for keeping medications and medical records with
these patients. Hospitals should receive advance notice of the BOXÂ€22-3â•…â•‡COMMON REACTIONS TO
impending emergency transports. Advance notification allows A DISASTER
the hospital to mobilize staff and resources to meet the sudden
increase of emergency patient admissions and to treat the more Psychological
critically injured patients in a timely manner. If there is more Sadness or apathy
than one hospital in a local community, patients should be tri- Guilt or shame
aged to each hospital on the basis of the hospital's capabilities at Disorientation
that time. The EOC should establish communications with each Difficulty concentrating
hospital to determine the current capabilities and to advise the Difficulty with decision making
hospitals of the estimated number of patients being transported Feelings of helplessness or hopelessness
Moodiness, irritability
and the severity of their injuries.
Withdrawal or disconnectedness
Hospitals must have well-honed disaster plans to meet the
Fatigue
needs of large groups of victims in a short time. These plans
Nightmares and/or panic attacks
should be practiced at least twice each year. The plans should Anger
provide for disasters that occur internally as well as externally. Feelings of loss or grief
An internal disaster is a catastrophic event occurring on the Mood swings
medical center grounds and resulting in multiple injuries, for
example, an outbreak of severe acute respiratory syndrome Physical
(SARS) in a hospital. An external disaster is a catastrophic Immediate
event occurring off the medical center grounds and resulting Shock symptoms, including difficulty breathing; chills; pale, cold,
in multiple injured persons for whom the hospital would need clammy skin
to provide emergency care, for example, a building collapse in Hyperventilation
the community. To meet the accreditation requirements of the Chest pains, palpitations
Joint Commission, all hospitals must have disaster plans, hold Rapid heartbeat
disaster drills, and regularly evaluate these plans and activities. Hypertension
Sometimes, the disaster is of such a massive scale that
Delayed
local medical services and facilities are unable to respond. In
Skin rashes or disorders
Hurricane Katrina, hospitals and other medical facilities in Increased use of caffeine, alcohol, or drugs
Alabama and Louisiana were destroyed or damaged and were Loss of or increase in appetite
unable to function. In such massive disasters, the federal gov- Increased startle reflex
ernment needs to step in to organize medical response teams to Headaches, fainting
help with medical services and to evacuate health care person- Gastrointestinal problems, including nausea, vomiting, diarrhea,
nel and injured citizens. constipation
Teeth grinding
RECONSTRUCTION AND RECOVERY Insomnia
Hyperactivity
The reconstruction of the victim's life begins with initial care
and continues until the victim has recovered. This might take
days, months, or years. Victims, disaster workers, and volunteers Psychological Reactions after Disaster
must receive adequate psychological counseling and emotional BoxÂ€22-3 lists some common reactions to disaster. Psychological
support to be able to return effectively to normal living. reactions can be categorized along three dimensions: (1) mild
to severe, (2) normal to pathological, and (3) immediate to
Stages of Emotional Response delayed. A reaction might be severe but normal or might be
The victims of a disaster go through four stages of emotional mild and yet abnormal. A few people will be so overwhelmed
response similar to the four-stage response to death and dying by the trauma that they will experience extreme psychological
(Richtsmeir & Miller, 1985): distress immediately. Others, despite their intense involvement
• Denial: Victims might deny the magnitude of the problem in the disaster, might appear unaffected psychologically during
or, more likely, will understand the problem but might seem both the impact and postimpact phases. These people might be
unaffected emotionally. The victim might appear unusually using denial and repression as defenses to handle their thoughts
unconcerned. and feelings. For example, one firefighter treated for an obvi-
• Strong emotional response: People are aware of the problem ously painful eye injury during the September 11, 2001, disaster
but regard it as overwhelming and unbearable. Common reac- denied that he had a serious injury (Taintor, 2003). It should
tions during this stage are trembling, tightening of the muscles, be noted that all disaster victims and workers might need criti-
sweating, difficulty speaking, weeping, heightened sensitivity, cal stress debriefing and possible referral and follow-up with a
restlessness, sadness, anger, and passivity. Victims might want mental health professional to restore them to their predisaster
to retell or relive the disaster experience over and over. mental health level.
• Acceptance: Victims begin to accept the problems caused by Feelings of guilt might arise in survivors when many vic-
the disaster and make a concentrated effort to solve them. tims have died. Fear of death or occurrence of another disas-
They feel more hopeful and confident. ter is a frequently seen reaction. For example, survivors of
• Recovery: Victims feel they are back to normal and experience the 1993 World Trade Center bombing reported that they
a sense of well-being. Routines become important again. felt hypervigilant, just waiting for the next attack to occur
(Taintor, 2003). Anger might be exhibited as general irrita- Emotional

bility or full-fledged rage and might be directed toward the Peer problems
cause of the disaster, displaced onto the support system,
or directed inward. For example, after the September 11,
2001, attack, there were assaults on foreign-looking persons,
including the following:
• A Sikh gas station owner killed in Mesa, Arizona
• A Pakistani Muslim grocery store owner killed in Dallas,
Texas
• A Middle Eastern taxicab driver beaten up by two passengers Hyperactivity Conduct
in Northridge, California
Long-Term Effects of the Disaster Experience

FIGUREÂ€22-7â•‡Lingering problems associated with children
The psychological stress experienced as a result of a disaster exposed to Hurricane Katrina. (Data from Abramson, D.M., Park,
might lead to long-term effects such as interpersonal or social Y.S., Stehling-Ariza, T. et al. [2011]. Children as bellwethers of recov-
problems. Some individuals might turn to alcohol or drugs ery. Disaster Medicine and Public Health Preparedness, 10(4), E1-E11.
in an attempt to relieve their stress. Others might have diffi- Retrieved July 7, 2011 from http://www.dmphp.org/cgi/content/abstract/
culty resuming their usual routines and relationship patterns. dmp.2010.7vl.)
Lingering health effects were reported by witnesses, survi-
vors, and emergency personnel 1â•›year after September 11, 2001 Posttraumatic stress disorder (PTSD) was first recognized in
(FigureÂ€22-6). Vlahov and colleagues (2002) reported a substan- veterans of the Vietnam War. It is now known to occur after
tial increase in substance use among Manhattan residents in the other traumatic events, including war, terrorism, kidnap-
acute postdisaster period after these attacks. Other problems ping, and disasters. According to the American Psychiatric
include long-term respiratory syndromes such as asthma and Association (APA, 2000), the following are the three character-
bronchitis and mental health problems such as posttraumatic istics of the syndrome:
stress disorder (PTSD) and depression (Lin etÂ€al., 2010; Nandi 1. The person is exposed to a traumatic event and experiences
etÂ€al., 2009). Children are particularly vulnerable after a trau- fear or horror related to the event.
matic event. A survey of children exposed to Hurricane Katrina 2. The trauma event is reexperienced through flashbacks,
found that 37% were exhibiting mental or behavioral problems dreams, or triggering events.
years after the event (FigureÂ€22-7). 3. The person avoids things that remind him or her of the
trauma.
Health officials estimate that over 400,000 people have lin- In addition, victims of PTSD experience two or more of
gering health effects from September 11, 2001. Dust particles the following symptoms: hyperalertness, exaggerated startle
contained carcinogens, concrete, and other environmen- response, sleep disturbance, survivor guilt, decreased concen-
tal hazards. Swallowing or breathing these toxins can create tration, impaired memory, and avoidance behavior. Reminders
severe physical problems that might not be apparent for 15 of the trauma increase the symptoms in victims of this syn-
to 20â•›years (Wielawski, 2006). A consortium of public health drome (APA, 2000).
officials (federal, state, local, and others) are conducting long- Community health nurses and others involved in treating
term surveillance of survivors to identify and document ill- clients should be aware that the symptoms of PTSD might not
nesses caused by exposure to contaminants from the disaster. be evident for some time after the actual event. Several factors
have been identified that will increase the likelihood of an indi-
vidual's developing PTSD. These include witnessing a violent
act, witnessing or experiencing a previous disaster event, lack-
ing a social support network, and having a previous history of
psychiatric illness (Nandi etÂ€al., 2009).
NEW CHALLENGES FOR DISASTER PLANNING

AND RESPONSE
The recent acts of biological terrorism (bioterrorism) and
chemical terrorism using biological and chemical agents as
weapons to inflict death, injuries, property damage, and disrup-
tion of public services have created the need to reexamine disas-
ter plans at all levels of government and public health agencies.
All public safety, public health, and health care organizations
must work closely together to develop plans, train personnel,
FIGUREÂ€22-6â•‡ New York, September 27, 2001. The remaining sec-
educate the professional responders and the public on the use
tion of the World Trade Center is surrounded by a mountain of
rubble following the September 11 terrorist attacks. (From Federal of protective equipment, and develop communication models.
Emergency Management Agency, Washington, DC. Retrieved June 26, Nurses practicing in all health care settings need to be involved
2011 from http://www.photolibrary.fema.gov/photolibrary/photodetails. in disaster planning and receive disaster response education
do?id5691.) and training (Cox, 2008; Eckert, 2006; Gebbie & Qureshi, 2006).
Training must include strategies to protect health care workers An early, effective response to a bioterrorism act depends on
from possible biological or chemical agents. The Occupational the quality of health surveillance. There must be routine, manda-
Safety and Health Administration (OSHA, 2009) has published tory, timely reporting of certain illnesses by laboratories, schools,
guidelines to assist hospitals with developing practice criteria hospitals, and other health care facilities. Routine reporting cre-
for mass casualty incidents involving hazardous substances. ates challenges. The routine reporting from medical laboratories
is highly reliable; however, there are many weaknesses in timely
Bioterrorism reporting from public health agencies and health care providers.
The USDHHS (2007) is responsible for developing an imple- Methods for secondary surveillance that exist in some local com-
mentation plan to address chemical, biological, radiological, munities and state health departments include monitoring sales
and nuclear threats. Currently, the USDHHS has identified 14 of over-the-counter medicines, monitoring diseases in animals,
potential threat agents and medical countermeasures for these. and monitoring emergency department ambulance diversions;
The CDC began planning for the public health response to however, this information is not usually timely and may have
bioterrorism when the possibility of anthrax attacks occurred in a lag time of weeks to months. In planning an effective defense
1998. Planning determined how to improve public health pre- against bioterrorism, new models of surveillance that yield
paredness for possible acts of bioterrorism. One outcome was timely information must be developed, and ongoing continu-
improvements by the CDC to the following: ing education of primary care and emergency care providers is
• The Laboratory Response Network for Bioterrorism—improved crucial. Syndromic surveillance is one example of such a model
surveillance and reporting of suspicious illness clusters and focuses on syndromes such as dyspnea, pneumonia, rash,
• The Strategic National Stockpile (SNS)—updating and expan- nausea and/or vomiting, diarrhea, encephalitis, and other unex-
sion of the number of medications available for dispensing plained or unusual illnesses or causes of death (Yan etÂ€al., 2008).
in the event of an incident This type of surveillance can be helpful because many potential
These improvements allowed for an effective public health bioterrorism agents cause similar symptoms. For example, fever,
response to the 2001 bioterrorist-related anthrax outbreak malaise, and cough are symptoms that can result from inhala-
(Perkins etÂ€al., 2002). As part of an ongoing educational effort on tional anthrax, pneumonic plague, and/or tularemia.
bioterrorism, the CDC issued a guide to assist health care pro-
fessionals in preparedness and response planning (CDC, 2009). Chemical and Hazardous Materials
The USDHHS is responsible for planning upgrades to the Today, in the United States, there is a high probability of acci-
public health infrastructure. The current priority is improve- dental and/or deliberate environmental contamination with
ment in communication and responses in all types of disaster a hazardous substance. The Agency for Toxic Substances and
situations (see Healthy People 2020 objectives in ChapterÂ€29). Disease Registry (ATSDR), an agency of the USDHHS, pro-
The National Institutes of Health (NIH) has a bioterrorism tects the public from hazardous wastes and environmental
research program led by the National Institute of Allergy and spills of hazardous substances (see ChapterÂ€9). The ATSDR is
Infectious Diseases. This research program includes both short- the lead agency within the Public Health Service to help prevent
term and long-term research targeted at designing, developing, or reduce further exposure to hazardous substances. Its func-
evaluating, and approving the diagnostic methods, therapies, tions include public health assessments of waste sites; health
and vaccines needed to control infections caused by microbes consultations concerning specific hazardous substances; health
that have a potential for bioterrorist use (Fauci, 2005). surveillance and maintenance of registries; and education and
It is crucial that health care personnel be trained to imme- training concerning hazardous substances.
diately recognize bioterrorism agents and take steps to pro- The ATSDR has prepared an education and training series,
tect themselves and to treat the victims. According to the CDC Managing Hazardous Material Incidents (MHMI), for rescue
(2007), training for hospital emergency staff is progressing but and health care workers. The MHMI books and video pro-
still needs improvement. The CDC survey of hospital emergency vide recommendations for on-scene (prehospital) and hospital
response managers found a range of training levels depending medical management of patients exposed during a hazardous
on the toxic agent, with 86% of hospital staff trained to rec- materials incident. This information is available on the ATSDR
ognize smallpox (highest level) but only 52% of staff receiving website (see Community Resources for Practice at the end of
training about hemorrhagic fever (lowest level). A recent sur- the chapter to access this site).
vey by the American Nurses Association (ANA) (2011) found The ATSDR operates a surveillance system for chemical and
a majority of nurses felt their facility was not prepared for a hazardous substances. This system is known as the Hazardous
disaster. Prophylactic caches of antibiotic medications as well as Substances Emergency Events Surveillance (HSEES) system.
distribution plans must be developed to protect first responders The ATSDR works with states to collect and analyze informa-
and first receivers until additional medications arrive. tion about releases of hazardous substances. This information is
There are special characteristics of biological agents that are then used to develop strategies to prepare and respond to events
used by terrorists. The biological agent must be capable of caus- involving hazardous substances and to assist federal, state, and
ing morbidity and possible mortality, and/or cause a disease local public health agencies in planning for any type of haz-
that is difficult to diagnose and treat. The fear factor is impor- ardous release. The HSEES system is used to do the following
tant to the terrorist; the more severe the morbidity and mor- (HSEES, 2001):
tality, the greater is the fear factor. Other characteristics of the • Describe the distribution and characteristics of hazardous
agent that must be considered by the terrorist are (1) accessi- substances emergencies
bility, (2) reproducibility, (3) stability, and (4) dispersibility • Describe the morbidity and mortality experienced by
(Lashley, 2011). Potential biological agents have been catego- employees, responders, and the general public as a result of
rized on the basis of their characteristics (TableÂ€22-3). hazardous substance releases
TABLEÂ€22-3â•…â•‡CRITICAL BIOLOGICAL AGENTS BY PRIORITY

CATEGORY DESCRIPTION AGENTS DISEASE
A High-priority agents, including organisms that pose a risk to Variola major Smallpox
national security because they can be easily disseminated Bacillus anthracis Anthrax
or transmitted person-to-person; cause high mortality, with Yersinia pestis Plague
potential for major public health impact; might cause public Clostridium botulinum toxin Botulism
panic and social disruption; and require special action for Francisella tularensis Tularemia
public health preparedness Filoviruses
â•… Ebola Ebola hemorrhagic fever
â•… Marburg Marburg hemorrhagic fever
Arenaviruses
â•… Lassa Lassa fever
Junin and related viruses Argentine hemorrhagic fever Q fever
B Second-highest priority agents, including those that are Coxiella burnettii Brucellosis
moderate morbidity and low mortality; require specific Brucella species Glanders
enhancements of the diagnostic capacity and enhanced Burkholderia mallei Venezuelan, Eastern, and Western
disease surveillance of the Centers for Disease Control Viral encephalitis equine encephalomyelitis
and Prevention (CDC) (Alphaviruses)
Chlamydia psittaci Psittacosis
Rickettsia prowazekii Typhus fever
Ricin toxin Toxic shock
Epsilon toxin of Clostridium
perfringens
Staphylococcus enterotoxin B
Subset of B agents, including pathogens that are Salmonella species
foodborne or water-borne Shigella dysenteriae
Escherichia coli 0157:H7
Vibrio cholerae
Cryptosporidium parvum
C Third-highest priority agents, including emerging pathogens Nipah virus
that could be engineered for mass dissemination in the Hantaviruses
future because of availability; ease of production and
dissemination; and potential for high morbidity and mortality
and major health impact
Data from The Centers for Disease Control and Prevention. (2011). Bioterrorism agents/diseases. Retrieved July 6, 2011 from http://emerging.cdc.
gov/agent/agentlist-category/asp.
• Identify the risk factors associated with morbidity and NURSING'S RESPONSIBILITIES IN DISASTER
mortality MANAGEMENT
• Identify the strategies that might reduce future morbid-
ity and mortality resulting from the release of hazardous Disaster nursing can be defined as the adaptation of pro-
substances fessional nursing skills to recognize and meet the nursing,
An analysis of the HSEES data for 2007 to 2008 indicates 7559 physical, and emotional needs resulting from a disaster. The
hazardous substance emergency events occurred. Most (88.6%) goal of disaster nursing is to achieve the best possible level
involved one substance (ATSDR, 2008). A relatively small num- of health for the people and the community involved in the
ber of events (550) accounted for 1685 victims and 39 deaths. disaster.
Most hazardous events occurred at fixed facilities (69%); only Many nurses in various clinical specialties are involved in
31% were transportation related (ATSDR, 2008). disaster management at some level, either in preplanning, imme-
Health care providers must be aware of these chemical and diate care, or recovery efforts. Some nurses are directly involved
hazardous substance threats and know how to access infor- in providing disaster care. These include nurses belonging to the
mation on self-protection from contamination and the appro- following groups:
priate client decontamination and treatment measures for the • Community/public health nurses employed by state and local
specific contaminate. Local communities and hospitals may health departments. They are involved in preplanning, public
participate in the CDC's CHEMPACK program which prede- education, and immediate disaster response. They are part of
ploys needed antidote therapy stockpiles for exposure to nerve the first cadre of personnel alerted for disaster relief.
agents (CDC, 2008). To date, the CHEMPACK program has • Emergency System for Advance Registration of Volunteer
placed over 1600 containers of antidotes for nerve gas agents. Health Professionals. A national state-based volunteer regis-
Planning for chemical and hazardous substance contamina- try system for medical personnel. The program is adminis-
tion must be part of all health care agencies’ disaster planning tered by the state health department or the state emergency
and training. response system.
• Disaster medical assistance teams (DMATs), whose mem- emergency responders need to have previous knowledge of and
bers are volunteers and include physicians, nurses, and training in how to assess potential hazards at disaster sites such
other emergency personnel (Potera, 2010). These are rapid as unstable building structures, possible explosive hazards, and
response teams. As part of the NDMS system, they can be chemical or other hazardous substances.
deployed nationwide. For example, on September 11, 2001,
DMAT teams from New England and the mid-Atlantic region Impact of Domestic Disasters on Disaster Planning
were deployed to New York, and in 2005, teams from all over All health care organizations should have disaster plans. The
the United States were deployed to Louisiana and Alabama to attacks of September 11, 2001, and the hurricane disasters of
assist with the care of survivors and rescue workers. 2005, in particular, spurred hospitals and other organizations to
• ARC disaster assistance teams (DATs). These teams, includ- review, update, and revise preexisting plans to accommodate all
ing nurses, are volunteers with ARC. DATs provide disaster types of potential hazards (Eckert, 2006; Lyons, 2010; Williams,
response, damage assessments, mass care, and shelter care. 2003). Agencies that did not have plans developed them. These
• U.S. Public Health Service Nurse Corps and U.S. Military Nurse disasters also prompted some agencies to perform more realistic
Corps. These nurses, employed by the federal government, are and frequent practice drills.
the government first responders in the event of disaster. The September 11, 2001, disaster prompted state nurs-
Other nurses provide direct care in disaster situations. These ing boards to update volunteer rosters or initiate new ones.
include local emergency department and intensive care nurses. For example, the Maryland Nursing Board sent a letter to all
They might provide care in their institutions or be sent as a registered nurses asking them to volunteer for disaster relief.
team to the disaster or a site in proximity to the affected areas. Nurses who responded were provided training and photo
Depending on the nature and duration of the disaster, other identification and were placed on a state notification roster.
nurses in the community might be asked to volunteer, work Maryland used the system in 2005 to deploy over 160 nurses
overtime, or provide relief for the first responders. Many nurses and other health care providers to the Gulf Coast in response
are involved in other areas of disaster management. to an Emergency Management Assistance Compact request
from Louisiana's governor. Other states have started similar
Preplanning: Developing a Response Plan processes.
A response plan should be concerned with delivering emer-
gency health care as efficiently and as quickly as possible. To Community Preparedness
that end, community nurses should know in advance all com- Community preparedness for disaster events should be part of
munity medical and social agency resources that will be avail- the planning preparation. Community health nurses, the ARC,
able during a disaster. They should know where equipment and and other volunteer nurses provide education programs. Public
supplies have been stored and their prearranged role and ren- education is directed toward safety, self-help, and first aid mea-
dezvous site. sures. A good education program should include information
Most agencies have a disaster notification network to alert about proper storage of food and water, rotation of canned
their personnel. Staff must follow a protocol of notification so goods to ensure use before expiration dates, and safety precau-
that all available personnel are alerted or called to duty when tions for water use (e.g., boiling water if equipment is available
the need arises. A good notification network should include a or using bottled water when plumbing is not working or tap
contingency plan for cases in which some personnel might not water is not safe to drink).
be reachable. In that way, the communication network is not A good first aid program should include information
Â�disabled. Nonresponders are simply bypassed, and the notifica- about the types of supplies needed in a home first aid kit
tion process continues. If possible, when disasters are predict- (BoxÂ€22-4). First aid courses help the public become pre-
able or probable, health care personnel should be prewarned or pared to address trauma injuries such as fractures, bleeding,
placed on alert. Having personnel on alert status reduces the and burns. Although the general public cannot be prepared
response time during the actual disaster. to deal with complex injuries, a sound knowledge of first aid
Another important element of a response plan is the desig- will help most families cope with the most likely injuries in a
nation of an alternative reporting site for health care workers. disaster situation.
In the event of a major disaster, some designated sites might Every family in the community should be encouraged to
be destroyed or damaged. A good plan will include alternative develop a personal preparedness plan (BoxÂ€22-5). Family mem-
response sites to which workers can report. bers should have a prearranged site at which to reassemble in
Emergency personnel should be very familiar with the equip- case they are forced to evacuate a dwelling from different exits.
ment and supplies they will use in the event of an actual disas- This simple plan can save confusion and the unnecessary inju-
ter. In addition to mock disaster drills, which allow personnel ries that often occur when family members attempt to reenter
to practice procedures and set up equipment, a periodic check a dwelling to look for others who have already evacuated. Every
of equipment and supplies should be part of the response plan. home should store the following items in a designated location:
Some supplies are perishable and need to be restocked at reg- • Emergency telephone numbers
ular intervals. If supplies are not actually unpacked at regular • Battery-operated radio
intervals, health care personnel might be disconcerted during • Working flashlight
a disaster to find that a significant portion of their supplies are • First aid kit
damaged, destroyed, or outdated. • Three-day supply of nonperishable food and water for drink-
Emergency personnel responding to a disaster site must ing and sanitation
have the appropriate personal protective equipment (PPE) and • Medical information (allergies, blood types, prescription
have knowledge of how to use this equipment. In addition, the medications)
BOXÂ€22-4â•…â•‡ITEMS FOR FIRST AID KIT Residents should be alerted to the types of supplemental
supplies that could ease shelter living in the event of an evac-
• Aspirin or nonaspirin pain relievers, adult and child formulas uation order. A survey of evacuees during Hurricane Elena
• Antibacterial ointment indicated that having items such as food, blankets, pillows, pre-
• Antacid (low-sodium) tablets scription medication, personal grooming items, portable chairs,
• Cleansing agents (isopropyl alcohol, hydrogen peroxide), soap, and a radio would have improved comfort in the shelter. Special
germicide, antiseptic wipes care items for infants, older adults, and disabled family mem-
• First aid manual bers (e.g., diapers, sanitary supplies, extra eyeglasses), a change
• Antidiarrheal agent (e.g., Kaopectate [bismuth subsalicylate]) of clothing, as well as diversionary equipment for children and
• Laxative
adults (e.g., crossword puzzles, card games, drawing materials,
• Moistened towelettes
and toys) are helpful.
• Gauze pads, assorted sizes
• Gauze rolls Emergency Response
• Adhesive tape
• Adhesive bandages, various sizes During the impact phase of a disaster, nurses and other emer-
• Latex gloves gency personnel are usually advised to remain in place until the
• Lubricant (e.g., petroleum jelly) situation has stabilized before attempting to provide care. In
• Triangular bandages weather-related or predictable disasters, such as hurricanes or
• Cold packs tornadoes, emergency personnel might be asked to evacuate the
• Cotton balls site of the pending disaster as a safeguard so that they can ren-
• Cardiopulmonary resuscitation (CPR) breathing barrier, e.g., a face der assistance after the disaster has struck.
shield
• Prescription medications Personal Concerns for Health Care Providers
• Vitamins Evacuation out of the danger area might be difficult for health
• Extra eyeglasses/contact lenses care personnel. Many are torn between carrying out their duties
• Scissors and the real need to remain with family members. Having a per-
• Tweezers sonal disaster plan that includes advance arrangements for fam-
• Sewing needle and thread ily members helps reduce anxiety (Peterson, 2006).
• Safety razor blades Health care organizations need to consider the personal needs
• Safety pins, assorted sizes of their personnel when developing disaster response plans
• Thermometer (Chaffee, 2006). Child care and family shelter should be part of
• Tongue depressors the plan. Alternative transportation and modes of communica-
• Sunscreen
tion are essential. In certain circumstances such as floods, earth-
Adapted from Federal Emergency Management Agency. (2011). Are quakes, and snowstorms, health care personnel might not be
you ready: Assemble a disaster supplies kit. Appendix B. Washington, able to report to their assigned posts on their own. If telephone
DC: Author. service is interrupted, telephones and pagers might not function.
It is important to include local radio stations, ham radio opera-
BOXÂ€22-5â•…â•‡FAMILY DISASTER PLAN tors, and telephone company representatives to assist in develop-
ing a realistic communication plan for the organization to allow
• Children knowing how to dial 911 for optimal communication among the organization, its person-
• Emergency phone numbers posted by phone nel, and other community organizations during a disaster event.
• How and where to turn off utilities
• How to escape and where to go Survey Assessments
• Where to meet with family members in case of separation (e.g., a After a severe disaster, survey teams are assigned to make a
neighbor's house or across the street from the front door) rapid assessment of the casualties and damage to infrastructure.
• Establish point of contact outside immediate area in case of family
Health care personnel are assigned to survey teams, and often
separation
community health nurses function as health assessment per-
• Plans for care of pets (pets are not allowed in shelters)
sonnel. Nurses who function on assessment teams are expected
• Safety precautions for various kinds of disasters (e.g., fire, hurricane)
• Practicing and maintaining the plan to perform casualty damage assessments, not render immediate
• A list of necessary items in the event of a disaster, including med first aid. This might also be problematic for some community
ications, dentures, or eyeglasses; special food or infant formula; health nurses, whose first instinct will be to render immediate
flashlight and batteries; water; sturdy shoes and clothing for cold or care. The information obtained from survey assessments is cru-
inclement weather; identification; checkbook, credit cards, driver's cial to help the EOC determine the emergency needs and plan
license, and other important papers; money in low-denomination for the appropriate equipment and personnel needs.
bills and coins; blankets; favorite toys and extra clothing for children
Determination of Immediacy of Care
In a shelter or emergency aid station, planning focuses on estab-
• Physicians’ names, addresses, and telephone numbers lishing the priority of care needs (triage) and deciding whether
• Persons to be notified in an emergency care can be provided at the station or only at an acute care hos-
Prearranged supplies and personal information make it pital. Discharge planning begins when a victim enters the shelter
more likely that the items will be easily located in case of an or aid station. If victims are transferred to a regular commu-
emergency or evacuation. nity health care facility, the nurse needs to determine medical
follow-up as needed in the community. Plans must also be made Psychological Needs of Victims
to deal with the dead, notify and provide grief counseling for Disasters produce physical, social, and psychological consequences
families, and arrange for burials. that are exhibited to varying degrees in different people, families,
communities, and cultures depending on past experiences, cop-
Role at Emergency Aid Stations ing skills, and the scope and nature of the disaster (see BoxÂ€22-3).
According to the ARC disaster services regulations, at least one Health effects can linger for long periods, as noted after September
registered nurse must be present while the emergency aid sta- 11, 2001, and Hurricane Katrina (Abramson etÂ€al., 2010; Farley,
tion is open. The ARC (1989) defines the functions of the disas- 2011; Wielawski, 2006). Because most people affected by a disaster
ter health service nurse-in-charge as follows: pass through predictable stages of psychological response, nurses
• Arranging with the volunteer medical consultant for initial and other health care professionals can anticipate and prepare for
and daily health checks based on the health needs of shelter the needs of the victims. The following victims of a disaster are
residents more likely than others to need crisis intervention:
• Establishing nursing care priorities and planning for health • Those who have lost one or more family members
care supervision • Those who have suffered serious injury
• Planning for appropriate transfer of clients to community • Those who have a history of a psychiatric disorder
health care facilities, as necessary • Those who have lost their home or possessions
• Evaluating health care needs • Those who have been previously institutionalized for a men-
• Arranging for secure storage of supplies, equipment, records, tal disorder
and medications and periodically checking to see whether • Those who have suffered a predisaster stress
material goods must be ordered • Those who are poor or on a fixed income
• Requesting and assigning volunteer staff to appropriate • Older individuals
duties and providing on-the-job training and supervision • Members of minority groups
• Consulting with the shelter manager on the health status of • Those who have not handled previous crises in a healthy way,
residents and workers and identifying potential problems especially those who have been hostile or self-destructive
and trends during a previous crisis
• Consulting with the food supervisor regarding the prepa- • Those without adequate support systems
ration and distribution of special diets, including infant After the September 11, 2001, disaster, undocumented or illegal
formulas immigrant families were less likely to receive aid. Many feared they
• Planning and recommending adequate staff and facilities would be detected and deported, so they did not seek out assis-
when local health departments initiate an immunization tance from volunteer and governmental agencies (Taintor, 2003).
program for shelter residents Most victims will have some psychological reaction to the
• Establishing lines of communication with the health care disaster situation. These reactions are usually transient, and
service officer many victims recover on their own with support from volun-
• Arranging with the mass care supervisor for the purchase teer workers and family members. The most important thing
and replacement of essential prescriptions for persons in the emergency personnel can do for victims is to recognize that they
shelter have a legitimate reason for their reactions and emotions and to
work toward providing them with emotional support. A psy-
Major Health Concerns after a Disaster chological assessment by the nurse will aid in identifying those
After a major disaster producing severe disruption of com- individuals more prone to severe psychological distress.
munity services and dislocation of citizens, a number of It is critical that each survivor of a disaster be assessed for the
health-related concerns are present. Some of these can be level of psychological stress she or he is suffering and the degree
anticipated and addressed in predisaster planning. In addi- of impairment she or he is experiencing in physical and emo-
tion, any major disruption can expect to have repercussions tional health and productive functioning. Individuals suffering
that have health-related consequences, including potential minimal distress usually need support only from family and
overcrowding in shelters and other types of community- friends. Those who experience a moderate amount of distress
living arrangements, decreased personal hygiene and sani- usually need the help of a support group or short-term counsel-
tation because of reduced services and privacy, increased ing. Persons with severe distress might need extensive therapy.
Â�personal injuries and malnutrition, potential contamination At the disaster site or primary triage point, simple support
of food and water supplies, and disruption of public health measures can alleviate the psychological trauma experienced by
services. Nurses working with a community disrupted by survivors. These measures include the following:
disaster can anticipate these types of problems and plan to • Keeping families together, especially children and parents
reduce the health hazards associated with them by activating • Assigning a companion to a frightened or injured victim or
community resources, ensuring adequate sanitation facilities placing victims in groups in which they can help each other
and on-the-spot health education to reduce health and sani- • Giving survivors tasks to do to keep them busy and reduce
tation hazards, initiating immunization programs to reduce trauma to their self-esteem
the spread of communicable diseases, and overseeing nutri- • Providing adequate shelter, food, and rest
tional and hydration programs to ensure adequate minimum • Establishing and maintaining a communication network to
standards for the population under care. During disaster sit- reduce rumors
uations, nurses must help individuals make the most of their • Encouraging individuals to share their feelings and support
health care, help maximize the population's health, and find each other
ways to improve the environment. • Isolating victims who demonstrate hysterical or panic behavior
BOXÂ€22-6â•…â•‡DISASTER STRESS REACTION psychosocial needs must be addressed. Victims need to be

ASSESSMENT linked with support agencies to help with food, clothing, shel-
ter, and long-term counseling needs. Depending on the extent
1. Has client experienced a disastrous event?â•… _____ Yes_____ No of damage to the community and the injuries of victims, the
2. Was this event generally outside the normal range of human experi recovery phase can be relatively quick or can extend over a
ence?â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•… _____ Yes_____ No long period. Community recovery from the hurricanes of
3. Would this event evoke symptoms in almost everyone exposed 2005 is expected to take years. The Gulf Coast evacuated 1.5
to it, including those who were emotionally healthy previously? million persons and many have still not returned (Abramson
â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•…â•… _____ Yes_____ No etÂ€al., 2010). In New Orleans, the recovery of health care facil-
If answer to first three questions is yes, client might be experiencing a ities has been slow. Only 15 of the 22 preexisting hospitals
disaster stress reaction. Continue assessment. are operational, and bed capacity has been cut in half (from
4. Does client have any of the following symptoms? (Place a check
4400 to only 2000 beds) (Berggren & Curiel, 2006). The San
next to each symptom experienced.)
Francisco area has still not completely recovered from the
_____ a. Reexperiencing of disaster through recurrent intrusive
earthquake of 1989.
recollections or dreams
_____ b. Reexperiencing of disaster in response to environmental It is very important for all emergency response personnel to
triggers learn from each disaster to improve response to the next emer-
_____ c. Feeling of unreality, numbness, or lack of responsiveness gency situation. For this reason, evaluation is an essential ele-
to events ment of any disaster plan. Evaluation should include assessment
_____ d. Decreased interest in previously significant people of the effectiveness of the immediate response, determination
_____ e. Decreased interest in previously meaningful activities of the impact of the disaster on the community, follow-up of
_____ f. Hyperalertness victims to determine how well victim needs were met by the ser-
_____ g. Increased startle response vices provided, and assessment of the impact of the disaster on
_____ h. Guilt about surviving disaster or about behavior during response personnel. The evaluation might result in new priori-
disaster ties, goals, and care plans.
_____ i. Difficulty concentrating and/or remembering
_____ j. Avoidance of activities or places that stimulate recollec Nurses from Massachusetts General Hospital in Boston
tion of disaster became part of a DMAT rapid response team dispatched
_____ k. Worsening of symptoms with exposure to events that to New York on September 11, 2001. Eighty-nine nurses,
symbolize or resemble disaster experience
doctors, and other health care professionals were in New
The presence of three or more of the preceding symptoms indicates
York 10 hours after the team was activated. They prepared
high likelihood that the client is having a disaster stress reaction.
Other symptoms that are not diagnostic of disaster stress reaction
to treat mass casualties, but there were few live victims.
but that might accompany the reaction are the following: Team members were rerouted to provide relief for burn
_____ Increased irritability unit nurses and care of rescue workers at Ground Zero.
_____ Unpredictable explosions of aggressive behavior After completing their mission and returning to Boston,
_____ Impulsive behavior (if a change from previous pattern) the team met to evaluate their performance and recom-
_____ Overwhelming sadness mend changes. Among their findings were the following
(Forgione etÂ€al., 2003):
Adapted from Demi, A. S., & Miles, M. S. (1983). Understanding
• Standard instrument kits were too heavy for workers to
psychological reactions to disaster. Journal of Emergency Nursing, 9,
13-16.
cart over the necessary distances without vehicle transpor-
tation. Recommended change: Kits were modified.
• Problems were encountered in sterilizing equipment and
Some persons will need more intensive support. Whenever using cauteries because of lack of electricity. Recommended
possible, community mental health nurses will be an important change: Battery-operated cauteries and waterless steriliza-
asset to the health care team to assist in meeting the psychoso- tion systems were identified and procured.
cial needs of victims. A quick psychological assessment guide is a • Client documentation was deficient. Recommended change:
useful tool to help emergency personnel determine the psycho- There is an ongoing effort to improve the documentation
logical state of victims (BoxÂ€22-6). Individuals at risk for suffer- process.
ing psychological crisis after disaster might not seek help, even
if they need it. Therefore, it is essential that the nurse assess the
stress level of victims, make other rescue team members aware Personal Response of Care Providers to Disaster
of this, and refer those victims who need help to appropriate Disaster workers are often overlooked when those affected by a
professional counselors. The nurse, as a member of the disaster disaster are considered. Health care workers are subject to the
team, participates in rescue operations and acts as a case finder same concerns and emotional traumas as are other community
for persons suffering psychological stress, intervening to help residents. Many disaster workers report being overwhelmed by
the victims deal effectively with the stress. the devastation and the extent of personal injuries. They might
feel unqualified to cope with some of the medical emergen-
Recovery cies presented. In major disasters, many work without relief
During the recovery phase of a disaster, nurses are involved for 24 to 36 hours. If they are residents of the affected com-
in efforts to restore the community to normal. Referral of munity, they must deal with personal losses and concerns for
injured victims for rehabilitation and convalescence is impor- friends and relatives in addition to working with the people
tant to reduce the chances of long-term disability. Ongoing under their care.
Responders can become stressed because of understaffing sources, including a state's Nurse Practice Act, professional
in their work environment. They might be overwhelmed for organization standards, a state attorney's opinions, and cur-
days or even weeks after a disaster. As they reflect on the event, rent and common practice laws. All nurses should be familiar
emergency personnel might second-guess their actions and with the Nurse Practice Act in the state in which they live and
question their competency. They might “burn out” on the job, work, not only for disaster purposes but also for the general
becoming detached or overinvolved. French and colleagues practice of nursing.
(2002) examined the responses of nurses during the aftermath of Although it does not have standards specific to disas-
Hurricane Floyd in 1999. They reported that the nurses experi- ter nursing, the ANA has standards for emergency nursing
enced conflict between family and work-related responsibilities. practice. These are professional, not legal, standards; how-
A 2005 study identified barriers that might prevent health care ever, compliance with standards-of-care criteria will protect
workers from reporting to work in an emergency (Qureshi etÂ€al., the nurse working within these standards of practice. Many
2005). These include concerns about personal and family safety; states have Good Samaritan laws. Nurses working with fed-
transportation issues; child care, elder care, or pet care needs; eral/state response systems are also covered (Peterson, 2006).
and other work or volunteer obligations. For example, a The ANA supports development of uniform state laws to pro-
health care worker might also be a disaster assistance response tect nurses and other medical personnel working under disas-
volunteer. ter conditions.
After a disaster, it is important that health care workers For nurses working with the ARC, protection is provided
address stress issues. They may have feelings of anger, grief, under the federal mandate. The authority vested in the ARC
and frustration about their personal losses. Supportive col- makes it unnecessary for state or local governments to issue
leagues can ease the stress for health care workers. The ARC special permission or a license for the ARC to activate or carry
encourages disaster workers to go through a debriefing pro- out its relief program. No state, territory, or local government
cess after their disaster work is complete. This process might can deny the right of the ARC to render its services in accor-
consist of one or several sessions and is designed to help dance with the congressional mandate and its own adminis-
health care workers recognize and deal with the personal trative policies.
impact of the disaster. As a volunteer during a disaster, a nurse is covered by the
“Good Samaritan” act of the state in most situations. The pur-
Ethical and Legal Implications pose of Good Samaritan acts is to encourage medically trained
There are no laws specifically defining the scope of practice persons to respond to medical emergencies by protecting them
for nurses during a disaster. There are, however, guideline from liability through grants of immunity.
KEY IDEAS
1. Disasters can occur naturally or be man-made. 8. The September 11, 2001, disaster heightened the country's
2. Individuals respond in many different ways to the disaster awareness of the need for disaster preparedness. This has
experience, and emergency care providers are not immune led to increased efforts to monitor biochemical hazards,
to personal responses to the experience. improvement in biological surveillance systems, and
3. A critical component of disaster preparedness is preplan- upgrades and revisions to many organizations’ disaster
ning and use of mock-disaster exercises to prepare response plans.
personnel for an actual event. 9. Community/public health nurses are an integral part of
4. During the preimpact phase of a disaster, nurses and other disaster planning and implementation efforts. They are
designated disaster relief personnel can initiate shelter prep- involved as planners, educators, direct caregivers, and
aration if there is a significant warning interval; if there is assessment supervisors. They might serve as community
minimal or no warning, they must respond to the commu- survey assessors or triage officers after the disaster has
nity's emergency needs after the impact of the disaster event. occurred.
5. Since the events of September 11, 2001, the federal govern- 10. Nurses can be involved in disaster relief and training by
ment has developed programs to strengthen emergency joining local metropolitan medical recovery systems for the
response and integration of recovery efforts among all lev- ARC or state or federal disaster response teams.
els of government: federal, state, and local. 11. Evaluation and reassessment of the actual disaster relief
6. Local, state, federal, and voluntary agencies should be effort is a crucial part of disaster management efforts. The
involved in community disaster planning efforts. information gathered by a thorough evaluation should be
7. The American Red Cross (ARC) is responsible for resident used to strengthen the community's response plan to better
relief during disasters, including shelter operations, health meet the next emergency situation.
care, and relief supplies for workers in the field.
1. Call your local branch of the American Red Cross (ARC) and yes, what would you do first? If you were home and heard
ask what kind of activities related to disaster relief the agency about the wreck on a radio news bulletin, would you report
has undertaken in the past 5â•›years. to work? Would you report to work if your supervisor called
2. Identify your local emergency management agency and your and asked you to come in? If you were not employed, would
local emergency operations center. If you are unsure about you call the ARC and volunteer your professional services?
how to find this information, call your local police or fire Would you go to the scene?
department, and ask for the information. 5. Research a major disaster that has occurred in the United
3. Ask other health care personnel if they have had personal States during the past 5â•›years. Identify the health care needs
experiences taking care of victims in disaster or emergency of the population. According to your research sources, was
situations. the disaster handled efficiently by the disaster health person-
4. Consider what your response might be in an emergency situ- nel? Were any areas singled out as needing improved perfor-
ation. What if you witnessed a car accident or a bus wreck? mance? Can you identify any areas for improvement based
If you were driving by, would you stop? If not, why not? If on your readings?

FEDERAL AGENCIES All national agencies have state and local offices that respond to
Agency for Toxic Substances and Disease Registry: http://www. disasters; the local group is the source of immediate response.
atsdr.cdc.gov/ If the disaster exceeds both local and state resources, includ-
Federal Emergency Management Agency: http://www.fema.gov/ ing those of the private sector and volunteer organizations,
Department of Homeland Security: http://www.dhs.gov/index.shtm the state might request aid from other states or the federal
Army Corps of Engineers: http://www.usace.army.mil/Pages/ government.
default.aspx
Department of Health and Human Services: http://www.hhs.gov/ LOCAL VOLUNTEER ORGANIZATIONS
Boy Scouts of America: http://www.scouting.org/
INTERNATIONAL DISASTER RELIEF AGENCIES Goodwill Industries: http://www.goodwill.org/
American Red Cross: http://www.redcross.org/ Mennonite Disaster Service: http://mds.mennonite.net/
Disaster Relief Organization: http://www.hopeforce.org/ Volunteers of America: http://www.voa.org/
United Nations Headquarters: http://www.un.org/cyberschool- Seventh Day Adventists: http://www.adventist.org/
bus/untour/subunh.htm Church of the Brethren: http://www.brethren.org/
Pan American Health Organization: http://new.paho.org/
WEBSITE

• NCLEX Review Questions 22A: Historical Presidential Disaster Declarations
• Critical Thinking Questions and Answers for Case Studies 22B: National Emergency Support Functions and Agencies
• Care Plans
• Glossary
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Demi, A. S., & Miles, M. S. (1983). Understanding of disasters: The practice guide (3â•›rd ed.). preparedness. Retrieved from http://www.chemm.
psychological reactions to disaster. Journal of Washington, DC: American Public Health nlm.nih.gov/html.
Emergency Nursing, 9(1), 13-16. Association. Veenema, T. G. (Ed.). (2007). Disaster nursing and
Downing, D. (2002). Learning as we go: Public Levy, V. W., & Sidel, B. S. (2003). Terrorism and emergency preparedness for chemical, biological,
health, one year later. American Journal of public health. New York: Oxford University Press radiological terrorism and other hazards.
Nursing, 102(9), 76-77. and the American Public Health Association. (2nd ed.). New York: Springer.
CHAPTER
23
Violence: A Social and Family Problem
Cara J. Krulewitch*
FOCUS QUESTIONS
What are some of the factors that contribute to family What are some primary, secondary, and tertiary prevention
violence? measures for the different forms of interpersonal
What criteria are useful in assessing for possible abusive or violence?
neglectful situations? What community resources are available to prevent abuse
What are the responsibilities of the community/public health and to assist the victims and perpetrators in abusive
nurse as a health care professional in abusive situations? situations?
CHAPTER OUTLINE
Extent of the Problem Intimate Partner Violence
National Health Priorities to Reduce Violence Definition
Violence in the Community: Types and Risk Factors Violence in Dating Couples
Exposure and Social Conditioning Characteristics of Abusers and Victims
Adolescents and Violence Cyclical Phases of Abuse
Bullying Blaming the Victim
School Violence Why Spouses Stay
Gang Violence Legal Efforts to Combat Intimate Partner Violence
Guns and Violence Consequences for Children Exposed to Intimate Partner
Additional Risk Factors Violence
Impact of Violence on the Community Nursing Care in Abusive Situations: Child Abuse
Violence within the Family or Partner Abuse
Generational Patterns of Abuse Secondary and Tertiary Prevention
Inequality of Family Members Primary Prevention
Child Abuse and Neglect Elder Abuse
Factors Associated with Abuse and Neglect Definition
Types of Abuse Factors Associated with Abuse by Family Members
Impact of Child Abuse Laws Nursing Care for Older Adults and Caregivers
Family Preservation Alternative
Long-Term Consequences
KEY TERMS
Bullying Elder abuse Mandatory reporting
Child abuse Emotional abuse Physical abuse
Child neglect Incest Sexual abuse
Child protective services Intergenerational transmission of violence Social learning theory
Cycle of violence Intimate partner violence (IPV) Violence
*The author acknowledges the contribution of David R. Langford to this chapter in previous editions of the book.
575
576 CHAPTER 23â•… Violence: A Social and Family Problem
Violence at home and in the community is an issue that Â�generates Care must be exercised in determining the real risks of vic-
enormous public concern and has become a focus of preven- timization within a community based on these statistics from
tion in nursing and public health. Violence consists of nonac- the Bureau of Justice Statistics (2010). The myth and fear of
cidental acts that result in physical or emotional injury. Every stranger violence is often exaggerated, given that most individ-
day, local and national news reports are replete with examples of uals are at greater risk for victimization by family members or
Â�violent actions and their tragic consequences. In fact, violence has acquaintances.
become so commonplace that it is unusual to find anyone who Violent and property crimes have been steadily decreasing,
has not been exposed to violence either by personal experience and in 2000, they reached the lowest levels recorded since 1973
or by acquaintance with a victim. In some communities, violence (Rand & Truman, 2010). Adolescents and young adults are at
is so prevalent that residents are desensitized to it. Community especially high risk for being victims or perpetrators of violence,
members feel powerless to stop it and instead concentrate on and the young from minority groups are at an exceptional risk.
efforts to ensure their safety and that of their family members. FigureÂ€23-1 shows the rates of violence by age group. Teens and
young adults have the highest rates of victimization, and the
rates in these groups have demonstrated the most Â�significant
EXTENT OF THE PROBLEM decline since the early 1990s. Young African American men are
especially vulnerable, experiencing more overall violence than
Violence, like other community health problems, has patterns are their white male counterparts.
that, when identified, can help nurses to better understand the
distribution of the problem and delineate those at risk and risk
factors. What often appears or is reported as random violence is NATIONAL HEALTH PRIORITIES TO REDUCE
not. For example:
• Men are more likely victims of violent crimes by strangers, VIOLENCE
whereas women are more likely to be victimized by intimate Violence and injury prevention is a global health priority
partners, relatives, friends, or acquaintances. (World Health Organization [WHO], 2010). Specific objec-
• Close to 8 in 10 sexual assaults against women are committed tives in Healthy People 2020 related to injury and violence
by intimates, relatives, friends, or acquaintances. Â�prevention are aimed at reducing injuries, disabilities, and
• After spousal homicide, children killed by their parents are deaths due to unintentional injuries and violence. The Healthy
the most frequent type of family homicide. Most children People 2020 box on the next page outlines the objectives related
who are killed are male, and the offenders are male. to injury and violence and progress in meeting those goals. As
• About 16% of male murder victims and 9% of female mur- with many other community problems, there is a significant
der victims were killed by strangers, and strangers were disparity among population groups in exposure to violence
responsible for about 42% of all violent crimes. and abuse. For example, homicide is the leading cause of death
• Intimate partner violence (IPV) is the primary crime against in blacks aged 15 to 34â•›years and the second leading cause of
women. death in black children aged 1Â€to 4â•›years (Logan et al., 2011).
• Overall, violent crimes are more likely to occur during the The homicide rate for African American men and women is
day (6â•›am to 6â•›pm). The exception is rape, which more often well above the rate for their Hispanic and white non-Hispanic
occurs at night (6â•›pm to 6â•›am). counterparts.
125 Age
100
75
50
12-15
16-19
20-24
25 25-34
35-49
50-64
65
0
1973 1980 1987 1994 2001 2008
FIGUREÂ€23-1â•‡Violent crime victimization by age of victim, 1973 to 2008 (victimization rate per
1000 persons in age group). (From Bureau of Justice Statistics. [2009]. Key facts at a glance: Trends
in victimization rates by age. Retrieved August 31, 2011 from http://www.ojp.usdoj.gov/bjs/content/glance/
vage.cfm.)
CHAPTER 23â•… Violence: A Social and Family Problem 577
HEALTHY PEOPLE 2020 BOXÂ€23-1â•…â•‡FACTORS ASSOCIATED WITH

Violence and Abuse Prevention Objectives RISK OF VIOLENCE
Sociological
1. Reduce homicides to 5.5 homicides per 100,000 population
Low socioeconomic status
Â�(baseline: 6.1 homicides per 100,000 population in 2007).
Involvement with gangs
2. Reduce maltreatment of children to 8.5 per 1000 children younger
Drug dealing
than age 17â•›years (baseline: 9.4 child victims of maltreatment per
Access to guns
1000 children younger than age 17â•›years in 2008).
Media exposure to violence
3. Reduce the rates of physical and sexual assault and Â�psychological
Community exposure to violence
abuse by current or former intimate partners (developmental
Â�objective, no set goal) Developmental/Psychological
4. Reduce rates of bullying among adolescents to 17.9% (baseline: Alcohol or drug abuse
19.9% of students in grades 9 through 12 reported that they were Rigid gender role expectations
bullied on school property in the previous 12â•›months in 2009). Peer pressure, especially for adolescents
5. Reduce children's exposure to violence to 54.5% (baseline 60.6% Poor impulse control
of children were exposed to any form of violence, crime, and abuse History of mental health problems
measured in 2008). High individual stress level
6. Reduce physical assaults to 14.7 physical assaults per 1000 Â�persons Manual laborer, unemployed, or employed part-time
aged 12â•›years and older (baseline: 16.3 physical assaults per 1000 Younger than 30â•›years
persons aged 12â•›years and older in 2008).
7. Reduce to 24.8% the proportion of adolescents engaging in pÂ� hysical Family
fighting (baseline: 31.5% of adolescents in grades 9 through 12 History of intergenerational abuse
engaged in physical fighting in the previous 12â•›months in 2009). Social isolation
8. Reduce to 4.6% the proportion of adolescents carrying weapons on Verbal threatening of children by parents
school property (baseline: 5.6% of students in grades 9 through 12 High levels of family stress
carried weapons on school property during the past 30â•›days in 2009). Two or more children
Data from U.S. Department of Health and Human Services. (2010). Healthy
People 2020. Washington, DC: Author. http://www.healthypeople.gov. DuRant and colleagues (2006) reported that teens who watch
televised professional wrestling programs are more likely to
VIOLENCE IN THE COMMUNITY: TYPES AND engage in fighting and date fighting, and to carry weapons. In its
RISKÂ€FACTORS policy statement on media violence, the American Psychological
Association (APA) calls for physicians and other health care
To date, there is no accurate method of predicting which indi- professionals to get more involved in working with families and
viduals will engage in violent behaviors. Studies have identi- the political system to reduce children's exposure to media vio-
fied factors that place individuals at greater risk for engaging lence (Carll, 2006). The American Academy of Pediatrics (2009)
in violence (BoxÂ€23-1). However, not everyone to whom these has urged parents to limit their children's media exposure and
risk factors applies behaves violently. An individual's use of vio- to be actively involved in the selections of materials viewed by
lence seems to be influenced by a variety of factors both external children and teens.
(family, society, and other environmental conditions) and inter-
nal (innate personality characteristics). Adolescents and Violence
Adolescents are exposed to and particularly vulnerable to increas-
Exposure and Social Conditioning ing violence at school and in the community (MacKay & Duran,
One explanation for violence is that people learn to use violence 2008). An alarming number of adolescents know victims of or
when violence is condoned or is considered an acceptable strat- have witnessed assaults, rapes, or other life-Â�threatening violence.
egy in solving problems. This view is based on the principles Inner-city youth have the greatest exposure risk (Stodolska &
of social learning theory, according to which children learn to Shinew, 2011; U.S. Department of Justice [USDJ], 2008). AÂ€cross-
respond with acts of violence by observing role models and see- sectional survey of inner-city children found that 61 experi-
ing problem solving through violence portrayed as successful in enced at least one direct or witnessed victimization in the past
the media (Warriner, 1994). year. Almost half had experienced a physical assault (Finkelhor
Many American cultural institutions model and even etÂ€al., 2009). In 2009, 22.5% of all violent crime was committed
encourage violence and aggression. Aggressive actions are by juveniles (Rand & Truman, 2010). Some have suggested that
applauded in sports, movies, television, and video games. It these family dynamics, self-concept, and self-esteem are predic-
is estimated that by the age of 18â•›years, the average television tive of youth violence. (Kim & Kim, 2008; Rohany etÂ€al., 2011).
viewer has witnessed 200,000 acts of violence on television, in Bollard and colleagues (2001) found that hopelessness was rela-
video games, and through other media channels (Committee tively rare in teens; however, when present, it was predictive of
on Public Education, 2001). This exposure to media violence fighting and carrying weapons. Other predictors of adolescent
is positively related to increases in aggressive behavior. Viewing violence are poor grades, deviant behavior, weak bonds in mid-
violence on television, in movies, and in games has been linked dle school, early drug use, and association with peers using drugs
to increased violence and aggression and increased risk taking (Children's Defense Fund [CDF], 2005; RMC Research Corp,
in children and adolescents, which carries over into adulthood 2010). There is a high rate of co-occurrence of substance use and
(Anderson etÂ€ al., 2008; Carll, 2006; Huesmann etÂ€ al., 2003). violence in youth (Van Dorn etÂ€al., 2009).
The National Center for Injury Prevention and Control 2011). Lyznicki and colleagues (2004) listed the following ques-
(2010a; 2010b) at the Centers for Disease Control and tions the nurse can ask children to help identify bullying issues:
Prevention (CDC) reported the following for 2007: • What do you do when others pick on you?
• More than 656,000 young people aged 10 to 25â•›years were • Have you ever told a teacher or an adult what happened?
treated in emergency departments for injuries sustained • What kinds of things do you get teased about?
through violence. • Do you get teased about your illness or handicap?
• Eleven percent of youth in grades 9 through 12 reported
being in a physical fight in the past 12â•›months, and 5.6% School Violence
reported carrying a weapon in the previous month. School violence takes many forms; for example, excessive teas-
• Five percent of students in grades 9 through 12 report not going ing, pushing and shoving, bullying, intimidation, stalking, seri-
to school on one or more days in the previous month because ous physical assault, and murder. In 2008 to 2009, students
they felt unsafe at school or on their way to or from school. were exposed to 1.2 million nonfatal crimes at school, includ-
• Homicide is the second leading cause of death among young ing 626,800 violent crimes such as assault, rape, and robbery
people aged 10 to 24â•›years. (Robers etÂ€ al., 2010). Many of these children showed signs of
• Firearms are responsible for 84% of the homicides among anxiety and depression, and 61% worried about their safety.
young people aged 10 to 24â•›years. Higher exposure to violence was associated with lower grade
• Homicide is the leading cause of death among African point average and more days absent from school. According
American youth and the second leading cause of death to the U.S. Department of Education and Justice, approxi-
among Hispanic youth aged 15 to 24â•›years. mately 5% of students skip school, avoid places within school,
or avoid school activities because they are fearful (Robers etÂ€al.,
Bullying 2010). The presence of youth gangs in elementary and second-
The impact of bullying and being bullied is an important aspect ary schools increases the rate of serious crime in those schools.
of violence. Bullying has health consequences across the life Approximately 20% of public schools report gang activity in
span. The beliefs that bullying is a normal part of growing up, their schools (Robers etÂ€al., 2010). Mulvey and colleagues (2010)
that it is temporary, that its impact on health is minimal, and described the links between gangs and drug use. This link is
that it happens as a result of children's being left unsupervised both at the individual level and within peer groups. When stu-
are myths and underestimate the risk and impact of bullying. dents are preoccupied with their safety and schools must divert
Bullying is a pattern of physical, verbal, or other behaviors energy and resources to deal with potential violence and violent
directed by one or more children toward another child that are behavior, the educational mission of the schools suffers.
intended to inflict physical, verbal, or emotional harm. Many
children with preexisting health conditions or disabilities are Gang Violence
at risk for victimization because they are different or act dif- There were an estimated 774,000 gang members and 27,900
ferently from their peers. Children who are overweight or have gangs active in the United States in 2008. This is an increase of
attention-deficit/hyperactivity disorder (ADHD) are more 28% in the number of gangs and 6% in that of gang members
likely to be bullied (Cook etÂ€al., 2010; Lumeng etÂ€al., 2010). since 2002 (Egley etÂ€al., 2010). Most gang members are male, but
The prevalence of bullying among middle and high school female membership is growing. Although most gang members
students varies widely with estimates from 7% to 54% world- are adolescents and young adults, gang members range in age
wide (National Center for Education Statistics, 2007; Undheim from 8 to 55â•›years.
& Sund, 2010). Male students report higher rates of bully- Gangs are flourishing in both rural and urban commu-
ing, and bullying is most prevalent in the sixth through eighth nities. Gangs can provide a sense of stability and family for
grades. Boys use more physical forms of bullying, whereas girls many disenfranchised adolescents with unstable family situa-
use more relational forms of bullying such as exclusion, isola- tions (Egley etÂ€ al., 2010). Gang members identify five reasons
tion, and initiation of rumors. for joining gangs: (1) only option, no jobs available; (2) peer
Bullying is a form of violence that has a significant impact Â�pressure; (3)Â€protection; (4) companionship; and (5) excitement
on children's health. Many somatic and mental health com- (Morrissey, 2011; Palm Bay Police Department, 2007). Having a
plaints such as bedwetting, headaches and stomachaches, neck previous conduct disorder and having friends who joined gangs
and shoulder pain, back pain, anxiety, fatigue, loneliness, short or engaged in aggressive behaviors are predictive of joining a
temper, depression, suicidal ideation, increased drug and alco- gang among adolescents (Palm Bay Police Department, 2007).
hol use, aggression, and delinquency are related to being bul- Violence is part of everyday life for gang members. Youth
lied (Fekkes etÂ€al., 2004; Kim etÂ€al., 2005; McCenna etÂ€al., 2011; gang members are more likely to engage in drug use, drug
Sullivan etÂ€ al., 2006). Bullying is also a risk factor for violent trafficking, and violence than other youth and are three times
behavior and injury and teenage pregnancy (Perren, 2011). more likely to be involved in violent activities than non–gang
Young people who bully or are bullied are more likely to be members (Morrissey, 2011; Mulvey etÂ€al., 2010; National Drug
involved in fights, injured in fights, and carry weapons to school Intelligence Center, 2009). Violence is a part of their neighbor-
(Fox etÂ€al., 2003; Nansel etÂ€al., 2003). Being rejected and bullied hoods and families, and violence is an expected part of their role
by peers is a characteristic common to students who commit and individual status as gang members. Over half the homicides
school shootings (Leary etÂ€al., 2003; Reuter-Rice, 2008). in Los Angeles and Chicago are gang related (Egley etÂ€al., 2010).
School nurses and nurses working with children and adoles- In Rochester, New York, 68% of all adolescent violent offenses
cents can screen for bullying during routine health care visits were committed by gang members (Howell, 2006). A sense of
such as school physicals. School nurses are more likely to see belonging, peer pressure, or the threat of retaliation makes it
students who are bullies or have been bullied (Vernberg etÂ€al., difficult for individuals to leave gangs.
Entire communities must come together to reduce gang Parents’ increased concern and anxiety about safety in their
membership and violence. Preventing young men and women neighborhoods (presence of gangs, child aggression, crime, vio-
from joining gangs should be the first priority. Strategies include lence, traffic) is related to lower levels of children's physical activ-
preventing youth from dropping out of school and strengthen- ity and outdoor play (Stodolska & Shinew, 2011; Weir etÂ€al., 2006).
ing social institutions to better provide activities and legitimate The family is the first place in which acceptable social behavior
economic opportunities for youth (CDF, 2005; USDJ, 2008). is learned. Abusive behavior that starts within the family
Â� has an
Several cities—including Boston, Massachusetts; Indianapolis, impact on the entire community, economically and emotionally.
Indiana; and Stockton, California—have initiated successful Although community health nurses encounter violence and
comprehensive gang violence reduction programs. These entail violence-related concerns in a number of situations, their most
concentrated police enforcement, involvement of community lead- frequent professional contact is with individuals and families in
ers and pastors in violence reduction messages, and a Â�network clinics and homes. For this reason, the remainder of this chapter
of support services for at-risk youth. concentrates on family violence and the nursing role in preven-
tion and intervention with the family.
Guns and Violence
Firearms are the second leading cause of death among youth aged VIOLENCE WITHIN THE FAMILY
10 to 19â•›years (Morbidity and Mortality Weekly Report [MMWR],
2011). Over a 28-year period, 110,645 children were killed by Family violence involves the direct use of force, emotional bat-
firearms. In 2007, the 3042 gun related deaths in children were tering, or neglect carried out by one family member against
almost the same as the number of U.S. deaths in Iraq (CDF, 2010). another. It is very difficult to determine with certainty the
Regulations regarding the manufacture and Â�licensing of firearms actual prevalence of family violence. Most cases go unreported.
are more lenient in the United States than in other developed Family violence researchers use data from both small and
countries, which makes firearms easily accessible. Higher rates of national samples to estimate the extent of the problem. Much
household ownership and accessibility of firearms are associated of the research has also been conducted on clinical popula-
with disproportionately higher homicide rates (Miller etÂ€al., 2002). tions, those who have already been identified, and therefore,
A number of interventions have been tried to reduce firearm care must be taken when generalizing these findings to non-
violence in the United States. An evaluation of the laws enacted clinical populations.
to prevent firearm violence found inconclusive evidence that
bans, restrictions and waiting periods, registration and licensing Generational Patterns of Abuse
regulations, laws regulating the carrying of concealed weapons, A pattern of abusive behavior in families continuing one genera-
child-access laws, and zero-tolerance laws in schools and other tion after another, also called the intergenerational transmission
public places have had little if any impact in reducing firearm vio- of violence, has been widely documented. However, the relation-
lence (Centers for Disease Control and Prevention [CDC], 2003). ship between being abused and witnessing abuse as a child and
Opponents of gun control such as the National Rifle Association being abusive or victimized as an adult is complex. Not all chil-
(NRA) argue that criminal assault and injury will continue dren who grow up in violent homes become violent in later life.
despite gun control and that assailants will simply switch to other Lackey (2003) found that exposure to violence at home as an
weapons. Proponents argue that stricter gun control laws will adolescent was strongly related to partner violence in men but
help to bring murder and injury rates in line with those of other not in women. Hamby and Jackson (2010) found that witnessing
nations. The National Research Council (2005) conducted a sys- partner violence was closely associated with several forms of mal-
tematic literature review in 2004 and did not find significant data treatment and other forms of victimization and called for a need
to support the effect of gun-control laws on reducing violence. to better integrate services to adult and child victims of family
violence. This has important leader in coordination of care.
Additional Risk Factors
Poverty is an important risk factor associated with victimization Inequality of Family Members
through violence. Individuals are at greater risk for being the vic- Gelles and Straus (1988) contend that people abuse family
tims of violent acts if they are poor (Bureau of Justice Statistics, members because there are few or no repercussions. There
2007). Poverty and living in impoverished neighborhoods also continues to be inequity in arrest or criminal prosecution for
increase the risk for IPV (Caetano and Ramisetty-Minker, 2010; IPV. Social attitudes, the private nature of family violence, and
CDC, 2010a; Fox & Benson, 2006). In addition, the increas- the structural inequalities in family relationships combine to
ing levels of drug, alcohol, and tobacco use among adolescents create a climate in which violence is acceptable and toler-
were associated with their increasing exposure to violence, not ated. Violent acts against family members often go unpun-
only in the United States but internationally (Vermeiren etÂ€al., ished, although similar actions against other people would be
2003). Using drugs exposes adolescents to victimization through criminally prosecuted. Parental use of physical punishment is
violence, delinquent peers, and drug dealing. Adolescents subse- widely practiced and often socially condoned. Increased vis-
quently develop favorable attitudes toward violence that continue ibility of family violence and national campaigns are slowly
even when they are not using drugs any longer (Kuhns, 2005). changing public attitudes and acceptance of family violence.
What happens within the family has been considered a pri-
IMPACT OF VIOLENCE ON THE COMMUNITY vate “family matter.” Because of the strong belief in family privacy,
neighbors, family members, and authority figures such as teach-
Violence in the community creates a sense of fear and danger. ers, health care professionals, police, and prosecutors often hesitate
TheÂ€fear of violence has a tremendous impact, causing residents to intervene (Jecker, 1993). Culturally, the values of men, women,
toÂ€be suspicious of one another and to become more isolated.
Â� and children have been considered unequal. Historically, this was
supported by legal statutes under which women and children were Black children are at highest risk of substantiated maltreat-
considered property and had few rights under the law. Children ment and Asian American children have the lowest risk (Federal
could be sold into slavery, loaned to work for wages collected by Interagency Forum on Child and Family Statistics, 2011).
the father, or bartered into marriage without legal recourse. In Children who live in homes at lower socioeconomic levels are
fact, it is still very difficult for minor children to establish rights at greater risk of substantiated maltreatment than those from
independent of their parents. Since the late 1900s, state by state, higher income homes. Large national family surveys do not show
women have slowly been granted the right to personal assets and African American families to be at greater risk for child abuse
property, independent of a spouse. It was 1929 before women in (Gelles & Cornell, 1990). The discrepancy between substanti-
the United States were granted the right to vote nationwide. Social ated reported cases and family survey data might be explained
inequalities among family members persist, creating a climate in by reporting bias. The larger number of reported cases of child
which violence continues. abuse and neglect among the poor (more of whom are African
American families) is probably the result of those families’
CHILD ABUSE AND NEGLECT involvement with Â�public social and health services and emer-
gency departments (CDF, 2005). These caregivers are more likely
The National Center for Injury Prevention and Control (2010a) to report abuse and neglect. Family cultural practices might pro-
reported the following for 2008: vide supports to reduce risks for abusive situations. For exam-
• In the United States, 1740 died as a result of abuse or neglect. ple, African American and Hispanic families tend to have greater
• Child protection services investigated 3.3 million reports extended family involvement and use family networks for emo-
ofÂ€ child abuse and neglect; this amounts to approximately tional, financial, and child-rearing support. These characteris-
5.5 million children in the United States. tics might offset the stressors of higher unemployment and less
• 1 in 5 U.S. children experience some form of maltreatment. socioeconomic power.
• Most children were maltreated by their parents, who were
typically less than 39â•›years of age. Types of Abuse
• Rates of victimization were higher among African American, There are four major types of maltreatment or child abuse.
American Indian or Alaska Native, and multiracial children. Generally, child abuse applies to abuse of persons younger than
• Children who have experienced abuse and neglect are at 18â•›years of age. Definitions, however, vary among the states.
increased risk for adverse health effects and behaviors as
adults, including smoking, alcoholism, drug abuse, physical Physical Abuse
inactivity, severe obesity, depression, suicide, sexual promis- Physical abuse of a child is characterized by the infliction of
cuity, and certain chronic diseases. physical injury as a result of punching, beating, kicking, bit-
• Infants are at greatest risk of dying from homicide during the ing, burning, shaking, or otherwise harming a child. The par-
first week of infancy, with the risk being highest on the first ent or caregiver might not have intended to hurt the child; the
day of life. Children younger than 1â•›year account for 44% of injury might have resulted from overdisciplining or physical
fatalities related to child maltreatment. punishment. BoxÂ€ 23-2 provides examples of Â�moderate and
Children also encounter violence and abuse from caregivers severe abuse as well as some injuries that might be indica-
other than parents. Daycare providers (especially unlicensed pro- tive of child abuse. Because physical abuse is often not an
viders), family friends, and neighbors might also abuse children. isolated incident, evidence of past injuries might be present.
However, the greatest risk is from family members and relatives. The explanations for old or healing injuries should be care-
fully explored.
Factors Associated with Abuse and Neglect
Abuse is inflicted sometimes on all of the children in a family, Child Neglect
but often one child is singled out or targeted to receive most Child neglect is characterized by failure to provide for the
or all of the abusive attention. A child who is considered dif- child's basic needs (U.S. Department of Health and Human
ferent or has a physical or emotional disability is at special risk Services [USDHHS], 2007). Neglect can be physical, educa-
of abuse (Hibbard & Desch, 2007; United Nations Children's tional, or emotional. Physical neglect includes failure to pro-
Fund [UNICEF], 2005). Children with disabilities are nearly vide adequate food, clothing, and shelter; refusal to seek or
3.5 times more likely to be abused than children without dis- delay in seeking health care; abandonment, expulsion from
abilities (Govindshenoy & Spencer, 2007; Sullivan & Knutson, the home, or refusal to allow a runaway to return home; and
2000). The study by Mandell and colleagues (2005) reported inadequate supervision. Educational neglect includes allow-
that 18.5% of children with autism had been physically abused. ing chronic truancy, failing to enroll a child of mandatory
It is important to note that other siblings in the family, although school age in school, and failing to attend to special educa-
spared the immediate abuse, are also affected. Removal of one tional needs. Emotional neglect includes such behaviors as
child does not guarantee a solution to the problem. Another marked inattention to the child's needs for affection, Â�failure
child in the household usually becomes the next target. to provide needed psychological care, spousal abuse in the
The nurse should exercise caution in generalizing from child's presence, and permitting drug or alcohol use by the
reported case data because these data may be biased. Although child. Assessment of child neglect requires consideration of
child abuse and neglect occur across the socioeconomic spectrum, cultural values and standards of care as well as recognition
poverty seems to be a risk factor, whereas parental education is a that the failure to provide the necessities of life might be
poor predictor. The rate of abusive incidents is relatively uniform related to poverty.
across educational levels (CDF, 2005). Social expectations about Neglect is a pattern of failure to provide care rather than a
race and poverty often influence who is reported as abusive. single incident. In neglect cases, neighbors or relatives will
BOXÂ€23-2â•…â•‡SELECTED EXAMPLES OF Â�
perpetrator of sexual abuse is a family member (incest), family
PHYSICALLY ABUSIVE ACTIONS friend, neighbor, foster parent, or guardian (USDHHS, 2007).
AND INJURIES Emotional Abuse
PHYSICALLY ABUSIVE ACTIONS Emotional abuse includes acts or omissions by parents or other
Mild/Moderate Severe caregivers that cause, or could cause, serious behavioral, cogni-
Pushing Kicking tive, emotional, or mental disorders. Emotional or psychologi-
Throwing something Biting cal abuse is very hard to detect, and the behavioral consequences
Grabbing Hitting with fist might take years to develop. Acts that might not immediately
Spanking with bare hand Spanking with an object harm a child can be sufficient to warrant reporting and investiga-
Trying to hit with an object tion by child protective services. For example, the parents or care-
Beating up givers might use extreme or bizarre forms of punishment such as
Threatening with a weapon confinement of a child in a dark closet. Less severe acts such as
Using a weapon habitual scapegoating, belittling, or rejecting treatment are often
Shaking difficult to prove, and therefore, child protective services might
PHYSICAL INJURIES PRESENTED IN CHILD not be able to intervene without evidence of harm to the child.
ABUSE CASES Abuse and neglect are repetitive patterns of behavior.
Inconclusive Approximately 30% of children named in reports of child
Type Very Suspicious (Investigate) abuse or neglect had been the subject of a report to child pro-
Physical Immersion burns Subdural hematoma tective services at least once before in the previous 5â•›years
Whiplash syndrome in infants Fractured skull (Fluke etÂ€ al., 2005). In half the cases of child abuse–related
Cauliflower ears Injuries to face; black eye, deaths, a previous report of abuse or neglect had been filed
Spiral fractures of upper loose or missing teeth, with the state's child protective agency (Child Welfare League
extremities fractured jaw of America, 2004). BoxÂ€23-3 reviews behaviors and symptoms
Radiological evidence of healed Fractures of extremities common in abuse and neglect.
orÂ€healing fractures with no Inexplicable scars
history of treatment Chest or abdominal injuries Impact of Child Abuse Laws
Identifiable marks on body, such as inconsistent with reason Because of national concern, the federal government enacted the
hand print, belt buckle, human or trauma Child Abuse Prevention and Treatment Act (CAPTA) in 1974.
bites, shoe print, cigarette burns It was most recently amended and reauthorized on December
Severe cranial trauma in infants 20, 2010. The act sets established minimum definitions of child
(shaken-baby syndrome) abuse and neglect. CAPTA provides federal funding to states for
Sexual Report of sexual conduct with Repeated urinary tract use in the prevention, investigation, prosecution, and treatment
adolescents or adults infections with negative of child abuse and neglect. In addition, it establishes the Office
Evidence child posed for urine culture results on Child Abuse and Neglect and the National Clearinghouse on
pornography Genital itching or discharge, Child Abuse and Neglect Information.
Sexually transmitted diseases lacerations, bruises, or
Child abuse and neglect are crimes in all 50 states. All 50
Enlarged/stretched vaginal opening injury to genitals
states, plus the District of Columbia, have mandatory child
abuse and neglect reporting laws that require certain profes-
sionals and institutions to report suspected cases of maltreat-
Â�
frequently recall that they felt uneasy about a situation but did ment to a designated child protection agency. More than 60% of
not report the parent or caregiver to the appropriate authori- all reports of alleged child abuse or neglect are made by profes-
ties. Substance abuse and addiction are frequently implicated in sionals (USDHHS, 2009). These laws emerged from the moral
parental failure to provide an adequately nurturing environment. concerns of protecting the vulnerable and promoting nurturing
families (see the Ethics in Practice box). Each state has differ-
Sexual Abuse ent criteria and procedures for reporting suspected cases. Child
Sexual abuse includes fondling, intercourse, incest, rape, exhi- protective services is the agency assigned to investigate reports
bitionism, and commercial exploitation through prostitution of child abuse or neglect. The emotional aspect of abuse is not
or the production of pornographic materials (USDHHS, 2007). clearly addressed in most laws and has been difficult to pros-
Many experts believe that sexual abuse is the most underre- ecute in practice. Physical neglect of a persistent nature with
ported form of child maltreatment (National Center for Victims severe consequences is more likely to incur legal prosecution
of Crime, 2011). than are subtler forms of physical and emotional neglect.
It is important to note that sexual abuse of children can be To prove neglect, an adult's recognition that his or her actions
committed by strangers, acquaintances, or trusted leaders of have or could cause adverse consequences to the child is usually
the community, as well as by family members. The sex abuse a legal requirement to show intent. Economic, emotional, and
scandal involving priests in the Catholic Church is a good mental health factors might cloud the issue.
example of how sexual abuse of children can be perpetrated
by trusted members of a community and how it can stay hid-
A child was seen for an ear infection. An antibiotic was pre-
den for many years. Widespread publicity and public outrage
scribed, but the prescription was never filled. The child
prompted changes and better oversight of priests within the
developed complications and had to be hospitalized.
Catholic Church. In approximately 80% of cases, however, the
BOXÂ€23-3â•…â•‡SELECTED BEHAVIORS from their parents. It has been many experts’ belief that abusive
TO ASSESS IN SCREENING families can benefit from intense, long-term community sup-
port and supervision that addresses the myriad social and fam-
FOR CHILD ABUSE AND
ily issues that precipitated the abuse or neglect. Preservation
NEGLECT
programs stress intensive intervention with all family members
Behaviors of Abusive Parents and stringent supervision. The intent is to provide basic needs,
• Do not volunteer information or are vague about cause of child's educate, and build on family strengths to keep families together
Â�illness or injury rather than to place children in foster care. Evaluation of such
• Tell contradictory stories to explain injury programs has shown disappointing results. Some studies have
• Delay getting medical attention for child found fewer subsequent reports of child maltreatment, decreased
• Respond inappropriately to child during treatment, such as ignoring, frequency of out-of-home placements of children, and use of a
offering no comfort, or showing no concern, or, conversely, showing broader array of community support services among families
overinvolvement with attention linked to a family preservation caseworker who provided strong
• Have record of “hospital shopping” or using different facilities for collaboration in developing a treatment plan than among fami-
treatment of child lies without a family preservation caseworker (CDF, 2005; Littell,
• Blame siblings or baby-sitters without substantiation or place blame
2001; Walton, 2001). Others, however, have found no improve-
on child's clumsiness
ment in the level of family functioning, effectiveness in prevent-
• Show obvious signs of drug or alcohol use
ing future maltreatment, or risk of future foster home placement
Behaviors of Abused Child (Chaffin etÂ€al., 2001; Walton, 1996; Westat etÂ€al., 2002).
• Accepts injury as punishment
• Tells several stories of how injury occurred, which might appear Long-Term Consequences
rehearsed Children who are abused or mistreated are at increased risk
• Looks to parent for behavioral cues or is excessively obedient for learning disorders, mental retardation, and developmental
• Gives story inconsistent with observed injuries delays, including delays in language development, speech, and
• If confronted, often defends parent or refuses to cooperate with gross motor activities. Abused and neglected children generally
investigation have lower IQ (intelligence quotient) scores than children with
• Has psychosomatic complaints with no obvious organic cause similar characteristics who have not been abused and are much
• Emotional abuse should be ruled out in withdrawn children, overeaters, more likely to have academic difficulties in school (USDHHS,
truants, and runaways 2005). Physical abuse in childhood and the cumulative effects
of experiencing maltreatment and witnessing family violence
Behaviors of Neglected Child
• Has vacant or frozen affect are also related to chronic physical and mental health problems
• Does not cry, even if situation warrants throughout childhood and into adulthood (DePanfilis, 2006;
• Might be wary of physical contact or crave physical contact with Turner etÂ€al., 2006).
virtual strangers Mistreated children find it difficult to initiate mutually
• Has delayed development physically, emotionally, cognitively satisfying interpersonal relationships with peers and adults.
• Shows poor grooming of body, hair, and clothes on a regular basis Their social skills and self-concept suffer. They have difficulty
• Has behavior related to lack of supervision, including poor school setting limits or boundaries with others. Classmates might
performance and attendance describe them as socially withdrawn or as troublemakers.
• Pregnancy in young females in both abuse and neglect situations Physically abused individuals are more likely to be suicidal,
use drugs, and exhibit aggressive behaviors (Chen etÂ€al., 2010;
Currie & Widom, 2010; Rew, 2003). Children who are abused
and/or neglected are at greater risk of involvement in juvenile
Does this constitute deliberate neglect? Are there cultural or or other criminal activity. Compared with children who are
religious factors that might impact parents’ decisions to seek not maltreated, those who are abused and neglected are up to
and follow medical care? Some of the issues the authorities six times more likely to be involved in the juvenile justice sys-
would examine before deciding to prosecute include parental tem and up to three times more likely to be arrested as adults
understanding of the risks of withholding medication, ability (CDF, 2005, p. 117).
to pay for the prescription, and, finally, intent. Was the decision Children who run away from home often do so to escape
not to provide medication deliberate or the result of multiple sexual and other abuse in the home (Brandford etÂ€ al., 2004;
stressors or poor coping skills? National Runaway Switchboard [NRS], 2011). Girls run away
more often than boys do and also run away multiple times. This
Family Preservation Alternative suggests that girls may be subject to more dysfunctional rela-
The question of what should be done with the children who are tionships or feel less able to protect themselves at home. Once
victims of child abuse is a social policy challenge. Approximately on the street, runaways are vulnerable to predators, sex traffick-
20% of child victims are removed from their homes by court ers, drug dealers, and those engaging in other types of exploita-
order. Most are placed in foster care (USDHHS, 2009). Many tion (see ChapterÂ€21). Girls and boys often engage in sex acts for
of these children will bounce between foster care and a parent money, which can lead to a lifetime of problems. Prostitution
before parental rights are terminated. Most will not be adopted and promiscuous sexual activity are more prevalent among
and will remain in foster care until adulthood. adults who were sexually assaulted as children. Victims of Â�sexual
Family preservation programs are being tested as an alter- abuse report lifelong difficulty in Â�maintaining healthy adult
native to parental punishment, jail time, or removal of children relationships.
ETHICS IN PRACTICE
Protecting the Vulnerable Gail Ann DeLuca Havens, Ph.D., RN
“Victoria has become so introverted since the beginning of the school mother does meet with Melissa, the concern remains that she will be
year. Her schoolwork is suffering terribly. She rarely engages in conver- angry at the nurse's interference in her private life and retaliate by
sations or in play with classmates, and her absences have increased becoming even more abusive of Victoria.
significantly. I know something is troubling her, but she has not shared The other course of action that Melissa is obliged to take is to report
anything with me when we have had the opportunity to talk. I came to Victoria's story and past behavior observed in school to the child pro-
see you today in the hope that, as our school nurse, you might be able tection agency that serves the neighborhood in which Victoria and her
to find out what is troubling her.” family live. This action has the advantage of involving individuals in
In response to the third-grade teacher's plea, Melissa, the community the case who have expertise and accountability in addressing this type
health nurse for the four Central City elementary schools, establishes of family problem. It is an action that will better serve the interests
a rapport with Victoria over the next several weeks. Today, Melissa of Victoria, her siblings, and her mother. The short-term consequences
asks Victoria why she was absent from school all of the previous week. of the action involve the issue of trust because Victoria confided in
Tearfully, Victoria describes the beating she received from her mother Melissa as the school nurse, not necessarily intending that others
a week earlier. She had not cleaned up the kitchen to her mother's would become involved in the situation. Again, there is the fear of pos-
satisfaction. Her mother had hit her so hard that it hurt to walk. She sible reprisal by Victoria's mother. Another consequence is the possibil-
described her urine as having looked “like blood,” as well. Melissa ity of Victoria's being placed in a foster home.
learns that Victoria has been receiving beatings from her mother The nurse's primary moral concern in this situation is the pro-
since her father left the family last summer. Victoria has a sister and a tection of Victoria from further harm. Nonmaleficence, or doing
brother, both younger than she. Melissa does not believe that they have no harm, is one of the fundamental principles that guide nurses’
been hurt by their mother. clinical decision making (American Nurses Association, 2001). Even
This situation presents questions regarding the rights of children ver- though Melissa is not harming Victoria directly, having knowledge
sus the rights of parents. When does a child cease to be the biological of the harm she is experiencing and choosing not to intervene car-
offspring of two individuals and become, instead, a member of society ries with it the same moral force as direct harm. This kind of inac-
with all of the rights, duties, and responsibilities accorded such indi- tion is a breach of duty contrary to professional standards of care
viduals? Parents in our society are permitted a great deal of latitude (Beauchamp & Childress, 2009). There is, however, an equally com-
in raising their children. To a great extent the process of child rear- pelling moral principle operating here. By acting to protect Victoria
ing is defined by the prevailing cultural norms of the particular family from harm, Melissa acknowledges that the child is a distinct mem-
unit. It is presumed that the safety and well-being of the child will be ber of society and that she is not defined solely by her mother's
preserved within that family unit. As in Victoria's situation, however, identity. In essence, by her actions Melissa acknowledges Victoria's
when a question of child abuse arises, it becomes necessary to ques- autonomy, her independence as a person with particular needs and
tion the scope of parental authority. Child abuse is contrary to the soci- rights, and her separate identity.
etal norms that set the standards for moral parental behavior. A child A second moral concern is that Victoria be a member of a safe, nur-
has the right to be protected from harm. Being a parent, however, does turing family unit. To protect her from further abuse and to ensure that
not make one incapable of inflicting harm to one's child. Under what her family becomes a safe haven for Victoria, it is necessary that her
circumstances do others have a duty to protect children from their par- mother's needs be attended to. Melissa is aware that people usually
ents? Are there limits to parental authority, or do parents have inviolate attribute responsibility for an abusive incident to the parent. However,
rights to exercise their discretion in raising their children? What obliga- a characteristic that is common to abusing parents is a history of hav-
tions, if any, do others have to the abuser? ing been abused themselves (Adams, 2005). Victoria's mother must be
Melissa believes that she is obliged to protect Victoria from fur- “reparented” to effectively intervene in the child abuse cycle (Thomas,
ther harm. She is also concerned for the future safety and well-being 2007). As Melissa intervenes in this case, she acknowledges her pro-
of Victoria's siblings. Finally, she is concerned about the changes in fessional and moral commitment to assist both Victoria and her mother.
Victoria's mother's behavior and the underlying problems. Melissa is
also aware that the law requires her to report any suspected cases of References
child abuse to the local child protection agency caseworker. Adams, B. L. (2005). Assessment of child abuse risk factors by advanced
Melissa considers the courses of action that she perceives are practice nurses. Pediatric Nursing, 31, 498-502.
options in this situation. She can ask Victoria's mother to come to American Nurses Association. (2001). Code of ethics for nurses with
school to discuss the child's problems in school with her. This might interpretive statements. Washington, DC: Author.
offer a means to reveal to Victoria's mother the harm she is doing to Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical
her daughter. It also might be a catalyst for her to seek counseling and ethics (6th ed.). New York: Oxford University Press.
support. This action might serve to diminish the harm to Victoria, if Thomas, J. N. (2007). Evidence-based practice can reduce child abuse
her mother appears for the meeting. However, the mother has not kept in low-income communities. Journal for Specialists in Pediatric
appointments scheduled in the past by Victoria's teacher. If Victoria's Nursing, 12, 294-296.
INTIMATE PARTNER VIOLENCE caused by other criminal activities. The rates of IPV have not
decreased significantly over the past 10â•›years (Breiding etÂ€al.,
Intimate partner violence (IPV) is also often referred to as 2008). Findings from the National Violence Against Women
partner abuse, domestic violence, or woman battering. IPV is Survey (CDC, 2011a; Tjaden & Thoennes, 2000) include:
the leading cause of injury for women. According to national • Nearly 25% of women and 7.6% of men surveyed reported
crime statistics, battering is the single most common cause of being physically assaulted or raped by a former or current
injury to women, far exceeding accidental injuries and injuries spouse or partner over their lifetimes.
• In the United States, estimates are that approximately 1.5 However, the size and strength differences between men and
million women and 834,732 men are assaulted annually by women create a perception that male-on-female violence is
their partners. more frightening, which possibly draws more attention to them.
• It is estimated that approximately 503,485 women and There is legitimacy to the claim that cases in which the woman
185,496 men are stalked annually in the United States. is the aggressor are underreported because the male victims fear
• Rates of IPV vary greatly among women of diverse ethnic ridicule (Hamby & Jackson, 2010). Whitaker and colleagues
backgrounds. (2007) found that 25% of all relationships had some violence
• Women experience more assaults and injuries from their and that half of those were reciprocally violent. Nurses should
intimate partners than men do. be aware that anyone can be a victim or an assailant, so careful
• Of women reporting IPV, 41.5% reported being injured by evaluation is critical during assessment.
their partners during the most recent assault, compared with IPV includes physical, sexual, verbal, and emotional abuse.
20% of men. Physical assault ranges in degree from slapping to murder. Sexual
• It is estimated that approximately two million intimate part- abuse includes unwanted or forced sexual acts. All the abusive
ner rapes and assaults against women will result in injury and actions are aimed at controlling the other person, humiliating
that 552,192 of the victims will require medical treatment. the person, and reducing the victim's self-esteem and identity.
• Most IPV is not reported to the police. Only 20% of rapes, Verbal and emotional abuse breaks down women's self-esteem. A
25% of physical assaults, and 50% of stalking perpetrated common theme of verbal abuse is criticism of the victim's ability
against intimate female partners have been reported. to adequately perform her roles as mother and wife. Verbal abuse
There is a growing body of research documenting the range convinces the victim that she deserves harsh treatment, and it
of significant health problems and resulting disability experienced serves to reinforce the abuser's belief that his actions are justi-
by victims of physical and sexual abuse. Battered women are less fied, even required, to ensure that the spouse acts appropriately.
healthy and have a variety of battery-related health problems. The Domestic Abuse Intervention Project (also called the
These include traumatic injuries, chronic pain, bone and joint Duluth Model) has been a pioneer in intervening to prevent
pain, headaches, sleep disorders, autoimmune disorders, urinary men's violence against their female partners. This treatment
and vaginal infections, unplanned pregnancy, increased substance and education model is based on the theory that power and
abuse, depression, and increased suicide attempts (Bonomi etÂ€al., control are at the heart of IPV. The power and control wheel
2007; Chen etÂ€al., 2010; Leone etÂ€al., 2010). Adolescents who are (FigureÂ€23-2) illustrates the variety of strategies used for con-
the victims or perpetrators of severe dating violence report poorer trolling others’ behaviors. These behaviors should serve as
quality of life, increased suicide ideation and attempts, sub- warning signs of potentially abusive relationships.
stance abuse, and lower life satisfaction and risky sexual behavior
(Alleyne etÂ€al., 2011; CDC, 2006; Coker etÂ€al., 2000). Violence in Dating Couples
Battered women use more health care services compared with The definition of IPV has expanded to include violence in
women who have not been battered (Bonomi etÂ€al., 2007; Rivara dating relationships. According to data from the Youth Risk
etÂ€al., 2007; Ulrich etÂ€al., 2003). Battering is predictive of more Behavior Survey, 9.8% of high school students have reported
hospitalizations, clinic use, and mental health service use. Rivara experiencing physical violence and 7.4% experienced sexual
and colleagues (2007) estimated the total health care costs of IPV violence in their dating relationships (CDC, 2010a). The preva-
to be about $19.3 billion each year for every 100,000 women age lence of victimization was about the same among young women
18 to 64â•›years enrolled in the health care program they evaluated. and young men. In a large national survey of college women,
Women are at increased risk for violence during pregnancy. 20% to 25% reported experiencing rape or attempted rape dur-
Estimates vary widely, but between 8% and 65% of all pregnant ing their college years (Fisher etÂ€ al., 2000). Ninety percent of
women are battered. In addition to nonfatal violence, women the assailants were known to their victims. Thirteen percent of
are also at risk for fatal violence. Studies that evaluate the inci- the college women in one survey and 20% in another survey
dence of homicide during or up to 1â•›year following pregnancy reported being stalked by boyfriends, classmates, or someone at
estimate 8% to 46% (Krulewitch etÂ€al., 2001). In their study of work (Fisher etÂ€al., 2000; Haugaard & Seri, 2004). Twelve per-
women in Maryland, Krulewitch and colleagues (2003) found cent of a sample of 5400 high school students reported being
that female victims of homicide were twice as likely to be preg- either victims or perpetrators of severe physical or sexual dating
nant. Battering is also related to poor pregnancy outcomes such violence in the previous 12â•›months (Coker etÂ€al., 2000). In a lon-
as miscarriage, preterm labor, and low-birth-weight infants. gitudinal study of college women, Smith and colleagues (2003)
This suggests that both obstetric and pediatric offices might be found that 88% of the women reported at least one incident
important places to screen for IPV. of physical or sexual violence during adolescence or their col-
lege years. This study also found that young women who expe-
Definition rienced dating violence in adolescence were at greater risk for
IPV entails a pattern of verbal and physical attacks by one experiencing dating violence in college.
intimate partner against the other. The definition of abuse
includes violence between unmarried, cohabiting, separated or Characteristics of Abusers and Victims
divorced, and dating partners as well. All abuse between part- National family surveys indicate that socioeconomic status is
ners, whether married, unmarried, or dating, is referred to as a risk factor although abuse is prevalent at all income levels.
IPV in this chapter. Besides low income there are a number of risk factors includ-
In this chapter, the assailant is referred to as male and the ing low self-esteem, low academic achievement, and alcohol use
victim or survivor as female because in 80% of IPV incidents, (Abramsky etÂ€al., 2011; CDC, 2011b). A strong predictor of IPV
the assailant is male and the victim female (Rennison, 2003). is alcohol use (Abramsky etÂ€al., 2011).
AL
VIOLENCE SEX
C
Y SI UA
L
PH
USING COERCION USING

AND THREATS INTIMIDATION
Making and/or carrying out threats Making her afraid by using
to do something to hurt her looks, actions, gestures
• threatening to leave her, to • smashing things • destroying
commit suicide, to report her property • abusing
her to welfare • making pets • displaying
her drop charges • making weapons.
USING her do illegal things. USING
ECONOMIC EMOTIONAL
ABUSE ABUSE
Preventing her from getting Putting her down • making
or keeping a job • making her her feel bad about herself
ask for money • giving her an • calling her names • making
allowance • taking her money • not her think she's crazy • playing mind
letting her know about or have access games • humiliating her
to family income. • making her feel guilty.
POWER
AND
CONTROL
USING MALE PRIVILEGE USING ISOLATION
Treating her like a servant • making all Controlling what she does, who she
the big decisions • acting like the sees and talks to, what she reads,
"master of the castle" • being the one where she goes • limiting her outside
to define men's and women's involvement • using jealousy
roles. to justify actions.
USING MINIMIZING,
CHILDREN DENYING
Making her feel guilty AND BLAMING
about the children • using Making light of the abuse
the children to relay messages and not taking her concerns
• using visitation to harass her about it seriously • saying the
• threatening to take the abuse didn't happen • shifting
children away. responsibility for abusive behavior
• saying she caused it.
PH L
YSI UA
CAL SEX
VIOLENCE
FIGUREÂ€23-2â•‡Relationship of violence to use of power and control. (From Domestic Abuse
Intervention Project. [n.d.]. Wheel gallery. Retrieved February 18, 2012 from http://www.duluth-model.org.)
There are different personality subtypes of abusers. Abusive battering phase, and (3) the apologetic phase (FigureÂ€23-3).
partners might lack some social skills such as communication In the tension-building phase the batterer's levels of frustra-
skills, particularly in the context of problematic situations with tion, anger, and belittlement of the victim escalate. Women
their intimate partners; they are more likely to have experienced are able to identify cues of the increasing tension that are dis-
or witnessed child abuse or physical violence in childhood and played by the abuser (Langford, 1996). The victim attempts
been involved in nonpartner violence. (Abramsky etÂ€al., 2011). to placate the abusive individual by being attentive, nur-
Some scientists suggest that violent intimate partners might turing, and self-deprecating. Avoidance strategies are often
be more likely to have personality disorders such as borderline unsuccessful, and tension continues to escalate, culminating
personality disorder, antisocial or narcissistic behaviors, and in violence.
dependency and attachment problems (Holtzworth-Munroe During the battering phase, the abuser physically and often
etÂ€al., 2000). sexually assaults his partner. The violence might last an hour
or several days. The battering phase is followed by a contrite
Cyclical Phases of Abuse and apologetic phase during which the batterer is apologetic
Walker (1979) identified three general phases in a repeat- and loving and may shower his partner with gifts and promises.
ing cycle of violence: (1) the tension-building phase, (2) the He assures his partner that the episode will not be repeated,
Why Spouses Stay

VIOLENT ACT One of the most difficult things nurses and other health care
providers have to accept is the battered spouse's continued
De-escalation of angry
reluctance to end the relationship. The most frequently heard
TRIGGERS comment is, “Why doesn't she just leave?” The woman stays for
feelings and regret
a variety of realistic and unrealistic reasons, the most frequent
of which are the following:
ESCALATION THE BATTERING
CYCLE Reconciliation • She hopes her husband will reform.
of angry feelings • She thinks there is no place to go.
• Children make it difficult to leave, both for financial rea-
Perception sons and because it is harder to find alternative living
HOPE arrangements.
of threat
• She has financial problems—she is unemployed or has
Stress and
tension no money.
FIGUREÂ€23-3â•‡Cycle of violence. (From Browne, K., & Herbert, • She is afraid of living alone.
M. [1997]. Preventing family violence. New York: John Wiley & Sons. • She is emotionally dependent on the abusive spouse.
Reproduced by permission.) • She believes that divorce is shameful.
• She fears reprisal from her husband.
Many battered women fear reprisal from their partner if
Â�
perhaps blaming it on stress at work or consumption of too they choose to leave. Their concern is very real. Women are at
much alcohol. This is often referred to as “the honeymoon greater risk of being killed when they leave their abusive part-
phase.” Often, the abusive partner will make an effort to please ners (Campbell etÂ€ al., 2003, 2009). For this reason, shelters
in other ways, such as helping with housework or planning for battered women often do not publish their addresses. In
activities that are sure to please family members. This honey- rural areas, it is much more difficult to escape and hide from
moon phase eventually gives way to tension building, however, the abuser.
and the cycle is repeated.
Legal Efforts to Combat Intimate Partner Violence
Blaming the Victim Legal efforts to combat IPV have been limited and incon-
The batterer refuses to acknowledge responsibility for the sistent, although there has been substantial improvement in
abuse. In fact, he will blame his boss, alcohol, stress, and his recent years. Penalties for abusive partners are still not con-
partner for his violent behavior. The abuser's sincerity and the sistent with penalties imposed on individuals convicted of
victim's willingness to accept responsibility for “fixing” prob- similar offenses against strangers, friends, or acquaintances.
lems and maintaining the relationship lead to the victim's There is a tendency to consider the relationship as a mitigat-
acceptance of blame for the abusive behavior. “If only I had not ing Â�factor that provides some rationale explaining the perpe-
gotten him mad” and “I know he hates me to fold his socks that trator's behavior.
way” are examples of victims’ internalization of the blame for Restraining orders have been one legal avenue used to restrict
their assailants’ abusive behavior. Families of battered women access of an abuser to his partner. Although the news often reports
often inadvertently support victim blaming by saying things the stories of women who have secured restraining orders that
such as “What did you do to make him react so violently?” were subsequently violated by abusers with tragic results, there is
Many of the behaviors such as lack of focus and/or passivity evidence that restraining orders are effective in reducing contact,
that health care providers see in battered women might not be threats, violence, and injury from an abusive partner (Holt etÂ€al.,
personality characteristics leading to abuse or failure to leave a 2003; McFarlane etÂ€al., 2004).
batterer but, instead, might be a manifestation or coping mech- Stalking is a serious problem in abusive relationships. Data
anism resulting from the battering itself. from the large National Violence against Women Survey showed
that 5% of the women surveyed reported having been stalked by
Connie and her husband John are an upper-middle-class a current or former partner or date (Tjaden & Thoennes, 2000).
couple married for 20â•›years with three children. There is vio- Congress passed legislation making stalking a federal offense.
lence in their relationship. Connie has some postsecondary Stalking is a crime in all 50 states. It remains to be seen whether
education but has not worked outside the home since her making stalking a federal crime will be effective in increasing
marriage. John is a college graduate with a very successful, arrests and prosecutions.
but stressful, career. John started hitting Connie during her A number of communities have developed comprehensive
first pregnancy. She tried to tell her mother about the situ- approaches aimed at reducing the number of repeat offenders
ation, but her mother told her that all couples need time to (Post etÂ€al., 2010). These communities have instituted special-
adapt and that John was a wonderful person. Since that time, ized domestic violence units within the police department and
Connie has kept the violence and her injuries secret from domestic violence courts in the justice system that specialize in
family members, neighbors, and John's business acquain- complex issue of IPV. Other legal interventions include manda-
tances. Connie is very unhappy but says she cannot leave tory arrest or counseling and, in some instances, jail time, even
because she has no job prospects; she knows her husband for first offenders. The intent is to penalize the offender, raising
will not cooperate with support, and her children need to the cost of continuing his offensive behavior. The focus is on
have an adequate home. breaking the cycle of violence by concentrating on the offenders
and not blaming the victim.
The greatest boost in combating domestic violence came in Sometimes, parents are troubled enough about their behavior
1994 when the federal Violence against Women Act was passed. to seek the nurse's opinion. They might attempt to justify their
The Act was reauthorized in 2005 and was up for reauthoriza- behavior or the behavior of another caregiver by presenting a
tion in 2012. The Violence against Women Act of 2005 contains list of complaints about the child.
a number of new initiatives aimed at helping children exposed The type of injury and the circumstances under which it
to violence, training health care providers, encouraging men to occurred should always be evaluated. The nurse should ques-
teach nonviolence to the next generation of men, and improv- tion whether the explanation of the cause is consistent with the
ing crisis services for victims of rape and sexual assault. The act type of injury found. Serious injuries in children deserve spe-
also includes initiatives aimed at improving the legal system's cial vigilance. Certain types of trauma are particularly sugges-
response and improving supportive services such as transitional tive of physical or sexual abuse (refer to BoxÂ€23-2). Most injuries
housing for women and children forced to leave their homes are not easily classified as resulting from abuse. Children are
because of violence. very active, sometimes clumsy, and not often safety conscious.
The ultimate decision to stay in an abusive situation or to Bruising is common. Nurses must be sensitive to subtle signs
leave is the victim's. Leaving a relationship is a difficult decision, of abuse or neglect. Reports by friends or neighbors, even if no
and many choose to return to their partners. It is important for observable injuries are present, should not be dismissed. It is
health care professionals to support the decision of the victim. particularly important to suspect any cases of repeated trauma
Nurses should place their emphasis on ensuring women's safety to either a child or adult.
and on maintaining an accepting, supportive relationship with Victims of IPV might be ashamed or reluctant to volunteer
women who experience abuse, rather than focusing on whether information but might provide information if asked. Emergency
or not the women leave the abusive relationships. Over time, the department nurses are in a position to identify IPV. Crandall
nurse might see positive results from sustained support. and colleagues (2004) found that 93% of murdered women
had at least one previous injury-related visit to the emergency
Consequences for Children Exposed to Intimate department. Routine screening of women for IPV is recom-
PartnerÂ€Violence mended and is shown to increase identification (The National
Recently, there has been a growing recognition that IPV has Association of Country and City Health Officials [NACCHO],
long-term health and behavioral effects on children who wit- 2008; Poirier, 1997; Wiist & McFarlane, 1999). Adding four
ness the abuse (Ernst etÂ€al., 2009; Rosewater, 2003). Finkelhor simple questions to a nursing history are effective in assessing
and colleagues (2009) found that among children surveyed, a woman's abuse history (McFarlane etÂ€al., 1991, 1996; Hewitt
one in 10 had witnessed family assault. Although some children et al., 2011). These questions are as follows:
show no obvious effects, others show signs of distress, anxiety, • Within the last year, have you ever been hit, slapped, kicked,
depression, and poor self-esteem (Holt etÂ€al., 2008). Rhea and or otherwise physically hurt by someone?
associates (1996) recommended incorporating standard ques- • Within the last year, has anyone forced you to engage in sex-
tions about family violence into all mental health and school ual activities?
counseling interviews. • Are you afraid of anyone?
• Since you have been pregnant, have you been hit, slapped,
NURSING CARE IN ABUSIVE SITUATIONS: kicked, or otherwise physically hurt by someone?
CHILDÂ€ABUSE OR PARTNER ABUSE Many barriers exist to implementing widespread assessment
of violence as part of client histories. Reasons cited by health
Community health nurses see children and families in a vari- care providers for not screening are lack of education, lack of
ety of settings and community organizations. Nurses are in time and effective interventions, and fear of offending clients
an important position to identify and intervene with persons (MacMillian etÂ€al., 2009; Waalen etÂ€al., 2000). Colleges and uni-
experiencing violence and abuse. Their long-term relation- versities educating nurses, physicians, and other health care
ships with clients and families allow them the opportunity to providers have started increasing the course content on IPV and
maintain ongoing monitoring and support of at-risk families. other family violence.
Nursing efforts should be directed at case finding and assess- Emotional Abuse. Assessing for emotional abuse is much
ing risk of abuse, ensuring safety, providing emotional support, more difficult than assessing for physical abuse. Emotional
and advocating for abuse victims, as well as performing primary abuse is frequently overlooked by health care professionals.
prevention aimed at reducing risk and eliminating the intergen- Community health nurses are in a position to observe family
erational transmission of violence. dynamics and interactions more frequently than are other pro-
fessionals. Consistent tension, anger, and demeaning remarks
Secondary and Tertiary Prevention are causes for concern. Frequent episodes of yelling, cursing,
Screening and Assessment or derogatory remarks aimed at a child are indicative of emo-
The community health nurse should always be alert to pos- tional abuse. Some children react to a nonsupportive and hos-
sible abuse or neglect. Some of the risk factors for abuse in tile environment by displaying behavioral problems at home or
families were identified earlier in the chapter (see BoxÂ€ 23-1). at school. Some develop somatic complaints. If there is no obvi-
Documentation by the nurse of risk assessment, anticipatory ous explanation for such behavior in a child, the possibility of
guidance, and physical condition is essential. abuse should be considered.
Physical and Sexual Abuse. In assessing child abuse and Increased stress might also result in numerous physi-
neglect, the nurse should be suspicious of atypical or unusual cal complaints in physically or emotionally abused spouses.
injuries and ask for an explanation. The nurse should remain Sometimes, the only signs of abuse are emotional and stress
nonjudgmental and be accessible and open to parental Â�concerns. related. BoxÂ€23-4 lists common health and behavioral Â�indicators
BOXÂ€23-4â•…â•‡EMOTIONAL AND PHYSICAL In this instance, the community health nurse and the fam-
PROBLEMS ASSOCIATED WITH ily have different sleep–wake patterns and dietary habits.
Although the nurse might feel that the mother demonstrates
VIOLENCE VICTIMIZATION
neglectful behavior, the situation as presented does not jus-
Physical tify her feelings. If the children are adequately fed and given
Atypical chest pain sufficient sleep time, the mother is not neglectful. If this pat-
Asthma tern continues, a problem might develop in school-aged chil-
Recurrent headaches dren. Reassessment at that time would be justified to see if
Somatic complaints with no identifiable cause the family has or has not adjusted the sleep–wake pattern to
Eating disorders and other gastrointestinal tract complaints schoolÂ€demands.
Emotional
Legal Responsibilities of the Community/Public Health
Anxiety, panic attacks
NurseÂ€in Cases of Child Abuse
Depression
Drug overdose Nurses are included in a class of designated professionals
Forgetfulness who are required to report suspected cases of child abuse
Hopelessness/helplessness/suicide attempts and neglect. All suspected cases must be reported but health
Guilt care professionals are not expected to determine the valid-
Inability to solve problems or make decisions ity of the claim. Nurses file a report to the designated local
Low self-esteem authorities (child protective services or the police), and the
Sleep disturbances authorities conduct an investigation. The agencies that inves-
tigate child abuse are authorized to remove children who are
in imminent danger of injury. In most reported child abuse
the nurse can use to screen for abuse. Both victims of domes- cases, there is no immediate danger, and the child remains
tic violence and those who witness abuse might show physical in the home. The procedure for investigating reported cases
and emotional signs of posttraumatic stress disorder, or PTSD varies among states. BoxÂ€ 23-5 illustrates a common proce-
(Dutton, 2009). dure for reporting child abuse. Neighbors, friends, or rela-
More often than not, the nurse is faced with situations that tives of the child might also take action but are not clearly
are not clearly abusive or neglectful and can find making a deci- required to do so by law.
sion about contacting local authorities very difficult. Exemptions from Liability. One concern of those mandated to
report suspected cases of abuse is the possibility of a legal suit
Jim is a 7-year-old boy whose school reports that he is often should the investigation not result in charges against the parent
tardy, comes wearing dirty clothes, and is doing poorly
academically. The community health nurse is visiting his
mother and new sister for well-baby visits. Jim's mother says BOXÂ€23-5â•…â•‡TYPICAL PROCEDURE
that she is exhausted caring for the infant and is doing the FOR NOTIFICATION AND
best she can. INVESTIGATION IN CHILD
ABUSE AND NEGLECT CASES
Is Jim being neglected? Does the nurse have enough evidence
to warrant contacting protective service? Are the conditions in Actions Taken by Community Health Nurse
• Identification of suspected case of abuse/neglect
the home different from those in which many poor people live
• Verbal report to:
in the area? The nurse might want to look closely at issues such
1. Child protection agency, or
as the following: (1) whether Jim has enough to eat, (2) whether 2. Local law enforcement agency
he is adequately clothed for the weather, and (3) whether he has • Report sent to child protection agency within 48 hours of initiating
missed school days and, if so, how many. Most of the time, sin- complaint and a copy sent to the state's attorney's office.
gle episodes do not provide clear evidence of abuse or neglect.
It is the accumulation of concerns, circumstances, and obser- Actions Taken by Designated Child Protection Agency
vations that points toward abuse or neglect. The community • Prompt investigation within 24 hours—if abuse; usually within
health nurse must examine the impact of his or her personal longer period—perhaps as much as 5â•›days—if neglect
values and expectations on the assessment of the situation. The • Completion of investigation within 10â•›days and reporting of findings
reasons for suspecting abuse or neglect cannot be based on dif- to state's attorney's office
ferences in personal values. • Dispensation of case:
1. No evidence found
2. Inconclusive; file kept open
During a home visit with Joan D., the community health 3. Evidence exists; action taken
nurse finds Joan and her three children (18â•›months, 3â•›years, • Possible actions include:
and 4â•›years) still in sleepwear at 2â•›pm. They are having a break- 1. Mandated supervision in home
fast of hamburgers, chips, and soda. Joan explains that they 2. Imposition of conditions on parents to continue custody (e.g.,
just got out of bed because they all were up late last night attend parenting classes, drug rehabilitation)
watching movies. The community health nurse is personally 3. Temporary removal of child to foster care or other relatives’ homes
upset that Joan's children are up late at night and are not eat- 4. Permanent removal of child from home
ing the usual breakfast-type foods. 5. Court action to terminate parental rights to clear for adoption
or caregiver. In every state, the law protects health care profes- BOXÂ€23-6â•…â•‡PERSONAL SAFETY PLAN
sionals from legal action if the charges are unproved. The threat
of legal action against an individual who reports suspicions can If you have left your abusive partner:
have an impact on the willingness to report. It is hoped that • Change the locks on doors and windows, increase outside lighting.
protection offered by law will encourage those who have con- • Teach children to call the police.
cerns to feel more comfortable about reporting such incidents • Talk to the school and child care providers about who has permis-
to the proper authorities. sion to pick up the children.
• Obtain a restraining order that includes home, work, children's
Nurse's Legal Responsibilities in Partner Abuse school, and forms of electronic contact.
• Develop an escape plan.
Unlike in cases of suspected child abuse, there are no national
mandatory reporting requirements in clear or suspected If you are leaving your abusive partner:
cases of IPV. Currently, six states and the armed services • Decide whom you can trust to tell that you are leaving and whom
require that health care providers, including nurses, report you might rely on if you need somewhere safe to go.
IPV to local authorities (Gupta, 2007). There is much con- • Plan how you will travel safely to and from work and school, and
troversy about these laws and whether they prevent women other routinely traveled routes.
from getting the health care they need and increase the risk • See also items in previous section.
of violence. The American Medical Association (AMA) and
emergency room (ER) physicians are against mandatory If you are returning to your abusive partner:
reporting (AMA, 2008; American College of Emergency • Decide whom you can call in a crisis. Do you have someone you
Physicians, 2011; Thomas, 2009). One of the arguments trust about the abuse? Could you stay with that person, if needed?
against reporting laws is that it takes the responsibility away • Work out a signal with children and neighbors to tell them that they
from women who are adults and are capable of such report- should call the police.
• Plan escape routes.
ing themselves.
• Prepare a bag or suitcase with the following items you will need if
The nurse should be aware of the resources available for
you have to flee. Store it in a safe place such as a friend's house:
survivors of IPV. The nurse's first step should be taking a his-
Important papers such as birth certificates, Social Security cards, mar-
tory to assess for violence and carefully documenting specific riage license, driver's license, insurance information, car title, credit
injuries observed. Nurses can assist victims with referrals to cards and account numbers, immunization and health records
resources such as legal aid organizations for civil protection Extra keys to the house or apartment and the car
orders, domestic violence shelters for shelter, and often support Prescription medicines for yourself and the children
or counseling. A change of clothing for yourself and the children
A favorite toy or blanket for the children
Ensuring the Safety of the Abuse Victim
When the nurse suspects an abusive situation, the priority is Safety planning for you at the workplace:
to ensure the safety of the victim or victims. Efforts should be • Save any threatening or harassing messages.
directed toward eliminating potential harm or reducing the risk • Park close to the entrance, talk to security personnel, and have
of assault. Families may choose to stay with relatives or friends, someone escort you to your car or other transportation after work.
or use the services of a shelter; some may consider it safer to • Have calls screened and remove your name from the office directo-
return home. Many communities have shelters for battered ries and website.
women. Shelters are often overcrowded, however, and as many • Relocate your workstation to a more secure area.
as 40% of those seeking shelter have to be turned away because • Secure a restraining order; keep it current and always carry it with
you.
of space limitations.
• Provide a photo of the abusive person to security personnel and
Nurses can work with women to develop a safety plan. The
receptionists, and plan a response if he or she contacts you at work.
goal of a safety plan is to have a plan in place to maximize
• Review safety plans for the children and arrangements with schools
a woman's safety and minimize the potential for violence. and child care providers.
A safety plan should include plans for leaving the abuser, • Create and distribute to trusted persons an emergency contact list.
returning home, being at work or school, and dealing with
children's safety at school. BoxÂ€23-6 outlines basic elements
of a safety plan. or work on family dynamics. Often batterers are referred to
treatment programs through the courts after they have been
Referral to Community Resources arrested and charged. Some programs allow self- or volun-
One intervention is education and referral of survivors of IPV tary referrals.
to the resources available in the community. Communities The community health nurse should know of appropriate
vary in the resources they offer. Smaller rural regions may community resources available for families before, during,
have to share resources across an entire county. Resources and after the occurrence of abuse. Nurses must be familiar
that are available in most communities are women's shel- with the specific resources available in their communities to
ters, support groups for women who are survivors of abuse, ensure speedy referrals. They should invite agency represen-
batterer's treatment programs, treatment programs for child tatives to speak to nursing audiences at nursing association
witnesses of partner violence, and victim assistance pro- meetings or at work. In addition, it might be possible to visit
grams to help women obtain court orders and follow through or tour some agencies.
in legal proceedings. Treatment for the partner's violence is Community health nurses can address the health needs of
essential and should precede other interventions to reconcile women and children living in shelters. Formal health services are
rarely provided in shelters. Stress and health issues related to the domestic violence. This model can be adjusted to guide inter-
violence are not the only health needs to be considered. Many vention in other types of family violence cases.
of the shelter residents will have had past difficulty arranging
for health services and routine care such as immunizations, as Prevention for Families
well as for immediate health needs related to children's develop- Community health nurses often work as part of a team with
mental phases such as those resulting from accidents (Kulkarni other professionals in addressing family health needs, nor-
etÂ€al., 2010). mal and abnormal child growth and development issues, and
parenting styles. The CDC (2003) reviewed the effectiveness
Primary Prevention of early childhood home visitation programs and found that
Primary prevention measures should include public education they were effective in preventing child abuse and neglect. Home
efforts to transform attitudes about child and partner violence visitation programs commonly target high-risk families; low-
as well as to identify and assist individuals at risk. The equality income, young, less educated, first-time mothers; substance
wheel (FigureÂ€23-4) outlines multifaceted strategies that health abusers; families with low-birth-weight infants; and other
care professionals can use when intervening with survivors of Â�families at risk for child abuse or neglect. Although Â�early-start
NONVIOLENCE
NEGOTIATION AND NON-THREATENING

FAIRNESS BEHAVIOR
Seeking mutually satisfying Talking and acting so that she
resolutions to conflict feels safe and comfortable
• accepting change expressing herself and doing
• being willing to things.
compromise.
ECONOMIC RESPECT
PARTNERSHIP Listening to her
Making money decisions non-judgmentally • being
together • making sure both emotionally affirming and
partners benefit from financial understanding • valuing opinions.
arrangements.
EQUALITY
SHARED RESPONSIBILITY TRUST AND SUPPORT

Mutually agreeing on a fair distribution Supporting her goals in life • respecting
of work • making family decisions her right to her own feelings, friends,
together. activities and opinions.
RESPONSIBLE HONESTY AND

PARENTING ACCOUNTABILITY
Sharing parental respon- Accepting responsibility
sibilities • being a positive for self • acknowledging
non-violent role model for the past use of violence
children. • admitting being wrong
• communicating openly and
truthfully.
NONVIOLENCE
FIGUREÂ€23-4â•‡ Equality wheel for use in developing intervention strategies for intimate partner
violence. (From Domestic Abuse Intervention Project. [n.d.]. Wheel gallery. Retrieved February 18, 2012
from http://www.duluth-model.org.)
home Â�visitation programs may improve child outcomes, they BOXÂ€23-7â•…â•‡PARENTAL BEHAVIOR
have not been shown to improve family-related or parent- ASSESSMENT GUIDE
related outcomes (Fergusson etÂ€al., 2006).
The presence of guns in the home is a clear risk. Nurses Good Behaviors
should assess families for the presence of firearms and, if they • Makes good eye contact
are owned, ensure that they are safely stored. Many children • Shows caring, gentle handling
(1.7 million) live in homes where firearms are loaded and • Talks to infant/child in warm, accepting manner
improperly stored and accessible to children (Okoro etÂ€al., • Sets age-appropriate limits in a calm manner
2005). Nurses should assess and advise families on proper • Gives feedback that is mostly positive and involves praising
firearm storage and the use of trigger locks to reduce the remarks
• Shows affection easily, hugs, smiles, pats
accessibility of firearms. If the family is willing, the family
may consider disposing of the firearm. Risk Behaviors
Parent–Child Interactions. A key indicator of parental • Makes little or no eye contact
risk for neglectful behavior is poor maternal–infant bond- • Shows rough or careless handling
ing. By observing parent–child interplay, the nurse can get a • Yells or screams at infant or child as primary communication
good idea about parenting technique and bonding. If bond- technique
ing appears weak, the nurse can work on increasing attach- • Sets no limits and/or sets age-inappropriate limits; this might be
ment and parental confidence in the role of caregiver. The accompanied by hitting or slapping
Domestic Abuse Intervention Project (n.d.) has developed • Gives no feedback or primarily negative feedback
guidelines to assist health care professionals in identifying • Does not show affection; avoids physical contact
troublesome parental or caregiver behaviors as well as guide- • Leaves child alone when not appropriate
lines for identifying nurturing behaviors. The nurturing
behavior guide can be used to assist parents and other care-
givers in developing and strengthening their positive nurtur-
ing behaviors. of parental behaviors to help identify parents who are expe-
Access to positive role models is crucial for at-risk families. riencing difficulty in bonding and appropriate parent–child
One strategy is the foster grandmother program, which matches interactions.
volunteer older women with young, at-risk mothers. Social sup- Abusive parents often have unrealistic expectations of age-
port programs such as this can be expanded to include abusive appropriate behavior from their children. It is important to
as well as at-risk parents. include a review of developmental milestones of infants and
Family and cultural beliefs about discipline are an area for children, such as motor and cognitive abilities, during at least
exploration and intervention. The community health nurse one home or clinic visit. This information helps parents rec-
should encourage alternatives to hitting as a means of disci- ognize age-appropriate behavior. The nurse can validate real-
pline. Spanking should be discouraged because it role-Â�models istic expectations for the child with the parent and dispel
hitting as an acceptable means of teaching children how to unrealistic ones.
behave. A review of the research on spanking found substantial
evidence that spanking is associated with a higher prevalence An 8-month-old girl is admitted to the hospital for injuries
of abuse, more delinquency, more aggressive behavior, poorer sustained in a beating. The parent said that the baby was not
mental health, poorer parent–child relationships, and other cooperating with toilet training and needed to be disciplined.
negative health consequences in children (Gershoff, 2002).
Slade and Wissow (2004) report spanking was associated with Stringham (1998) proposed a series of questions and inter-
behavior problems in children from white families but not in ventions associated with well-child primary care starting at the
those from African American or Hispanic families. Taylor and newborn or 2-week visit and continuing through adolescence.
colleagues (2010) found 3-year-olds who were spanked had Roberts and Quillian (1992) integrated the topic of violence
more aggressive behaviors than those who were not. into a general health teaching tool that nurses can use periodi-
Proactive anticipatory guidance by health care providers is cally with parents. The list of health teaching issues in BoxÂ€23-8
essential for violence prevention. Community health nurses includes many of these suggestions. Schools have also initiated
traditionally provide parental education about growth and conflict resolution programs designed to teach children non-
developmental milestones, parenting stress, and effective violent ways to handle disputes. Interventions which success-
parenting skills. Murry and colleagues (2000) suggested that fully reduce the use of parental corporal punishment have been
the traditional child abuse screening protocols are not sensi- shown to reduce the levels of children's aggression (Beauchaine
tive or concise enough to identify children under 3â•›years of etÂ€al., 2005).
age who are at risk for abuse or neglect. One suggested way Prevention of Intimate Partner Violence. Primary preven-
of screening very young children is to include at least three tion of IPV consists of reducing the social belief that vio-
nurse checks in the first 9â•›months of life (Browne, 1989). The lence in relationships can be justified. Working with teens
first screening should include assessment for the risk fac- to develop equitable and healthy relationships is one way
tors associated with abuse and neglect. The next visit should of preventing abuse. Teens, both young women and young
explore parents’ perceptions of their child and specific fam- men, can be helped to identify the warning signs of control-
ily stressors. The third visit should review infant behaviors ling behaviors and to set limits on intrusive or threatening
and attachment. BoxÂ€23-7 offers a quick guide for assessment behavior.
BOXÂ€23-8â•…â•‡NURSE/PARENT GUIDE TO abuse and violence in the community include (1) advocating
ANTICIPATORY VIOLENCE for inclusion of conflict resolution techniques in school curri-
cula, (2) working with community groups to develop programs
COUNSELING WITH CHILDREN
geared toward reducing exposure to violence and improving
• Periodically review television and movie-viewing habits; encourage safety for communities at risk; and (3) communicating with leg-
limits on viewing time and types of shows islators to increase funding for programs that supply economic,
• Stress the influence of peer pressure and recognize that it increases health, and other support services to communities and families.
with the age of the child Partner abuse prevention should include public education
designed to transform attitudes about IPV. Media awareness
For Elementary School Children:
programs are designed to meet several goals:
• Teach coping techniques to avoid fights in school and neighborhood
• Assist women in recognizing their legal rights in abusive
(e.g., walk away from situation)
situations
• Review stranger danger and good touch/bad touch safety issues
• Enhance public awareness that IPV requires legal interven-
For Children 10 to 12 Years Old: tion and is not just a private matter between partners
• Teach the danger of alcohol and drugs; start no later than 10â•›years • Recognize the need for improving the uneven application of
of age legal restraints and prosecution of violent partners
• Identify high-risk situations in which drinking, drugs, or other problems • Encourage efforts designed to assist with behavioral changes
are most likely to occur and role-play how to avoid or get out of them in battering and battered individuals
• Discourage victim-blaming dialogue in public and private
For Children 13 to 19 Years Old: discussions about spousal violence
• Review tobacco, alcohol, and drug use and the social and health • Enhance public understanding of the need for long-term
consequences of each programs to support both victim and abuser to improve the
• Reinforce the correlation between substance abuse and accidents chances of success
• Explore exposure to school violence
• Support policies that ensure equal opportunities for education
• Reinforce previous teaching related to avoidance of violent situations
and work for women, men, and persons from minority groups
From Roberts, C., & Quillian, J. (1992). Preventing violence through Working to prevent or ameliorate child abuse and partner
primary care intervention. Nurse Practitioner, 17(8), 62-64, 67-70. abuse should be a commitment for every community health nurse.
Social change takes a long time. The community health nurse can-
not expect to see substantive change in a week or a month; rather,
During a clinic appointment with Ashley, a pregnant 17-year- the nurse must be prepared for a sustained long-term effort. The
old who is moving in with her 24-year-old boyfriend, the com- National Advisory Council on Violence against Women has devel-
munity health nurse notices that Ashley's boyfriend repeatedly oped a checklist of community activities aimed at ending violence
calls her on a cell phone and that she defers many of the assess- against women (see Community Resources for Practice at the end
ment questions until she can ask her boyfriend if it is okay. On of the chapter). The checklist addresses 16 areas of community
further assessment, the nurse discovers that although Ashley's life, including health and mental health services, the workplace
boyfriend has not hit her, he does make derogatory com- and college campuses, media and the entertainment industry, and
ments about her personality, her intelligence, and her physi- churches. BoxÂ€23-9 highlights what the health care system and the
cal appearance. He also limits her association with friends and
her family. During a conversation, the nurse determines that
Ashley is hurt by her boyfriend's comments and frustrated BOXÂ€23-9â•…â•‡WHAT THE HEALTH AND
with this part of the relationship. Ashley and the nurse explore MENTAL HEALTH CARE
the range of controlling behaviors in the context of abusive SYSTEMS CAN DO TO MAKE
relationships and community resources that might be avail- AÂ€DIFFERENCE
able. During subsequent visits, the nurse will monitor and
encourage Ashley in her efforts. If the boyfriend's behavior • Conduct public health campaigns.
remains the same, the nurse should explore other options such • Educate all health care providers about violence against women.
• Create protocol and documentation guidelines for health care facilities,
as ascertaining Ashley's feelings about leaving the relationship
and disseminate widely.
and encourage her to seek supportive relationships.
• Protect victim health records.
• Ensure that mandatory reporting requirements protect the safety
Community Efforts at Primary Prevention and health status of adult victims.
The community health nurse can develop and assist with the delivery • Create incentives for providers to respond to violence against
of community education and support programs aimed at reducing women.
child abuse and adult partner abuse. The nurse can organize par- • Create oversight and accreditation requirements for sexual assault
ent support groups and parenting classes. Civic and religious groups and domestic violence care.
are often open to community guest speakers. The nurse can use • Establish health care outcome measures.
these forums to provide education about child abuse and spousal • Dedicate increased federal, state, and local funds to improving the
abuse and the impact that exposure to violence has on children. responses of the health and mental health care systems to violence
Part of the role of the community health nurse is working against women.
to improve the overall health of communities as well as that From National Advisory Council on Violence against Women & Violence
of individuals and families. In that role, nurses should become against Women Office. (n.d.). Toolkit to end violence against women.
politically active. Some of the ways the nurse can address child Retrieved August 31, 2011 from http://toolkit.ncjrs.org/default.htm.
mental health care system can do. Although the checklist is aimed • Physical abuse is the willful infliction of physical pain or
specifically at spousal abuse, the same activities can be used to injury (e.g., slapping, bruising, restraining).
address other forms of abuse as well. • Sexual abuse is the infliction of nonconsensual sexual con-
The funding of prevention efforts is particularly challeng- tact of any kind.
ing. A number of initiatives of the federal government have • Psychological abuse is the infliction of mental or emotional
provided funding to support prevention. Many states have anguish (e.g., humiliating, intimidating, threatening).
additional fees linked to marriage licenses and firearm registra- • Financial or material exploitation is the improper action of
tion that support shelters and other family violence prevention an individual to use the resources of an older person without
programs. In a study in California, two-thirds of those sur- his or her consent for the benefit of someone else.
veyed supported the use of surcharges and extra fees of up to • Neglect is the failure of a caregiver to provide goods or ser-
$5 to support domestic violence prevention (Sorenson, 2003). vices necessary to avoid physical harm, mental anguish, or
Although controversial, such fees remain an important means mental illness (e.g., abandonment, denial of food or health-
of funding prevention programs. related services).
Factors Associated with Abuse by Family Members

ELDER ABUSE
Elder abuse is found in all socioeconomic groups and at all edu-
The Administration on Aging (AOA, 2007) reported the following: cational levels. Older adults are often abused by their caregivers.
• Between 1 and 2 million Americans aged 65 and older have In 16% of cases, the abuser cannot be identified. Paid caregiv-
been injured, exploited, or otherwise mistreated by someone ers (including nurses and health care providers) often abuse or
whom they depend on for care or protection. neglect older persons in long-term care or housing facilities.
• Estimates of the frequency of abuse range from 2% to 10%, Both sexes are equally capable of being abusive. Older adults
depending on the survey and sampling. suffering from confusion, incontinence, frailty, or severe physi-
• An estimated 1 in 14 incidents, excluding self-neglect, comes cal and mental disabilities demand enormous amounts of time,
to the attention of authorities. It is estimated that for every energy, and patience from caregivers. Adults who have caregiv-
1 case of reported elder abuse, 5 go unreported. Elder abuse ing responsibilities for two generations—their parents and their
has received less media attention than child abuse or spouse children—are often referred to as the sandwich generation. For
abuse. The research on elder abuse is also less developed these individuals, the burden of working, raising children, and
than that on child abuse and partner abuse. Definitions of caring for an older parent can be overwhelming.
abuse and neglect in older adults are unclear and inconsis- A review of the research on elder maltreatment found a few
tent (Fulmer, 2002). Self-report methods used for measur- risk factors associated with an increased risk of abuse. Older
ing abuse and neglect in other populations are more difficult adults who shared living arrangements were at greater risk
to use in older adults because of changes in memory and, than those living alone (AOA, 2007). This seems to be related
in some cases, dementia. As individuals age, they require to opportunity, not to disability. Other risk factors were social
increased levels of caregiving that create a climate of stress isolation, dementia, and characteristics of the abuser such as
and opportunity for older adults to be abused, neglected, and the presence of mental illness and drug or alcohol abuse. In
exploited. Elder abuse is more common if the person lives addition, abusers were more often emotionally and financially
with family members. Elders who live independently are at dependent on the older family member (CDC, 2010b). There
less risk, unless socially isolated. was little evidence that the older person's needs for assistance or
A particular problem in gathering elder abuse data is the caregiver stress led to a greater risk of abuse.
reluctance of older adults and their caregivers to report sus- The prevalence of maltreatment in nursing homes is dif-
pected cases (CDC, 2010b). As with other types of abuse, most ficult to quantify. It is estimated that only 1 in 14 allegations
cases are never reported. Older persons do not report because of maltreatment is reported to authorities. Although allega-
they or their spouses might be afraid of the caregivers, be tions of maltreatment should be reported immediately, in
ashamed of the problem, or have limited alternatives for living 50% of cases the reports were submitted 2 or more days after
arrangements. Health care professionals do not report incidents the nursing home learned of the abuse (General Accounting
because of ignorance of the problem, ignorance of their legal Office, 2002). Delays in reporting severely compromise the
responsibilities in suspected cases, and lack of education about ability of law enforcement agencies to investigate. When
maltreatment that causes failure to adequately assess at-risk sit- an employee in involved, many agencies simply dismiss the
uations, and because of concern that alternative living arrange- offending employee.
ments might be less tolerable than the current one (Kahan & States must keep a registry of qualified nurse aides, the
Paris, 2003; Levine, 2003; Rodriguez etÂ€al., 2006). primary caregivers in nursing homes. Included in that reg-
istry are any substantiated findings that the nurse aide has
Definition been abusive or neglectful to residents (Centers for Medicare
Elder abuse is defined as maltreatment of older persons (usu- and Medicaid Services, 2009). Any such finding effectively
ally older than 65â•›years). The abuse can be physical, emotional, bans the nurse aide from employment at nursing homes in
or financial. Failure to provide adequate care and comfort to that state. Screening of workers in nursing homes and home
seniors who are under the community health nurse's care health agencies for criminal backgrounds and substance abuse
would be considered neglect. Financial exploitation of vulner- is an attempt to reduce some of the risk factors for caregiver
able older adults is a growing problem, recently identified as the abuse. However, crimes committed in other states often are not
single most common form of elder abuse. Definitions of abuse revealed by such searches. In addition, many of the employees
and neglect are as follows (CDC, 2010b): who work in nursing homes and who provide in-home services
for home care agencies are minimally educated and minimally • Does anyone slap you, pull your hair, hit you, or act rough
paid. These conditions make it difficult to retain well-qualified, with you?
competent employees. • Does anyone threaten to do any of these things?
• Does anyone force you to do sexual acts you do not want
Nursing Care for Older Adults and Caregivers toÂ€do?
Community health nurses are involved in primary, secondary, When assessing for abuse or neglect, the nurse needs to be
and tertiary prevention efforts for older adults and caregivers. aware that some older persons have cognitive impairments that
Four major areas in which nurses play an important role in affect their ability to make decisions about their safety (AOA,
addressing elder abuse are (1) identification of suspected cases; 2007). Depression and dementia to be significantly higher in the
(2) reduction of risk and maintenance of independence; (3) maltreated older adults (Hall & Weiss, 2007; Levine, 2003). The
oversight, supervision, and encouragement of caregivers; and study by Kahan and Paris (2003) found that half of all older
(4) development of support groups for caregivers. adults in reported elder abuse cases had diagnosed memory
impairments. Depression, poor judgment, confusion, and the
Identification of Suspected Cases inability to communicate clearly are also common responses to
Early identification of at-risk older adults is important. To that abuse, and nurses should assess for maltreatment in older per-
end, the nurse should become proficient at identifying potential sons with these symptoms. Some caregivers often overmedicate
or probable abusive or neglectful situations. BoxÂ€23-10 briefly or medicate to reduce an older person's activity. Sometimes,
identifies areas to screen for the presence of elder maltreatment. caregivers consider the use of medication to be a humane way
Clearly, any unexplained bruises or injuries should be assessed to control behavior and allow older adults to remain in a famil-
and evaluated. Older adults tend to bruise more easily than iar environment. Overmedication of an older adult is not to be
do younger adults, but explanations that do not ring true and condoned. The nurse should review medications during home
repeated incidents of bruising should arouse suspicion. As in or clinic visit to assess whether the existing supply of medica-
other abusive situations, reporting and documenting injuries is tion matches what would be expected if someone were taking
an important part of the nursing process. the medication as prescribed. A groggy or disoriented older per-
Currently, much research is focused on creating elder abuse son might be overmedicated if there is no obvious organic cause
screening tools to better identify older adults and caregivers at for the condition.
risk for abuse, but these are still in developmental stages (Cohen
etÂ€al., 2006; Meeks-Sjostrom, 2004). A diminishing social net- Nurse as Threat or Advocate
work and poor social functioning are emerging as potential risk It might be difficult for the nurse to decide whether there is
factors for abuse (Shugarman etÂ€al., 2003). sufficient reason to suspect abuse. Caregivers and older adults
Brandl and Horan (2002) list questions to be used as an ini- might be reluctant to share information or to answer ques-
tial screen for risk of abuse: tions. The nurse might be viewed as a threat rather than an
• Do you live alone? asset, especially if the family or the older person fears removal
• Who does your cooking? from the home.
• Who controls your finances?
• How often do you see or go out with friends? Mrs. E. is a 67-year-old woman with Parkinson's disease. She
• Are you afraid of anyone? is recently widowed. Although she can walk with a walker,
she requires help with activities of daily living and needs
assistance to travel outside the home. On a monthly home
check, the nurse finds that Mrs. E.'s much younger stepsis-
BOXÂ€23-10â•…â•‡SCREENING FOR ELDER ter Mrs. T. (42â•›years old) and her husband have moved in
MALTREATMENT to help. Since the nurse's last visit, the furniture has been
Physical abuse Acts of violence (e.g., force feeding, inappropriate use replaced with modern black lacquered pieces, and Mrs. T.
of restraints) has a new car. Mrs. E. tells the nurse that she misses her old
Physical signs (e.g., unexplained bruises, welts, furniture, but her brother-in-law did not like it. The new car
fractures) has been bought with Mrs. E.'s funds and is driven by Mrs. T.
Emotional abuse Verbal harassment, intimidation, threats, physical Mrs. E.'s old car is used by Mrs. T.'s son because Mrs. E. “did
isolation from visitors not need it any more.” Mrs. E. tells the nurse she is afraid that
Financial abuse Theft of money or possessions, coercion of older she does not have much money left in her bank account but
person into signing legal documents for power of begs the nurse not to do anything about it because she wants
attorney or turning over deeds, bank accounts, etc. to stay in her home.
Failure to contract for care when finances are
available Mrs. E.'s concern about institutionalization is valid. Almost
Sexual abuse Unexplained venereal disease or genital lacerations 50% of the cases handled by adult protective services are
or infections resolved by nursing home placement (Lachs etÂ€al., 2002).
Older adult's complaints of sexual assault
The overriding principle guiding the nurse's decision should
Neglect Failure to provide clean environment or physical needs
be the safety and well-being of the older client. The example
such as glasses, medication, dentures
provided is not an uncommon situation encountered by the
Absence of safety precautions
Signs in the older adult of dehydration,
community health nurse. If reasonable evidence of abuse is
malnourishment, pressure sores, poor hygiene
present, the nurse should report the circumstances and let the
designated authorities investigate the case.
Legal Responsibilities of the Nurse Reduction of Risk through Community Resources

All the states and the District of Columbia have laws that Because maintaining older individuals’ financial and physical
require the reporting of elder abuse; however, the states vary independence is the single most important factor in reducing
on who is required to report abuse (AOA, 2011). Because the elder abuse, a thorough knowledge of the community resources
mechanism for reporting cases varies among states, nurses available for older adults is important. Most communities have
need to be aware of the protocols and reporting agencies in senior centers and services for the aging that can provide some
their states. Elder abuse is commonly not reported. An esti- resources and support for senior citizens. A variety of home-
mated 84% of cases are not reported to adult protective ser- related services to assist in independent living are also available.
vices (Kahan & Paris, 2003; Robinson et al., 2011). Nurses Examples of these services are home repair and maintenance
affiliated with agencies serving the older population need to services, fuel assistance programs, home visiting programs,
work with providers to increase reporting rates. Three factors daily telephone call programs, meal delivery services, special
that have been associated with higher reporting rates are lower transportation services, and medically related services such as
socioeconomic status of the older population, more educa- visits by home aides, registered nurses, physical therapists, and
tion of community professionals about elder maltreatment, physicians. Respite care is an important resource for support-
and higher community agency service ratings (Jogerst etÂ€al., ing families caring for aging parents. In rural areas, the nurse
2005; Wolf, 1999). Nurses in community and hospital set- might need to help create informal networks of friends and vol-
tings need to take responsibility to learn the warning signs and unteers to address the variety of needs. Ombudsman programs
the procedure for reporting elder abuse. Physicians often do show promise for improving abuse reporting and the protec-
not know the warning signs or understand reporting mecha- tion of older adults in nursing homes (Jogerst etÂ€ al., 2005).
nisms, although efforts are being made to improve awareness ChapterÂ€ 28 provides more information on working with the
(Kennedy, 2005; Taylor etÂ€al., 2006). aging population.
State definitions of elder abuse vary; some do not include
neglect, and very few include financial exploitation. The specific Assistance to Caregivers
agency to which the nurse reports varies among the states but it Nurses can act as counselors and resource directors to assist
is usually the state's social service agency (adult protective ser- families at risk for elder abuse. Caregiving is demanding and
vices) or an independent senior service agency (office on aging) stressful, and caregivers need respite. The following are warn-
that investigates suspected cases of abuse. As in reporting child ing signs common among stressed caregivers (Capstead, 1993;
abuse, the nurse must state the circumstances that have led to Womenshealth.gov, 2008):
the belief that a problem exists, the name of the individual, the • Early signs
address, and the name of the caregiver if it is known. • Multiple complaints
• Anxiety
Autonomy versus Safety • Growing depersonalization (beginning to distance from
One of the most difficult issues in elder care is what to do when the older person)
an older adult chooses to remain with an abusive caregiver. In • Fatigue
cases in which immediate danger to life is present, the state may • Guilt
act and mandate action to safeguard the individual. However, • Late signs
the family preservation model is sometimes being applied to • Depression
address the problem of elder abuse and neglect. • Weight loss
• Anger
An older couple, 68-year-old Marie and 79-year-old Ryan M., • Avoidance or distancing
were forcibly removed from their home and placed in a nurs- • Misappropriation of financial resources
ing home. Mr. M. was visually impaired and had diabetes and This list is a valuable screening assessment tool for commu-
numerous open wounds on both legs. Mrs. M. was confused nity health nurses involved with older people and their care-
and frequently disoriented. Their home reeked of urine. givers. Counseling families to recognize caregiver stress and its
The couple had not paid their electric, telephone, and water impact on both the older adult and the caregiver is essential. The
bills for over a year. They had no water because of plumbing nurse can teach the family about a variety of stress-reduction
problems. They were malnourished and seldom shopped for techniques. The nurse also serves as a resource person recom-
food, although money was available. Mr. M. was prescribed mending community resources to assist with care and support.
insulin injections, but the couple seldom remembered to Beyond hotlines, support groups, and some classes offered by
administer them. Both vigorously resisted institutionaliza- social service or home care agencies, few resources exist for
tion. Six months after placement, both are still adamant that older adults at risk of abuse or for their caregivers.
they want to return home. Respite care is an option for many families. A variety of types
of respite care are available, but they are often not reimbursed.
Usually, the state acts only in extreme cases because of the Adult daycare offers a supervised structured setting during the
limited resources for alternative placement of older adults. For day while the caregiver is at work. Some facilities have begun to
the most part, the law recognizes an older adult's right to self- offer weekend programs so that family members can do chores
determination. Community health nurses frequently come in or engage in other activities without concern for the older per-
contact with older adults who choose to remain in abusive or son's safety. Another form of respite is 24-hour care for limited
neglectful situations. Accepting the personal rights of older periods to allow caregivers a break from their duties. Caregivers
adults might be one of the most difficult situations a nurse often get little benefit from respite care because respite care epi-
can face. sodes are too brief or infrequent (Strang & Haughey, 1999).
Not all communities offer respite services, and not all fami- of community nursing directs community health nurses toward
lies can afford to pay for such care. Health insurance does not establishing long-term relationships with individuals, fami-
always cover care associated with long-term illness, home care, lies, and communities. Both the American Nurses Association
medications, and supplies (see ChapterÂ€4). Low-income fami- (ANA, 2000) and the American Association of Colleges of
lies, because of their limited incomes, might have access to state Nursing (AACN, 1999) have issued position statements on vio-
and federally subsidized medical care and resources that some lence as a nursing issue. The AACN recommends specific com-
middle-class families do not. petencies for nursing in the areas of prevention and treatment
of violence. See Community Resources for Practice at the end
Nurse's Role in Community Education and Advocacy of the chapter for information on how to link to these position
Community health nurses should explore service options for statements and other Internet resources. New roles are emerg-
older individuals and in educating themselves and the public ing in nursing as the discipline gains a better understanding of
on the problem of abuse of older individuals. These goals can the health consequences of violence, the needs of survivors, and
be partly accomplished by designing and delivering educational the physical and biological evidence necessary to convict assail-
programs to community groups and organizations or by advo- ants. Two such emerging roles in nursing are those of the foren-
cating for legislation designed to help older adults remain inde- sic nurse and the sexual assault nurse examiner, who specialize
pendent and assist their caregivers, whenever possible. Public in evidence collection and preservation, and care of survivors
understanding of the aging process and safeguards to ensure and witnesses to violence (Campbell etÂ€al., 2005; International
a safe and secure environment for the senior members of our Association of Forensic Nurses, 2006; Sekula, 2005).
communities will go a long way toward reducing the problems The causes and consequences of violence are not readily
of elder abuse. eliminated. They are the result of multiple social and family
Violence is a public health issue and is preventable. influences. Community health nurses are in an ideal position
Community health nurses are in a unique position to address the to case-find and provide primary, secondary, and tertiary inter-
health needs related to violent behavior because the very nature ventions to address violence and prevent it from occurring.
KEY IDEAS
1. Violence is a major public health concern. 6. Primary prevention is the single most important method for
2. Violent behavior is the result of the complex relationship of reducing violent behavior among family members and in the
many issues and is influenced by sociological, environmen- society at large.
tal, and individual factors. 7. Accomplishing the behavioral and social changes needed to
3. Certain individual and group characteristics place people at mitigate violent activity or risk of victimization is a long-
risk for being victims or perpetrators of abusive behavior, but term activity.
not all persons with risk factors become victims or abusers. 8. Community/public health nurses are uniquely qualified and
4. Women, children, and older adults are at special risk for fam- well situated to work with victims and abusers and engage in
ily violence because society has been reluctant to breach the primary prevention efforts with individuals and community
family structure and dictate behavior. groups.
5. There is mounting evidence that education, social pressure,
and mandatory punishment for abusive behavior are effec-
tive in reducing such behavior.

A Violent Family Jennifer Maurer Kliphouse
Ms. Jones, a community health nurse, has been asked to do a home for the children by herself, and her problems with the landlord. She
assessment of the Charles family as part of an intensive home visit- relates that Mr. Charles has been ordered by the court to remain out-
ing program instituted by Child Protection Services. When Ms. Jones side the home and undergo therapy because he has been found to be
visits Mrs. Charles, she finds a 20-year-old woman living at home with responsible for a broken arm suffered by the 3-year-old. She says the
three children, aged 3â•›years, 2â•›years, and 7â•›months. Mrs. Charles is landlord does not respond to telephone calls about the housing situ-
attempting to correct the 3-year-old by threatening to beat her with a ation. She also tells the nurse that she has visited the social services
belt if she does not stop pulling her sister's arm. The home is untidy office for an application for financial assistance but that she has not
and cluttered, with dried food and several days’ dishes piled in the completed the application. Mrs. Charles has about $20 and 2â•›days’
sink. The children are in their nightwear and are just eating breakfast supply of food left in the house.
at noon. Mrs. Jones notices that there is no heat in the home, there is
no running water in the kitchen, and Mrs. Charles is using the gas oven Assessment
as a heat source. During the conversation that follows, Mrs. Charles • The nurse will perform a complete brief financial assessment, includ-
shares her concerns about money, her anxiety about having to care ing identification of all immediate income sources and expenses, to
THE NURSING PROCESS IN PRACTICEÂ�—CONT'D

A Violent Family
determine aid eligibility. Also, the nurse will evaluate the status of • The nurse will assess Mrs. Charles's knowledge of parenting tech-
the application for financial assistance from the Temporary Aid to niques and current practice.
Needy Families (TANF) program. • The available social support network for both Mrs. Charles and her
• The nurse will evaluate the current food supply for nutritional con- children will be evaluated.
tent and quality.
• The nurse will conduct a home environment and safety assessment, Nursing Diagnoses
both physical and psychological. • Impaired home maintenance related to insufficient financial
• The nurse will take a brief history and conduct a physical examina- resources as evidenced by available monetary funds of $20 and
tion of both Mrs. Charles and her three children. A standard growth 2-day food supply in house
and developmental assessment, as well as determination of cur- • Impaired parenting related to changes in family structure and legal
rent immunization status, will be included in the children's physical stress as evidenced by threats of physical abuse against her three
examinations. children
• The nurse will discuss with Mrs. Charles Mr. Charles's compliance • Risk for other-directed violence related to stress as evidenced by
with the judicial court's restraining order and directive to undergo past abusive behaviors of Mr. Charles and mother's threats against
counseling. Because Mr. Charles has continued to stay with the fam- the 3-year-old
ily, the nurse will assess the degree and quality of interaction Mrs. • Disabled family coping related to a court restraining order against
Charles and the children have with Mr. Charles and any safety con- Mr. Charles as evidenced by statements of anxiety about being sole
cerns stemming from these interactions. care provider for her children
Nursing Nursing
Diagnosis Goals Nursing Interventions Outcomes and Evaluation
Impaired home Family's Review the client's TANF application, and help the client The TANF application is completed that day.
maintenance financial situation complete the application process as necessary.
related to and food resources Arrange for emergency food assistance, including a TANF Food supplies are provided immediately, so Mrs.
insufficient will improve. emergency grant for food and funds for living expenses. Charles can feed her children and feel less
financial Include same-day transportation arrangements to the social anxious regarding food availability. In addition,
resources as services office and meet with the social worker to complete the acceptance process for long-term programs
evidenced these applications. begins, which addresses the long-term needs
by available of the family.
monetary Review and help the client contact other potential sources of The Women, Infants, and Children (WIC) program
funds of $20 financial assistance, such as church organizations and social provides additional food supplements. After
and 2-day food service agencies. initial familial crises have abated, Mrs. Charles
supply in the becomes involved in a local program that
house provides skills training.
The family's Explain the process of environmental bacterial growth Mrs. Charles verbalizes her understanding of
home environment and insect infestation to motivate Mrs. Charles to clean the simple bacterial growth and the fact that crumbs
will improve. apartment. and foodstuffs provide an inviting environment
for insects.
Review with Mrs. Charles normal child and infant behaviors, Mrs. Charles notes that her children do tend to
which include, but are not limited to, putting objects in their put many objects into their mouths. “I've been
mouths as they explore their environment. With knowledge, so anxious lately that I really haven't kept
Mrs. Charles will understand that foodstuffs on the floor the house as I would like to.” On subsequent
may pose potential harm to her children's health. visits, the nurse notes that although the
house is cluttered, the sink is clear of dishes
and the apartment isÂ€swept.
Contact the health department to perform an inspection of The health department inspects the building and
the apartment building. The health inspection will direct finds multiple code violations. Although
the landlord to complete necessary maintenance to provide Mrs. Charles expresses “worry” that the
a safe living environment for all tenants. At this point, it landlord will find out that “it was because of
would be important to note that Mrs. Charles may have me,” the landlord has made simple dwelling
to explore other immediate housing options because the improvements and has not engaged in verbal
landlord may be unwilling to make necessary repairs intimidation or investigated the source of the
or retaliate for health department notification through report.
illegalÂ€eviction.
1. Follow several reported family abuse cases in the newspaper the funding of such resources. Are they adequate to meet
to their conclusion in the court system. Review the life expe- the needs as identified by the agency personnel and persons
riences of the individuals involved, both abusers and abused, assisted?
and try to understand the family dynamics of each case. 5. Review state and local funding for support programs for
2. Become familiar with attempts to change laws related to abuse victims and perpetrators. Correspond with your local
abuse. What are the proposed new provisions? Why were state representative to determine his or her position on fund-
they proposed? What are the positions of advocates and ing priorities for resources for these programs.
opponents of the new law? Determine your position on 6. Discover whether your community has respite care for
the effort. caregivers. If none is available, what actions could you
3. Consult with fellow students and health care professionals take to encourage the community to provide such a
about their experiences with abusive situations. How were resource?
the situations resolved? Were the individuals involved satis- 7. Reflect on the meaning of family violence to you. What
fied that the victims were adequately protected? What would experiences with social, intimate, or family violence have
you do under similar circumstances? you had? How do your experiences and background affect
4. Explore community resources that might be valuable refer- your reaction to violent situations and victims of family
rals for children, spouses, or older adults in need. Review violence?

LOCAL ORGANIZATIONS Domestic Abuse Intervention Programs Project: http://www.
The following resources are usually available in a local commu- theduluthmodel.org/
nity. Check the local phone book or contact the local library for National Center for Education in Maternal and Child Health:
ways to contact these resources. http://www.ncemch.org/
National Center for Missing and Exploited Children: http://
Child Abuse www.missingkids.com/missingkids/servlet/PublicHomeServlet
Department of Social Services ?LanguageCountry=en_US
Big Brother and Big Sister programs National Runaway Switchboard: http://www.1800runaway.org/
Home care assistance program National Council on Child Abuse and Family Violence: http://
Prenatal classes www.nccafv.org/
Family preservation programs Parents Anonymous: http://www.parentsanonymous.org/
Foster grandparent program
Young Women's Christian Association (YWCA) Intimate Partner Violence
Future Without Violence: http://www.futureswithoutviolence.org/
Department of Justice Office on Violence against Women: http://
Intimate Partner Violence
www.ovw.usdoj.gov/
Department of Social Services
National Coalition against Domestic Violence: http://www.ncadv.org/
Local legal assistance organizations
National Women's Health Information Center, Office on
Local legal defense fund
Women's Health, U.S. Department of Health and Human
YWCA
Services: http://www.womenshealth.gov/
Crisis telephone line
VIOLET: Law and Abused Women: http://www.violetnet.ca/
Shelters
Stalking Resource Center: http://www.violetnet.ca/
Emerge: Counseling and Education to Stop Domestic Violence:
Elder Mistreatment http://www.emergedv.com/
Meal programs, such as Meals on Wheels National Domestic Violence Hotline: http://www.thehotline.org/
Senior centers
Senior daycare centers Elder Mistreatment
Senior companion programs National Center on Elder Abuse: http://www.ncea.aoa.gov/ncearoot/
State or local office on aging Main_Site/index.aspx
Administration on Aging, Prevention of Elder Abuse, Neglect,
NATIONAL ORGANIZATIONS and Exploitation: http://www.aoa.gov/aoaroot/aoa_programs/
Child Abuse elder_rights/ea_prevention/index.aspx
Children's Defense Fund: http://www.childrensdefense.org/home. American Association of Retired Persons (AARP): http://www.
html aarp.org/
Child Welfare Information Gateway, U.S. Department of Health National Institute on Aging: http://www.nia.nih.gov/
and Human Services: http://www.childwelfare.gov/ Older Women's League: http://www.owl-national.org/
WEBSITE
STUDY AIDS
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The effect of lifetime victimization on the mental children. Research on Social Work Practice, 11, violenceprevention/pdf/IPV_SV_Program_
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Ulrich, Y. C., Cain, K. C., Sugg, N. K., etÂ€al. (2003). learning theory suggests a child may copy acts children, 2010. Washington, DC: Author.
Medical care utilization patterns in women with of aggression seen through the media. Nursing Federal Interagency Forum on Child and Family
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Preventive Medicine, 24, 9-15. Weir, L. A., Etelson, D., & Brand, D. A. (2006). indicators of well-being, 2007. Washington, DC:
Undheim, A. M., & Sund, A. M. (2010). Prevalence Parents’ perceptions of neighborhood safety and U.S. Government Printing Office.
of bullying and aggressive behaviour and their children's physical activity. Preventive Medicine, Prothrow-Stith, D., & Spivak, H. R. (2004). Murder
relationship to mental health problems among 12- 43(3), 212-217. is no accident: Understanding and preventing
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Child Adolescent Psychiatry, 19(11), 803-811. Bell Associates. (2002). Evaluation of family Jossey-Bass.
CHAPTER
24
Adolescent Sexual Activity and
Teenage Pregnancy
Frances A. Maurer
FOCUS QUESTIONS
How prevalent is sexual activity among U.S. adolescents? What are some of the personal costs associated with early
What are some of the factors that influence a teenager's parenting for adolescents and their infants?
decision to engage in sexual activity? How can community/public health nurses act to reduce the
What are some of the risks associated with early sexual activity? risks of teenage pregnancy?
What are some of the reasons teenagers become pregnant? What are the nurse's responsibilities as a health care
What are some of the factors associated with increased risk for professional visiting an at-risk family?
pregnancy for young girls? What community programs are available to assist teenage
What are some of the social costs of teenage pregnancy? parents and their children?
CHAPTER OUTLINE
Teenage Sexual Activity Psychosocial Consequences
Extent of Sexual Activity among Teenagers Effects of Pregnancy on Family Dynamics
Mixed Emotions about First Sexual Intercourse Fathers of Babies Born to Adolescent Mothers
Increased Frequency of Oral Sex Legal Issues and Teen Access to Reproductive Health Services
Comparison of Teenage Sexual Behavior among Countries Exceptions to Parental Consent Requirements
Factors Associated with Decisions to Engage in Sexual Activity State and Federal Efforts at Influencing Consent Laws
Risk for Sexually Transmitted Diseases Restrictions on Abortion Consent
Contraceptive Use Legal Ambiguity Prevails
Teenage Pregnancy Nursing Role in Addressing Teenage Sexual Activity
Trends in Pregnancy and Birth Rates among Teens andÂ€Pregnancy
Intended versus Unintended Pregnancy Primary Prevention
Pregnancy Outcomes Educational Programs
Characteristics Associated with Risk for Pregnancy Screening for Risk Behaviors
Reasons for Adolescent Pregnancies Contraceptive Services
Comparison of Pregnancy-Related Issues in Other Countries Life Options or Youth Development Programs
Pregnancy Rates in Selected Countries Secondary Prevention: The Care of Pregnant Teenagers
Abortion Rates in Selected Countries Early Detection
Public Costs of Adolescent Pregnancy and Childbearing Pregnancy Resolution Services
Consequences of Early Pregnancy for Teenagers and Infants Prenatal Health Care
Role in the Poverty Cycle Childbirth Education
Educational and Economic Consequences Postpartum and Newborn Care
Less Prenatal Care Tertiary Prevention
Substance Use and Exposure to Violence Birth Control
Physical Consequences for the Mother Parenting Skills
Consequences for the Newborn and Child Comprehensive Programs
603
604 CHAPTER 24â•… Adolescent Sexual Activity and Teenage Pregnancy
KEY TERMS
Abstinence-only programs Risky behaviors Unprotected intercourse
Comprehensive sex education programs Sexting Virginity pledgers
Life options programs Teenage sexual activity
Low birth weight Unintended pregnancy
Teenage sexual activity involves sexual intercourse and other Mixed Emotions about First Sexual Intercourse
sexual acts in adolescents younger than 20â•›years of age. Early sex- Abma and colleagues (2010) conducted a study on teens and
ual activity is very common and is accompanied by major public their first sexual intercourse. Seven percent of girls reported
health concerns such as increased risk for sexually transmitted that their first sexual intercourse was not voluntary. In addi-
diseases (STDs), pregnancy, and early parenthood. Adolescent tion, 10% of girls and 5% of boys reported that they did not
parents are more likely to have substantial problems adjusting want their first intercourse to happen when it did, and 47% of
to parenthood and acquiring adequate parenting skills. Their girls and 34% of boys had mixed feelings about the timing of
children are often affected by their difficulties. Children born to their first intercourse. This suggests much ambivalence about
younger teens are at greater risk for health problems than chil- initiation of sexual activity. Educational programs and coun-
dren born to mothers in other age groups (Martin etÂ€al., 2010b; seling should continue to stress techniques to handle pres-
Mathews and MacDorman, 2010). sure from peers and potential partners related to initiation of
Although substantial progress has been made in educating sexual activity.
teens and in influencing sexual behaviors, much remains to be
done. The teenage pregnancy rate is the lowest ever recorded, Increased Frequency of Oral Sex
and as a result both the birth rate and the abortion rate among The practice of oral sex is now as common as intercourse in the
teenage girls have also declined (Morbidity and Mortality Weekly teen population. Approximately 25% of teens substitute oral sex
Report [MMWR], 2011a). There is evidence to suggest that for intercourse. In one survey, half of the teens did not consider
teens are delaying the start of sexual activity, but by age 18 to oral sex to be a sexual activity. Half of all college students who
19â•›years, the majority (70%) of teens have had a sexual experi- pledged to remain virgins reported that they engaged in oral
ence (Guttmacher Institute [GI], 2011a). sex (Dailard, 2003). One-third of teens reported having oral sex
with someone who was not the right partner for intercourse or
TEENAGE SEXUAL ACTIVITY someone with whom they wished to delay initiation of inter-
course (Chandra etÂ€al., 2011; Dailard, 2006). Most were unaware
Sexual intercourse, especially unprotected intercourse (Â�sexual of the risk for STDs associated with oral sex.
intercourse without the use of barriers or other contracep-
tives), carries the risk for pregnancy. The level of sexual activity Comparison of Teenage Sexual Behavior
among teenagers is extremely high (GI, 2011a). Peer pressure, among Countries
an Â�adolescent's need to belong, and the sexual content of media The most current comprehensive comparative study (United
messages make it difficult for teens to delay or abstain from Nations, 2008) shows little difference in sexual experience or age
Â�sexual activity. at initial sexual intercourse among teenagers in developed coun-
tries (FigureÂ€24-1). There are, however, differences in contra-
Extent of Sexual Activity among Teenagers ceptive behaviors and pregnancy rates. Teenagers in the United
Sexual activity among adolescents continues to be a prevalent States are less likely to be aware of contraceptive methods, to
issue, although some data suggest that there has been a decline know or to explore how to obtain and use contraceptives, and
in sexual activity among certain age groups. Since 1991, the to initiate action to protect themselves from unwanted preg-
number of high school teenagers who engaged in sexual inter- nancies either before or just after their first sexual experience
course decreased from 54% to 46% (MMWR, 2011a). There is (Abma etÂ€al., 2010; Albert, 2010). The reason for such sexually
some evidence to suggest that teens are delaying the age at first risky behavior is at least partially the way in which sexuality and
intercourse; however, the rate of sexual intercourse increases sexual behaviors are addressed in the United States.
with age. Approximately 13% of teens have had their first sex- In other developed countries, information about sexual
ual encounter before the age of 15â•›years. By age 17â•›years, only intercourse and birth control is regularly provided to teenagers.
27.7% of girls and 28.8% of boys have engaged in sexual activ- Government-sponsored sex education programs in the school
ity; by the time they reach 18 to 19â•›years of age, 59.7% of girls systems are common. Programs include health teaching on con-
and 65.2% of boys have engaged in sexual activity (Abma et al., traceptive methods, encouragement of responsible sexual activity,
2010). The Healthy People 2020 objectives (U.S. Department of and easy access to contraceptives and service is generally provided
Health and Human Services [USDHHS], 2010) have identified in a nonjudgmental fashion (GI, 2006a). Sexuality and contra-
priorities associated with teenage sexual activity, including the ception education is mandatory in public schools in England,
following (see also the Healthy People 2020 box on page 605): Wales, France, and Sweden and in most Canadian schools.
• Increasing the age at first intercourse The United States provides little information on contracep-
• Reducing the number of adolescents engaging in sexual tives, and contraception is not an emphasized element in most
activity school-based sex education programs. One-third of high school
• Increasing the number of adolescents who use protective students have had no formal education on contraceptives, and
measures when engaging in sexual activity. 24% of students received abstinence education Â�without any
CHAPTER 24â•… Adolescent Sexual Activity and Teenage Pregnancy 605
HEALTHY PEOPLE 2020

Adolescent Sexual Activity and Pregnancy
SEXUAL ACTIVITY
2006–2008
1. Increase to 91.2% for females and 90.2% for males, the proportion
Baseline 2020 Target
of adolescents who have never engaged in sexual intercourse before
the age of 15â•›years (baseline: 82.9% of females and 82% of males Formal instruction
have never engaged in sexual intercourse by age 15 in 2006 to 2008). Abstinence
2. Increase the proportion of adolescents aged 15 to 17â•›years who have Females 87.2% 95.9%
never engaged in sexual intercourse. Males 81.1% 89.2%
Birth control methods
Sex 2006–2008 Baseline 2020 Target Females 69.5% 76.4%
Males 61.9% 68.1%
Females 72.1% 79.3%
HIV/AIDS prevention 88.3% 97.2%
Males 71.2% 78.3%
Females
Males 89.0% 97.9%
FAMILY PLANNING
STDs
Females 93.2% 95.2%
1. Reduce teen pregnancies among adolescent females aged 15 to
Males 92.2% 94.2%
17â•›years to no more than 36.2 per 1000 adolescents (baseline: 40
pregnancies per 1000 females in 2005; African Americans, 61 per
MATERNAL AND INFANT HEALTH
1000; Hispanic Americans, 53 per 1000).
2. Increase to 56% the proportion of all pregnancies that are intended
1. Reduce infant mortality (under 1â•›year of age) to no more than 6.0
(baseline: 51% of pregnancies intended among women aged 15 to
deaths per 1000 births (baseline: 6.7 per 1000 in 2006).
44â•›years in 2002).
Risk Reduction Objectives Risk Reduction Objectives

1. Increase to 91.3% the proportion of females or their partners at 1. Reduce to 8.1% low-birth-weight newborns and to 1.4% very-low-
risk for unintended pregnancy who use contraception at most recent birth-weight newborns (baseline: 8.2% for low-birth-weight new-
sexual intercourse (baseline: 83% of females or their partners in borns and 1.5% for very-low-birth-weight newborns in 2007).
2006 to 2008). 2. Reduce to 28 per 100 deliveries the number of pregnant women who
2. Increase the proportion of sexually active, unmarried adoles- experience maternal complications during labor and delivery (base-
cents aged 15 to 19â•›years who use contraception that both effec- line: 31.1 per 100 deliveries in 2007).
tively prevents pregnancy and provides barrier protection against 3. Increase abstinence from use of tobacco, cigarettes, and other illicit
disease. drugs among pregnant women.
Method 2006–2008 Baseline 2020 Target 2007 Baseline

Condom Females age
Males 77.9% 85.7% Substance 15–44Â€years 2020 Target
Females 66.9% 73.6% Alcohol 89.4% 98.3%
Condom plus hormonal method Binge drinking 95% 100%
Males 18.1% 19.9% Cigarette smoking 89.6% 98.65%
Females 13.47% 14.8% Illicit drugs 94.9% 100%
3. Reduce the proportion of adolescents and young adults with Service and Protection Objectives
Chlamydia trachomatis infections. 1. Increase to 77% the proportion of pregnant women who receive
Sex 2008 Baseline 2020 Target early and adequate prenatal care (baseline: 70.5% in 2007).
2. Increase first-trimester prenatal care to at least 77.9% of live
Females aged 15 to 24â•›years 7.4% 6.7%
births (baseline: 57% all women; African Americans, 56%; Hispanic
attending Family Planning
Americans, 53.2%; American Indians and Alaska Natives, 67.5%;
clinics
whites, 69.5%; in 2008).
Males aged 15 to 24â•›years 7.0% 6.3%
3. Increase the proportion of pregnant women who attend a series
enrolled in National Job
of prepared-childbirth classes (developmental: no current
Training Program
baseline).
4. Reduce the proportion of females with human papillomavirus (HPV) 4. Increase to 45 states the number who provide appropriate new-
infection (developmental, no current baseline). born blood spot screening and follow-up testing (baseline: 21
states in 2010).
Service and Protection Objectives 5. Increase to 22.4% the proportion of children age 0 to 11â•›years with
1. Increase the proportion of adolescents who have received for- special health needs who receive their care in family-centered, com-
mal instruction on reproductive health issues before turning age prehensive, and coordinated systems (baseline: 20.4% of children in
18â•›years old. 2005 to 2006).
Data from U.S. Department of Health and Human Services. (2010). Healthy People 2020. Washington, DC: Author. http://www.HealthyPeople.gov;
and U.S. Department of Health and Human Services. (2011). Health, United States, 2010. Washington, DC: Author.
Peer Pressure and Intimacy Needs

Sweden Research suggests that one of the most important influences
on a teenager's decision to begin sexual activity is the attitudes
and behaviors of peers (Albert, 2010; National Campaign to
France Prevent Teen and Unplanned Pregnancy [NCPTP), 2009a).
Adolescent motives for sexual behavior are linked to the desire
for intimacy, social status, and pleasure (Ott etÂ€al., 2006).
Canada
Teenage girls listed intimacy as the most important motive
for sexual activity, whereas teenage boys listed pleasure and
Great social status as more important. Before 1980, race, socioeco-
Britain nomic status, type of neighborhood and dwelling, and religion
were significantly related to age at first intercourse. Although
United many of these factors still have an effect, they are diminishing
States
in significance.
0 20 40 60 80 100 Racial/Ethnic Differences
% of Women 20-24 Who Had Sex in Their Teenage Years Some differences are seen in the age of onset of sexual behav-
By age 15 By age 18 By age 20 ior among races. African Americans are sexually active at an
earlier age, but white and Hispanic youths are rapidly catch-
FIGUREÂ€24-1â•‡Percentage of women who engage in sexual
activity during their teen years by age: comparison of selected ing up. In 2009, 72% of all black male high school students,
countries. (Note: Data are for the mid-1990s.) (From Darroch J. 53% of Hispanic males and 40% of white male students
E., Frost, J. J., Singh, S., etÂ€al. [2001]. Teenage sexual and reproduc- engaged in sexual activity in high school. Female teenagers
tive behavior in developed countries: Can more progress be made? of all races initiate sexual intercourse later than do adolescent
[Occasional Report No. 3]. New York: Alan Guttmacher Institute.) males, but 58% of black females and 45% of Hispanic and
white females have had sexual intercourse during high school
information on birth control (GI, 2011b; Martinez et al., 2010). years (MMWR, 2011a).
The United States has also been ambivalent about providing
contraceptive services to teenagers. In some instances, federal Reasons for Delaying Sexual Activity
or state funding for clinics serving large numbers of young Religious upbringing has some impact on adolescent Â�sexual
disadvantaged females has been reduced or discontinued (see activity, reducing the proportion of teens who are sexually
ChaptersÂ€4, 21, and 27). A significant number of U.S. teenagers active. The main reason given by teens who have not initi-
and their families have no health insurance and find access to ated sexual activity was religious or moral beliefs (Abma
any kind of health care services (including contraceptive ser- etÂ€al., 2010). In addition to religious concerns, adolescents
vices) difficult (Gold etÂ€al., 2009; MMWR, 2011b). Some fed- listed fears of pregnancy and STDs as reasons for delaying
eral programs have actively attempted to restrict rather than sexual activity. More boys (30%) than girls (10%) stated that
increase access to reproductive services. they had not found the right partner (Abma etÂ€al., 2010). Of
Formal sexual education programs for adolescents are closely those who abstained during their teenage years, almost all had
monitored. Parental involvement and permission requirements Â�initiated sexual activity by 24â•›years of age regardless of mar-
and abstinence-only programs are two methods supported at ital status. Only 12.3% of females and 14.3% of males age
the federal level. Federal funding for abstinence-only sex edu- 20 to 24â•›years reported not ever engaging in sexual activity
cation programs increased by 157% between 1997 and 2005 (Chandra etÂ€al., 2011).
(Lindberg et al., 2006a) but has since been reduced, pending
results of the efficacy of such education programs. Socioeconomic Status, Family Composition,
In 2011, 37 states required parental involvement in sex and Risky Behaviors
education programs, and 3 states required parental consent Family income and academic standing also influence the
before a child could attend a sex education program (National adolescent's decision making related to sexual activity.
Conference of State Legislatures [NCSL], 2011). The type and Teenagers from poor and low-income groups are moderately
manner of “parental involvement” varies by state. In addition, more likely to be sexually active, and initiate sexual activity
37 states and the District of Columbia allow parents to opt out approximately 4 to 6â•›months earlier compared with adoles-
of sex education programs for their children. By contrast, the cents from higher-income families. This is especially true for
majority of states (73%) required education about STDs and adolescent females.
human immunodeficiency virus/acquired immunodeficiency Students who are academically motivated, are progressing
syndrome (HIV/AIDS). No program that takes federal funds well in school, are future oriented, and have established goals
is allowed to provide information about the positive effects of generally delay sexual activity and avoid pregnancy (Abma
contraceptive use. etÂ€al., 2010; Manlove et al., 2004). Frost and colleagues (2001)
reported that for girls, education seems to delay age of first
Factors Associated with Decisions to Engage intercourse. Thirty-three percent of girls who did not com-
in Sexual Activity plete high school reported starting sexual activity before age
An adolescent's decision to initiate sexual activity appears to be 15. Only 17% of female high school graduates and only 9%
influenced by multiple factors. A brief discussion of the most of females with some college education initiated sexual activ-
important findings is presented here. ity before age 15. Better school performance and parental
Â�
expectations positively influenced the decisions of both boys HIV infection, or unintended pregnancy (Kunkel etÂ€al., 1999).
and girls to postpone sexual activity (NCPTP, 2010a). L'Engle and colleagues (2006) found teens exposed to sexuality
Common opinion links single-parent families, poor parental in the media were more likely to engage in sexual activity. Teens
communication on sexual matters, and school-based sex educa- reported that TV shows which deal with teenage pregnancy or
tion with early sexual activity. Teens of both sexes who are from health and social problems associated with sexual activity made
single-parent homes are more likely to be sexually active and to them think more about the consequences of sexual intercourse
have a child at a young age compared with children from two- (Albert, 2010; NCPTP, 2007).
parent families (Abma etÂ€al., 2010). Recent studies indicated Sexting is a new form of sexual activity and is defined as
that the absence of a father in the household increases the risk sharing suggestive images of oneself over electronic media.
for both boys and girls for early sexual activity and pregnancy Sexting has become popular with teens, many of whom do not
(NCPTP, 2009b). Girls in one-parent families or blended fami- anticipate the problems and pressures they may encounter as a
lies and those in out-of-home placements are twice as likely to result of this practice. Albert (2010) reported that most teens
be sexually active compared with girls in two-parent families (71%) believe sexting leads to an increase in sexual activity
(Abma etÂ€al., 2010). among teens.
Parental connection seems to delay initiation of sexual activ- Some teens have additional concerns that can affect their
ity and reduce risky sexual behavior (Haggerty etÂ€al., 2007; decision process and behavior. Poverty, family dysfunction, and
Prado etÂ€al., 2007). However, over half of teens reported that poor school performance can negatively influence the develop-
they had not talked with their parents about saying no to sex or ment of a healthy self-esteem, hinder long-term goal setting,
about birth control methods (Martinez etÂ€al., 2010). and reduce future expectations. All these factors are associ-
Most studies found no relationship or only very weak cor- ated with an early initiation into sexual activity and an increase
relations between school-based sex education and a teenager's in pregnancy rates (Abma etÂ€al., 2010; Boonstra, 2002; Klima,
decision to initiate sexual activity. The most recent evidence 2003). One study that linked mental health and sexual activity
suggests that such education encourages the delay of initiation reported that sexually active teens were three times more likely
of sexual activity and sexually active teenagers to use contracep- to feel depressed and at greater risk of suicide than teens who
tives (Manlove etÂ€al., 2004; MMWR, 2011a). were not (Rector etÂ€al., 2003). Additional research in this area is
Teenagers who engage in other risky behaviors such as currently underway.
smoking, drinking, and drug use are more likely to risk engag-
ing in sexual activity (American College of Obstetricians and Risk for Sexually Transmitted Diseases
Gynecologists [ACOG], 2009; Eaton etÂ€al., 2006; NCPTP, 2011). Early onset of sexual activity increases the risk for multi-
This is especially true of younger teens. Adolescents 14 and ple sex partners, unprotected sex, and STDs (Abma etÂ€al.,
15â•›years of age who engage in other risky health behaviors are 2010; USDHHS, 2000). Each year, approximately 9 million
twice as likely as their peers to be sexually active (Albert etÂ€al., adolescents contract an STD (Guttmacher Institute, 2006b;
2003). For example, 25% of sexually active young teens drink or USDHHS, 2000). Of the top 10 infectious diseases, 5 are
use drugs before having sex (ACOG, 2009; Eaton etÂ€al., 2006). STDs: chlamydia, gonorrhea, AIDS, syphilis, and hepati-
Children and adolescents who have been sexually abused are at tis B. In 2008, a Centers for Disease Control and Prevention
greater risk for continued sexual activity (Brennan etÂ€al., 2007; (CDC) study reported that 26% of girls between the ages
Santelli etÂ€al., 2006a) (see ChapterÂ€21). of 14 and 19â•›years (3.2 million girls) were infected with at
Initiation of sexual intercourse during the teenage years least one of the most common types of STD (human pap-
tends to increase the risk for multiple partners (Abma etÂ€al., illomavirus [HPV], chlamydia, genital herpes, trichomonia-
2010; Eaton etÂ€al., 2006). The younger the adolescent at the start sis) (CDC, 2008). This study did not include syphilis, HIV
of sexual activity, the greater is the risk for multiple partners. infection, or gonorrhea, and it did not include young males.
Women who initiated sexual experiences by age 15 reported Incidence rates can be expected to be higher if the excluded
having more sexual partners than women who started sexual STDs and young males were included in the study.
activity later in their teens (Abma etÂ€al., 2010; NCPTP, 2002). The rates of chlamydia, gonorrhea, genital herpes, and syphi-
Abma and colleagues (2010) found that 30% of sexually active lis among sexually active teens are higher than the rates in the
male and female adolescents are most likely to have had two or general population. Abma and colleagues (2010) reported that
more partners in the previous year. 15- to 24-year-olds acquired nearly 50% of all STDs each year.
TableÂ€24-1 provides information on selected STDs actually
Other Factors Associated with Adolescent Sexual Activity reported to the CDC; not all STDs are reportable. In 2009, there
Early sexual maturation coupled with a prolonged transition were over 1.2 million cases of chlamydia, of which approximately
to independence compounds the adolescent's journey toward 600,000 occurred among teens and young adults (MMWR,
responsible adulthood. The number of years the youth are 2011c). HIV/AIDS is a growing problem in the adolescent pop-
expected to spend in preparation for work or a career is lon- ulation. Infections are often contracted in the teenage years and
ger than at any other time in history. Along the way, adoles- remain undetected until the infected persons reach their twen-
cents encounter mixed messages about sex, sexual activity, and ties or thirties (see ChaptersÂ€7 and 8). The rates of STDs are
responsible behavior (Albert, 2010; NCPTP, 2007). A longitudi- higher among racial and ethnic minority groups and adoles-
nal analysis of programming on four major television networks cents living in poverty than among adolescents in other racial
showed a steady increase in the amount of sexual activity and groups or teens living in families with higher socioeconomic
Â�
behavior (Frutkin, 1999; Kunkel etÂ€al., 1996). Fewer than 30% levels (see ChaptersÂ€7, 8, and 21). As the Â�differences among
of sexual situations involved responsible sexual activity such as racial and ethnic groups disappear, differences in STD rates will
waiting to have sex or attempting to reduce the risk for STDs, also disappear.
TABLEÂ€24-1â•…â•‡SEXUALLY TRANSMITTED than 20â•›years (GI, 2010a). The importance of subsidized family
DISEASES AMONG planning services has been stressed, but these services are likely
to see additional funding cuts as both the federal and state gov-
ADOLESCENTS
ernments deal with the current economic recession.
DISEASE NEW CASES
Human papillomavirus (HPV) infection NA TEENAGE PREGNANCY
Trichomoniasis NA
Chlamydia 430, 255 The United States has one of the highest teenage pregnancy
Genital herpes NA rates in the developed world.
Gonorrhea 87, 221 • Approximately 410,000 teenagers become pregnant each year.
Human immunodeficiency virus (HIV) 2036 • Eighty-two percent of these pregnancies are unintended.
infection • Of pregnancies in 15- to 17-year-olds:
Syphilis 1005 • 58% result in live births.
• 27.4% result in abortion.
From Centers for Disease Control and Prevention. (2010). 2009
Sexually Transmitted Disease Surveillance: STDs in adolescents • 14.6% end in miscarriage.
and young adults. Retrieved August 22, 2011 from http://www.cdc. • More than 400,000 babies are born to mothers younger than
gov/STD/Stats09/adol.htm; and Centers for Disease Control and 19â•›years of age each year.
Prevention. (2011). Basic statistics. Retrieved August 22, 2011 from • Pregnant teenagers are more likely to drop out of high school,
http://www.cdc.gov/hiv/topics/surveillance/basic.htm. live in poverty, and have limited occupational choices com-
pared with girls who do not become pregnant during the teen-
The rates of chlamydia and gonorrhea are higher among females age years (GI, 2010b; MMWR, 2011a; Ventura etÂ€al., 2011).
than among males. Much of that difference might be due to the
Trends in Pregnancy and Birth Rates among Teens
greater extent of screening and detection provided to females by
reproductive health care services. Males, who are largely asymp- Preliminary figures through 2009 point to a sharp decline in
tomatic, do not generally seek reproductive health care services, pregnancy and a more moderate decline in birth and abor-
and the infections are more likely to remain undetected (ACOG, tion rates among adolescents. Tabulation and publication
2009; Abma etÂ€al., 2004; Chesson etÂ€al., 2004;). Females are also of national data comparisons of pregnancy, birth rates, and
more likely to experience health complications from STDs, such as abortion rates among teens are delayed by 4 or more years.
pelvic inflammatory disease, cervical cancer, infertility, and ecto- FigureÂ€24-2 shows the most current information for all three
pic pregnancy (Mayo Clinic, 2011; USDHHS, 2007). categories. In 1991, the birth rate for teens (15 to 19â•›years)
was 62.1 per 1000. In 2009, the birth rate was 39.1 per 1000
Contraceptive Use (MMWR, 2011a). Nevertheless, both the pregnancy rate and
Contraceptive use among teenagers has steadily increased since teen birth rate remain high.
the 1980s. Approximately 12% of teens do not use protection
120
during intercourse (Abma etÂ€al., 2010; MMWR, 2011a). Birth
control use generally starts after sexual activity has already
begun. Teenagers use birth control sporadically and tend to 100
Number per 1000 Females
switch methods without taking the proper precautions (Abma

etÂ€al., 2010; Santelli etÂ€al., 2006b). 80
Condoms are the most common type of contraception used
at first intercourse. More than 95% of sexually active teens
60
reported using condoms (Abma etÂ€al., 2010). Teens who engage
in sexual activity on an ongoing basis switch to more effective
methods such as birth control pills, injectable Depo-Provera, 40
and intrauterine devices. About 52% of adolescent females
reported using birth control pills. Concern about HIV and STDs 20
have led to an increased use of barrier methods (condoms) in
conjunction with other birth control measures. Although dual
0
contraceptive use in teens has increased, only 35% of teens
report using two methods of birth control (Abma etÂ€al., 2010). 1976 1988 1993 2006
Poverty is associated with less access to and less successful Pregnancy Births Abortions
use of reversible contraceptive measures. Poor people have dif- FIGUREÂ€24-2â•‡Pregnancies, births, and abortions in U.S. ado-
ficulty obtaining contraceptive health care services and paying lescents aged 15 to 19â•›years for selected years. Rates per 1000
for birth control products. Frost and colleagues (2001) reported females. (Data from Guttmacher Institute. [2010]. U.S. teenage preg-
that poor teens are less likely to use birth control pills than those nancies, births, and abortion: National and state trends and trends by
who are more economically advantaged. The price of one cycle race and ethnicity. New York: Author; Centers for Disease Control and
Prevention. [2003]. Revised pregnancy rates, 1990-1997 and new rates
of pills averages $30 per month. Teens who are not well off must
for 1998-99: United States. National Vital Statistics Reports, 52 [7].
rely on public programs to obtain contraceptive services. Public Hyattsville, MD: National Center for Health Statistics; and CDC. [1999].
program services are financed by federal and state monies, pri- Highlights of trends in pregnancies and pregnancy rates by outcome:
marily Medicaid and Title X monies. Approximately 30% (5 mil- Estimates for the United States, 1976-1996. National Vital Statistics
lion) of women serviced at public-funded centers were younger Reports, 47[29]. Hyattsville, MD: National Center for Health Statistics.)
Approximately 14% of the decline in pregnancy rates is 100

attributable to delaying sexual activity, and 86% is related to the
Rate per 1000 Women Aged 15-19 Years

use of highly effective contraceptive methods among sexually
active adolescent girls (Santelli etÂ€al., 2007). 80
in Specified Group
Intended versus Unintended Pregnancy
60
Most teen pregnancies (82%) are unintended (Ventura etÂ€al.,
2011). Whether intended or unintended, adolescent girls who
become pregnant and choose to continue the pregnancy are 40
more likely to come from low socioeconomic circumstances,
live on their own or with one parent, have lower educational
and career aspirations, and have older sexual partners (Abma 20
etÂ€al., 2010; MMWR, 2011a).
An unintended pregnancy is an unplanned or accidental
pregnancy and is accompanied by increased risks for the preg- 0
nancy, the mother, and the baby. Unintended pregnancies are
at n
te
er
ac
ni
N ia
s
hi
nd
ive
more likely to result in premature or low-birth-weight babies,
pa
n Ind
Bl
la
is
Is
c
ka n
H
ni
ni
little or no prenatal care, abortion and miscarriages, and preg-
as ica
fic
pa
pa
ci
Al er
is
is
nancy complications (MMWR, 2011a; Ventura etÂ€al., 2011).
Pa
& Am
-H
-H
on
on
or
Unintended pregnancies have a social cost to young mothers.
n
ia
These young women are at great risk for limited educational
As
and employment opportunities, the consequences of which can FIGUREÂ€24-3â•‡ Birth rates for adolescents aged 15 to 19â•›years by
last a lifetime. race and/or Hispanic origin 2007. (Data from Centers for Disease
Control and Prevention. [2009]. Preliminary data for 2007. National Vital
Pregnancy Outcomes Statistics Reports, 57 No. 12, March 18, 2009.)
Approximately 60% of pregnancies result in birth, and one-

fourth of pregnancies end in abortion (see FigureÂ€24-2). Most provide some indication of pregnancy rates. American Indian
single mothers keep their infants rather than place them for and Alaska Native teens have the third highest birth rate, non-
adoption. Therefore, there is a greater demand for adoptions Hispanic whites the fourth highest, and Asian Americans and
than there are infants placed for adoption. Pacific Islanders have the lowest birth rate.
A common public perception is that among teenag-
Characteristics Associated with Risk for Pregnancy ers, most pregnancies and births occur in those from racial
Some variations are seen in pregnancy and birth rates among minority groups. This is not true. In 2007, white teenagers
adolescents. A teen's age and the age of her sexual partner, mari- accounted for the largest percentage of births (56%), fol-
tal status, racial/ethnic group, and socioeconomic status influ- lowed by black (34%) and Hispanic (4%) teens (Martin etÂ€al.,
ence the chances of pregnancy and childbirth. 2010a). Hispanic and black teenagers have a higher propor-
Older teens have a higher pregnancy and birth rate com- tional rate of adolescent pregnancy, but because they are
pared with younger teens, perhaps because more of the older fewer in number, the largest number of teenage births occurs
adolescents engage in sexual intercourse compared with younÂ� among white teenagers.
ger teens. The pregnancy rate for females 15 to 17â•›years of age Among adolescent females, there is a link between pregnancy
is 41.4 per 1000, and for females 18 to 19â•›years of age, it is rate and socioeconomic status. Teens from lower-income fam-
118.6 per 1000 (MMWR, 2009). The older the teen's sexual ilies start sexual intercourse at an earlier age, which increases
partner, the more likely it is that an adolescent female will their risk for pregnancy. Teens from lower-income groups are
become pregnant. more likely than those from middle-income or upper-income
In general, teens do not delay sexual activity or pregnancy groups to become pregnant and, once pregnant, to choose to
until marriage. Marriage because of pregnancy used to be com- have the baby (Abma etÂ€al., 2010; Young etÂ€al., 2004). Of teens
mon in the past; today, few teenagers opt for marriage if they aged 15 to 19â•›years, 19% of those with family income at or below
become pregnant. Approximately 84% of pregnant adolescents 150% of the poverty level have a child, compared with 2% of
remain unwed (CDC, 2009). Pregnancy is, however, still the teens with family incomes at or above 300% of the poverty level
main reason for teenage marriages. (Frost etÂ€al., 2001).
There are differences in pregnancy and abortion rates among
racial and ethnic groups. The highest rates of birth are among Reasons for Adolescent Pregnancies
black and Hispanic adolescents, and the lowest are among Asian With advances in birth control, increased sexual activity does
American and Pacific Islander adolescents (FigureÂ€24-3). The not necessarily mean an increased risk for pregnancy. Why,
pregnancy rates in all racial and ethnic groups have declined in then, are teenage pregnancy rates so high? There is no single,
the past decade, with the sharpest decline in African American clear-cut answer. Teenage pregnancies occur due to a variety of
pregnancy rates. Abortion rates are lowest among white ado- reasons. Any effort to reduce the rate of adolescent pregnan-
lescents, perhaps because they have a lower pregnancy rate. cies must begin with a clear understanding of the conscious or
African American adolescents chose abortion at twice the rate unconscious reasons and motives behind teenage pregnancies.
of Hispanic American teens. The pregnancy rates for other eth- Knowledge about the motives and reasoning of sexually active
nic groups have not been as widely published. Birth rate data teenagers helps the community health nurse identify teens at
particular risk for pregnancy. Some of the factors associated and that many lived in chaotic family situations. Approximately
with pregnancies in the teenage population are enumerated in 25% could not identify any future life goals. Many of the girls
BoxÂ€24-1. Many teens who become pregnant do not do well aca- reported that in their social circles early childbearing was com-
demically and have few expectations for the future (Albert, 2010; mon, and almost 70% identified an adolescent friend or sibling
Manlove etÂ€al., 2004). A study of pregnant teens in California who was either pregnant or already had a child (Frost & Oslake,
found that 44% had dropped out of school prior to pregnancy 1999; Raneri & Wiemann, 2007).
BOXÂ€24-1â•…â•‡FACTORS ASSOCIATED WITH TEENAGE PREGNANCY

Hormonal Changes, Awakening Sexual Awareness, examinations by health care professionals. Cost is an issue, and most
and Peer Pressure teens have never sought care without their parents’ permission. Public
Adolescence is a period of heightened sexual awareness, curiosity, and programs that provide contraceptives are underfunded and must limit
experimentation. Peer pressure influences some teens’ decisions to services (Lindberg etÂ€al., 2006b).
engage in sexual intercourse (Albert, 2010; Ott etÂ€al., 2006). Many preg-
nant teens know someone or have a relative who was a pregnant teen Destigmatization of Illegitimacy
(Manlove etÂ€al., 2004). In addition, teens who engage in sexual inter- Formerly, pregnancy out of wedlock resulted in severe social censure,
course are more likely to have friends who do so. especially for women. Today, unwed motherhood is common, and most
young girls who are pregnant remain single (Guttmacher Institute, 2010b;
Pervasive Sexual Messages in the Media
Hamilton etÂ€al., 2006).
Adolescents are exposed to multiple messages about sex, sexual activity,
and the importance of being attractive to the opposite sex (Albert, 2010).
Efforts at Independence
Involuntary Sexual Activity Adolescence is a turbulent period and a period of increasing indepen-
Adolescent sexual activity is not always voluntary. The younger the dence. It is a time in which children complete the task of separation from
pregnant teen, the more likely she is to have engaged in coercive sex. their parents and further develop their own identities. It also is a period of
Seven percent of girls who have sex before age 20 report that it was uncertainty and conflict and a time of exploration. As the child explores
involuntary, and another 10% report that they did not want to initiate and develops, conflicts arise with parents and other authority figures.
sexual activity when they did (Abma etÂ€al., 2010). IfÂ€the child's attempts at independence are severely restricted, “acting
out” behaviors may result. Pregnancy can be one means of acting out;
Inaccuracy or Lack of Knowledge about Sex Â�others include running away, performing poorly in school, and engaging in
and Conception Â�substance abuse.
The increase in sexual activity among teenagers is not necessarily accom-
panied by increased knowledge about sexual function, procreation, or Need to Feel Special, Loved, and Wanted
birth control (Martinez etÂ€al., 2010). Misunderstandings abound related to Pregnancy can make a person feel special. The teenager receives extra
risk periods and timing, including periods of susceptibility during the men- attention from family, peers, and acquaintances. Sometimes, for the
strual cycle, age-related susceptibility, and timing of male ejaculation. first time, she might be on “center stage” in the family unit. Some girls
Inconsistent or Nonuse of Contraceptives report that they got pregnant because they expect the infant to meet
Teenagers also lack accurate knowledge about specific birth control their need for love and attention.
methods and the correct use of contraceptives. Inconsistent use of
contraceptives is common (Santelli etÂ€al., 2008). One in four girls dis- Lack of Future Orientation and Maturity
continues the pill despite continued sexual activity (Kerns etÂ€al., 2003). Teenagers generally live in the present; future planning is minimal.
Regular, effective contraceptive use increases with age. Younger teens Teenagers who are oriented to the present and just beginning to
have a 25% higher failure rate compared with older teens (Darabi, develop abstract reasoning often do not consider the future con-
2009). Older teens are more likely to use birth control pills or long-acting sequences of their current sexual activity. As adolescents become
contraceptives and younger teens are more likely to use condoms. more developmentally mature and more proficient at identifying
psychosocial costs, their use of contraceptives increases. Older
Difficulty of Access to Birth Control girls are more likely to use birth control (Abma etÂ€al., 2010). Sexual
The most effective birth control methods (intrauterine device, birth con- abstinence is more common among academically achieving teens
trol pills, injectable implants, and injections) require appointments and (Manlove etÂ€al., 2004).
Data from: Abma, J. C., Martinez, G. & Copan, C. E. (2010). Teenagers in the United States: Sexual activity, contraceptive use and childbearing,
National Survey of Family Growth 2006-2008. Vital and Health Statistics, Series 23, No. 30, June 2010; Albert, B. (2010) With one voice: America's
adults and teens sound off about teen pregnancy: A periodic national survey. Washington, DC: The National Campaign to Prevent Teen and
Unplanned Pregnancy; Ott, M. A., Millstein, S. G., Ofner, S., et al. (2006). Greater expectations: Adolescents’ positive motivations for sex.
Perspectives on Sexual and Reproductive Health, 38(2), 84-89; Darabi, L. (2009) Adolescent women's contraceptive use is less consistent than
that of adult women, with a much higher failure rate. Guttmacher Mediaworks @ http://www.guttmacher.org. July, 21, 2009; Guttmacher Institute.
(2010b). U.S. Teenage pregnancies, births, and abortions: National and state trends by race and ethnicity. New York: Author; Hamilton, B. E., Martin,
J. A., & Ventura, S. J. (2006). Births: Preliminary data for 2005. Hyattsville, MD: National Center for Health Statistics; Kerns, J., Westhoff, C.,
Morroni, C., etÂ€al. (2003). Partner influence on early discontinuation of the pill in a predominantly Hispanic population. Perspectives on Sexual and
Reproductive Health, 35(6), 256-260; Lindberg, L., Santelli, J. S., & Singh, S. (2006b). Provisions of contraceptive and related services by publicly
funded family planning clinics, 2003. Perspectives on Sexual and Reproductive Health, 38(3), 139-147; Manlove, J., Papillio, A., & Ikramullah, E.
(2004). Not yet: Programs to delay first sex among teens. Washington, DC: National Campaign to Prevent Teen Pregnancy; Martinez, G., Abma,
J., & Casey, C. (2010). Educating teenagers about sex in the United States. National Center for Health Statistics – Data Brief No 44; Santelli, J.,
Sandfort, T., & Orr, M. (2008). Transnational comparison of adolescent contraceptive use: What can we learn from these comparisons. Archives of
Pediatric Adolescent Medicine, 162(1), 92-94.
COMPARISON OF PREGNANCY-RELATED ISSUES Sweden

IN OTHER COUNTRIES (18-19)
Sexual activity among teenagers is commonplace in all devel-

oped countries (GI, 2001, 2006b). Although the levels of teenage France
sexual activity are similar, developed countries differ in the ways
they deal with sex education and sexually active teens. Experts
Canada
suggest that the methods used in the United States are not as
effective as those used in other developed countries, as evi-
Great
denced by significantly higher rates of teenage pregnancy, birth, Britain
and abortion in the United States (Abma etÂ€al., 2010; GI, 2006b). (16-19)
Pregnancy Rates in Selected Countries United

States
The United States leads most developed nations in the rate of
teenage pregnancy (Albert, 2010; GI, 2006b). A comparison of
eight countries indicates that the U.S. pregnancy rate is two or 0 20 40 60 80 100
more times higher than the rates in all other comparable coun- % of Women 15-19 Who Used a Method at Last Intercourse
tries, except the Russian Federation (FigureÂ€24-4). Long acting Pill Condom Other
Teenagers appear to run a greater risk for pregnancy at an
Other methods are grouped with condom
earlier age in the United States than in other countries (Santelli
etÂ€al., 2008). A comparison of the five industrialized coun- FIGUREÂ€24-5â•‡Contraceptive use in female adolescents aged
15 to 19â•›years: comparison of selected countries. (Note: Data
tries shows that in all of them, contraceptive services are more
are for the mid-1990s.) (From Darroch J. E., Frost, J. J., Singh, S.,
readily available and in greater use than in the United States etÂ€al. [2001]. Teenage sexual and reproductive behavior in developed
(FigureÂ€24-5). This disparity in availability and use can be countries: Can more progress be made? [Occasional Report No. 3].
explained partly by the different types of health insurance avail- NewÂ€York: Alan Guttmacher Institute.)
able in each country. The four other countries—France, Sweden,
the United Kingdom, and Canada—all have national health care
systems. In those countries, contraceptive services and supplies
are provided free or at reduced cost; contraceptives are adver-
tised in the media; and contraceptive methods are included in
Denmark the sex education programs provided to adolescents (GI, 2006b;
Santelli etÂ€al., 2008). In the United States, many teens and their
families lack health insurance coverage (see ChaptersÂ€4 and 21).
United
Kingdom Furthermore, birth control supplies are not advertised in print
or television media, and many sex education programs restrict
information to abstinence-only approaches (NCSL, 2011).
U.S.
Abortion Rates in Selected Countries
When teenagers become pregnant, many choose abortion, with
Germany
some variations seen among countries. As with pregnancy rates,
the abortion rate is higher in the United States than in four of
Italy the comparable countries (see FigureÂ€24-4). The abortion rate
in the Russian Federation is partly the result of poor access to
contraceptives due to cost. The abortion rate is very similar in
Czech the United States, Sweden, and the United Kingdom. In Sweden
Republic
and Denmark, the rate of abortion (as a chosen alternative)
among pregnant teenagers is higher than that among pregnant
Russian
Federation teenagers in the United States.
In all the comparison countries, access to abortion is less
problematic, and there is little or no controversy about abortion
Sweden
compared with the United States. Abortion is provided by gov-
ernment health services or funded by national health insurance.
0 20 40 60 80 100 In the United States, abortion might be covered under health
Rate per 1000 Women Aged 15-19 insurance for those whose families have insurance, but some
Birth Abortion
policies specifically deny coverage—for example, federal insur-
ance programs and some state Medicaid programs (GI, 2006b,
FIGUREÂ€24-4â•‡Pregnancy and abortion rates per 1000 adoles- 2011c). Abortion services are provided by separate providers,
cents aged 15 to 19â•›years: comparison of selected countries.
(Data from Sedgh, G., Henshaw, L., Singh, S., etÂ€al. [2009]. Legal
not the teen's or family's regular physician or health care prac-
abortion worldwide: Incidence and recent trends. International Family tice. Some states have made it more difficult for teens to have
Planning Perspectives, 33[3], September 2007. TableÂ€3; World Health abortions, requiring parental consent, judicial reviews, waiting
Organization. [2009]. World Health Statistics 2008. New York: Author.) periods, and mandatory counseling sessions (see ChapterÂ€6).
Advocacy groups are attempting to further restrict service either chronically Â�underemployed or working minimum-wage
availability through boycotting or protest campaigns and are jobs. Changes in the TANF and in medical relief programs such
attempting to secure the passage of state regulations or legisla- as Medicaid and Children's Health Insurance Program (CHIP),
tion that restricts clinic operations. These efforts have met with as well as the effects of economic retrenchment, have long-
some success. term impacts on social program recipients (NCFH, 2009; see
ChapterÂ€21). Most states have announced cutbacks to Medicaid
PUBLIC COSTS OF ADOLESCENT PREGNANCY and state CHIP medical assistance programs and the effects of
AND CHILDBEARING the federal budget crisis are yet to be felt.
Forcing mothers off TANF support and limiting or denying
Teenage pregnancy has both short- and long-term effects on the medical assistance might simply delay problems and increase
national economy. Public funds pay for a significant amount of public costs. When people do not have health insurance, they
the care and consequences associated with teenage pregnancy, delay seeking care. Consequently, when they do seek medical
and therefore, all taxpayers ultimately contribute to the costs care, their health problems are more serious, take longer to
associated with teenage pregnancy. treat, and cost more to treat (see ChapterÂ€21). The health status
It is difficult to determine the exact health costs of teenage and quality of life of both mothers and infants who are affected
pregnancy and adolescent motherhood, but an estimate is $9 by these program changes are important factors that demand
billion per year (MMWR, 2011a). The costs include medical serious monitoring in the next few years.
care for pregnant adolescents without private health insurance
and the higher costs of medical care for their infants, who are at CONSEQUENCES OF EARLY PREGNANCY
greater risk for medical complications and death. FORÂ€TEENAGERS AND INFANTS
Young mothers and their families impact social welfare pro-
grams in ways other than medical costs. The need of young To provide quality care for pregnant adolescents, the commu-
mothers to care for infants and children and their relatively low nity health nurse must understand the scope of the problem
educational levels limit their ability to obtain and hold jobs that and the needs, concerns, and health issues of pregnant teenag-
provide a living wage. As a result, adolescent mothers and their ers. There are economic, medical, and emotional consequences
dependent children are at greater risk for needing welfare proof pregnancy and childbearing for young mothers and their
grams and for remaining in these programs for longer periods children (Albert, 2010; NCPTP, 2010b). Teenage mothers and
than are other welfare applicants. Between 25% to 50% of all their infants are at greater risk for serious medical complica-
teenage mothers receive welfare assistance after the birth of their tions, low birth weight of infants, and poorer outcomes com-
child (Dye, 2008; NCPTP, 2010c). An estimated $23.6 billion in pared with older women and their infants (Martin etÂ€al., 2006;
services was provided in 2004 to families headed by females NCPTP, 2010b). Teenagers who become pregnant jeopardize
who were teens when they had their first child (Hoffman, 2006). their educational progress and endanger their future expecta-
That amount includes funds for Temporary Assistance to Needy tions (Hoffman, 2006; NCPTP, 2010a). Children born to ado-
Families (TANF); food stamps; Women, Infants, and Children lescent mothers are at greater risk for poverty. Family members
(WIC) program; social service block grants; foster care; and and significant others are also affected because they are called
adoption services (see the Ethics in Practice box). on to provide physical, emotional, and financial support while
Starting in 1997, limitations were placed on the amount of burdened with their own responsibilities. Almost 8 million chil-
time young mothers could receive public assistance and sub- dren live in grandparent-headed households, and 1.9 million of
sidized health benefits. The full impact of recent reforms in these children do not have a parent present in the home (U.S.
the welfare system at both the federal and state levels is not yet Census Bureau, 2011).
known. All able-bodied adults receiving TANF are expected
to look for work. Persons are limited to 2 consecutive years of Role in the Poverty Cycle
TANF benefits and a life-time maximum of 5â•›years. All states Families headed by young females have a greater chance of
make some exemption for mothers with very young babies or being poor compared with other families (Hoffman, 2006;
children, but each state's definition of “very young” is different. NCPTP, 2010b). The child of a teenage mother who did not
For example, Oregon applies the term “very young” to children get a high school diploma or GED has a nine times greater
younger than 3â•›months of age, Texas to children younger than risk of growing up in poverty compared with a child whose
4â•›years of age. mother delayed having children until she was older (NCPTP,
Because of the time limits, the impact of the 1997 changes 2010c). More than 30% of single women with children live in
is just now starting to become apparent. What is known is that poverty (U.S. Census Bureau, 2010). Poverty is accompanied
families are moving off “welfare” programs. The preliminary by many quality-of-life problems for teenage mothers and their
data indicate that while some families have improved their children, including an increase in health problems and limited
economic situations, many of these families have not made access to health care services (see ChapterÂ€21). Teenage preg-
a successful entry to new jobs and financial independence nancy is viewed as the hub of the poverty cycle in the United
(Congressional Budget Office, 2007; Government Accounting States because teenage mothers are likely to rear children who
Office [GAO], 2010a) (see ChaptersÂ€4 and 21). The National repeat the cycle (Abma etÂ€al., 2010; Elfenbein & Felice, 2003;
Center on Family Homelessness (NCFH, 2009) reported that Hoffman, 2006).
the number of families using homeless services has increased.
Some families are homeless and receiving TANF benefits. Educational and Economic Consequences
However, many more no longer qualify for TANF and are less Pregnancy affects educational achievement. Only 66% of women
well off. These families are without health insurance and are who become mothers in adolescence complete high school
Â�
compared with 94% of women who delay childbirth until age 20 mothers is only half that of women who delay childbearing
to 21 (Perper etÂ€al., 2010). Many teenagers who became pregnant until after 25â•›years of age.
were not doing well in school and had dropped out even before
they became pregnant. Shearer and colleagues (2002) compared Less Prenatal Care
adolescent females’ test scores and found that teens with lower A third of pregnant teens receive inadequate prenatal care
cognitive scores initiate sex earlier and have a higher rate of preg- (Chen etÂ€al., 2007). Many pregnant teenagers delay seeking pre-
nancy compared with girls with higher test scores. Others drop natal care or do not receive regular care. Although the number
out of school because of the demands of pregnancy and child of young women who receive first-trimester care has increased
rearing. The younger the teenager at the time of pregnancy, the over the past 10â•›years, more than 33% have had no prenatal care
greater is the danger that she will not complete high school. Teen at the end of their first trimester (NCPTP, 2010b; Philliber etÂ€al.,
mothers are also less likely to attend college. Only 2% of women 2003). The same teenagers at greatest risk for pregnancy—those
who become pregnant before 18â•›years of age go on to college from poor families—are also at greatest risk for poor prenatal
(Hoffman, 2006). care. In general, this group tends to be more oriented to treat-
It is important for the community health nurse and oth- ment rather than prevention of illness in its health practices (see
ers involved with pregnant teens to encourage the girls to ChapterÂ€4). Delays in seeking prenatal care might also be influ-
remain in school, if possible. Lack of education hampers the enced by denial of the pregnancy and an orientation toward
mother's prospects in the job market. The income of young concrete, present-centered reasoning.
ETHICS IN PRACTICE
Distributing Community Resources Fairly Gail A. DeLuca Havens, PhD, APRN, BC
“It seems like coercion to me,” says Eileen. “Like we are being vindic- The problem appears to be just distribution of resources. The commu-
tive and punishing a teenager for getting pregnant and electing to carry nity has a finite budget allocated for multiple social services that serve
the baby to term. Teenagers are babies themselves in many respects. many different populations. It is being argued that a disproportionate
This doesn't solve the problem; it hides it so the community doesn't amount of the community's social services budget is being spent on
have to confront the underlying reasons for the high incidence of teen- aid to the dependent children of teenage mothers. A plan intended
age pregnancy that prevails here. This proposed regulation is nothing to ensure a more equitable distribution of social service resources
more than a cop-out.” across the community's populations has been proposed as a solution.
Cynthia disagrees. “In this day and age, getting pregnant is a choice. Theoretically, limiting the number of people covered by the TANF pro-
If a teenager with no means of financial support chooses to get preg- gram ought to make a greater percentage of the city's budget available
nant, especially when she already has one child, then she should for other social services programs targeted at underserved populations.
expect to have to decide whether she wishes to practice birth control The plan's defenders believe that although the solution does not
in the future or have the aid for her dependents decreased if she has include all the choices to which a teenage mother might be accus-
additional children. We can't afford to keep supporting all these young tomed, it does offer reasonable options considering the overall needs
mothers and their babies in this city, particularly when so many of our of the community. Detractors of the plan argue that it violates the
other health and social services are significantly underfunded. Consider autonomy of teenage mothers in the community because it coerces
the dollars we spend per capita on programs for the learning disabled them into not becoming pregnant to have the means they need to care
in our city, for example. Or the percentage of the city's budget allocated for the children they presently have. Coercion has been characterized
to programs for older adults. Both are significantly underfunded in com- as an extreme form of influence that entirely compromises one's auton-
parison to the dollars spent for similar programs in cities of comparable omy (Beauchamp & Childress, 2009).
size throughout the state.” If the proposal is adopted, it would be a step toward a more equitable
On the way home, Eileen and Cynthia continue the debate over the distribution of resources, and thus if the planning has been accurate, it
Department of Social Services’ proposed regulation requiring that ought to have some short- and long-term effects on the social services
females in the community younger than 18â•›years of age who are receiv- programs for the community. A plan such as this is grounded in the ethi-
ing benefits under Temporary Assistance to Needy Families (TANF) cal theory of utilitarianism, which seeks to maximize the positive con-
must show evidence of practicing birth control to continue the aid. The sequences of an action by achieving the greatest good for the greatest
proposal includes provision of free birth control counseling and prod- number (Beauchamp & Childress, 2009). Services in need of resources
ucts as well. Eileen and Cynthia are both community health clinical ought to be targeted, monitored, and measured to see if they benefit.
nurses employed by the community. Eileen practices in the Pediatric Adopting the proposal has the potential to jeopardize the health and
Service and Cynthia in the Council on Aging's Geriatric Intervention well-being of a population of children already at risk, namely, the chil-
Program. They have just attended the last of the public hearings spon- dren of teenage mothers.
sored by a joint task force created by the Departments of Health and If teenage females continue to have children, their ability to care for
Social Services and the school board to hear opinions from members of those children already dependent on them will be diminished because
the health care professions and the community at large regarding the of a lack of resources. The short-term consequences might be a rising
proposal, which is intended to address the problem of teenage preg- incidence of children who fail to thrive, are afflicted by disease, or are
nancy in the community. Now the task force will deliberate on the issue disabled by developmental and psychological problems. The long-term
and make recommendations to the departments and the board. If you consequences might be a generation of children who would overbur-
were a member of the task force, how would you go about the decision- den the community's social services. Such an action would contradict
making process? What would be your decision? Why? the ethical principle of nonmaleficence (i.e., avoiding harm), contained
Continued
Distributing Community Resources Fairly
in the Code of Ethics for Nurses (American Nurses Association, 2001). Outcomes directly attributable to school-based clinics include improve-
In addition, it would go against the value of promoting autonomy and ments in students’ health, lowered birth rates, increased use of contra-
self-determination through the achievement of health and well-being, ceptives, and improvements in school attendance (Santelli etÂ€al., 2006).
as expressed by the code.
Not adopting the proposal is an alternative. However, this changes References
nothing for the community and for its teenage mothers. Another alterna- American Nurses Association. (2001). Code of ethics for nurses with
tive attempts to address the issue of teenage pregnancy in the commu- interpretive statements. Washington, DC: Author.
nity by seeking ways to discover the underlying causes of the increased Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical eth-
incidence of teenage pregnancy. One strategy that has been success- ics (6th ed.). New York: Oxford University Press.
fully introduced in a growing number of communities is school-based Santelli, J. S., Morrow, B., Anderson, J. E., etÂ€al. (2006). Contraceptive
clinics. Decreased fertility rates, decreased pregnancy rates, and later use and pregnancy risk among U.S. high school students, 1991-2003.
sexual activity are evidence of the success of school-based clinics. Perspectives on Sexual and Reproductive Health, 38â•›(2), 106-111.
Substance Use and Exposure to Violence Consequences for the Newborn and Child
Pregnant adolescents are more likely to smoke than pregnant Infants born to teenagers are also at risk. Stillbirths are twice
women over the age of 20â•›years (ACOG, 2009). Alcohol con- as common among teens, and the mortality rate is two to four
sumption is also a concern. About 50% of all pregnant teens times higher during the first year of life for infants born to ado-
drink during their pregnancy (Wiemann & Berenson, 1998). lescents (Phipps etÂ€al., 2002; WHO, 2011). The highest risk is for
Teens who continue to drink alcohol are also more likely to use infants born to mothers 15â•›years of age or younger (Mathews &
illegal drugs. Some teens use multiple substances. Approximately MacDorman, 2008). Babies born to young mothers are at greater
63% of pregnant teens admitted to substance abuse treatment risk for health problems and hospitalization during childhood than
reported using two or more substances (Substance Abuse and babies born to older mothers (ACOG, 2007; Guevara etÂ€al., 2001).
Mental Health Services Administration, 2010). Teen mothers are more likely to have babies born with certain con-
Pregnancy increases the risk for physical abuse by a woman's genital anomalies such as anencephalus, spina bifida/meningo-
partner (see ChapterÂ€23). Pregnant teens appear to be at greater cele, hydrocephalus, microcephalus, and gastrointestinal anomalies
risk than most pregnant women. Research suggests that the risk (Martin etÂ€al., 2003). Child abuse and neglect are more common
of being murdered is three times higher for pregnant teens than among young mothers, perhaps because young mothers have mul-
for other teens (Chang etÂ€al., 2005; Krulewitch etÂ€al., 2003). tiple factors associated with risk for abuse (ACOG, 2009; Hoffman,
2006). Reducing the rate of teen pregnancy and therefore the cost
Physical Consequences for the Mother of care for abused or neglected children of teen mothers would
During adolescence, rapid growth patterns place considerable lower welfare costs by about $3.6 billion per year (Hoffman, 2006).
demands on the body. Pregnancy places additional demands. Some studies suggested that infants of adolescent mothers
In general, adolescents experience greater health problems with are at risk for a lower level of cognitive development, a prob-
pregnancy than do women older than 20â•›years of age (Scarr, lem usually attributed to the mother's single-parent status and
2002). The consequences are especially severe for the youngest low educational achievement (ACOG, 2009). Educational defi-
adolescents, those 12 to 15â•›years of age; older teenagers are not cits persist with time. Therefore, children born to teen moth-
as likely to experience serious difficulties. ers do not perform as well in school as children born to older
Teenagers are at greater risk for developing pregnancy-induced mothers (Hoffman, 2006; NCPTP, 2010a). These children are
hypertension and toxemia (ACOG, 2009; Martin etÂ€al., 2003). more likely to be placed in special education programs and have
The incidence of hypertension ranges from 10% to 35%, which higher rates of milder educational problems as well.
is higher than in any other age group except women over the age Low birth weight (birth weight under 5.5â•›lb [2500â•›g]) is asso-
of 40â•›years. Teenagers are also at increased risk for anemia, nutri- ciated with higher rates of infant mortality, birth injuries, neu-
tional deficiencies, poor weight gain, and urinary tract infections rological defects, and mental retardation (Martin etÂ€al., 2007;
(Koniak-Griffin & Turner-Pluta, 2001; Treffers etÂ€al., 2001). Studies NCPTP, 2003). Prematurity is a significant risk in teen births;
indicate that 10% to 40% of pregnant teens are anemic, a condi- the rate of premature births is higher for adolescents than for
tion exacerbated by the poor nutritional status of most teenagers women 20 to 24â•›years of age. In 2006, 10% of infants born to
(World Health Organization [WHO], 2011). Young girls are more mother 15 to 19â•›years of age were of low birth weight, compared
likely to deliver prematurely, undergo rapid or prolonged labor, with 8.3% of infants born to all mothers aged 25 to 29â•›years
experience eclampsia, and develop infections. Fetal infections and (Martin etÂ€al., 2009). Birth weights increase with the age of the
the presence of moderate to heavy meconium at delivery are also mother, but all teenagers are at greater risk for having low-birth-
more common in this age group (Martin etÂ€al., 2003; Scarr, 2002). weight infants than are those in other age groups.
Although some early studies suggested that teenagers are more There are also long-term consequences for children born to
likely to have cesarean section deliveries, current research shows teen mothers. These children are less likely to complete high
little difference in cesarean rates for 15-year-olds and 30-year-olds school, and partly as a result of their lower educational levels,
(ACOG, 2009; Martin etÂ€al., 2003). Effective, consistent prenatal they earn less over their lifetimes (Maynard & Hoffman, 2007).
care reduces the risk for complications. The estimated total wages lost for children born to teen mothers
in 2004 was $5.53 billion (Hoffman, 2006). This also translates Siblings and other family members can become resentful.
into a corresponding shortfall to the government in lost taxes Siblings might feel they have to compete for attention. When
because of lower wages. the infant arrives, both siblings and other household members
Daughters born to teen mothers are more likely to repeat the might have less privacy and might be forced to share sleep-
cycle of early pregnancy and childbirth. Approximately one- ing space to accommodate the new arrival. Sometimes, the
third of the daughters of teen mothers have a first child as a teen extended family shares or assumes the economic costs of caring
compared with only 11% of teens whose mothers postponed for the pregnant teenager and her child.
pregnancy until their twenties (Hoffman & Scher, 2007).
The sons of teen mothers are 2.2 times more likely to be Fathers of Babies Born to Adolescent Mothers
incarcerated than the sons of mothers who delay pregnancy Most pregnancies in adolescent girls are the result of relation-
until later. Hoffman (2006) estimated that the public sector cost ships with young adult males (20-plus years) rather than teen-
of confinement would drop by $5.3 billion per year if the sons age males. Only 1.9% of males 19â•›years of age or younger have
of teen mothers had an incarceration rate similar to that of the a child, whereas 7.8% of females the same age have a child
sons of older mothers. (Martinez etÂ€al., 2006). This means that men over age 19â•›years
are responsible for most births to teen mothers. Fifty-three
Psychosocial Consequences percent of men aged 20 to 24â•›years report that their female
Pregnancy can be a crisis that disrupts the adolescent's transition partner is younger, and 58% of men aged 25 to 29â•›years report
to independence. The pregnant teenager is abruptly thrust into the having younger female partners. In fact, 33% of men aged 25
responsibilities of adulthood. She must learn to function as a par- to 29â•›years have female partners who are either 3 to 6â•›years
ent while struggling to solidify her own identity, which is a daunt- younger or 7 or more years younger (Martinez etÂ€al., 2006). A
ing task. Social isolation is possible because she and her friends study of California teen mothers found that the fathers of their
may no longer have the same interests and because she is less likely babies were, on an average, 3½â•›years older than the mothers
to attend school (Grady & Bloom, 2004). Only 4 of 10 teen moth- (Frost & Oslake, 1999). This suggests that interventions aimed
ers complete high school (Hoffman, 2006). If the pregnant teen's at fathers need to target a wider audience of males than cur-
family is not supportive, there might be additional stress. Many rent programs do. When available, intervention programs are
report feeling depressed. Stress and isolation increase after deliv- aimed primarily at adolescent fathers.
ery, when the adolescent must cope with demands of the infant Teenage fathers, like teenage mothers, have monetary and
and interactions with peers become even more limited (Holub educational problems. Although more teenage fathers than
etÂ€al., 2007). Stress can lead to child abuse, neglect, or suicide mothers complete high school, almost 50% drop out, which
attempts (Frost & Oslake, 1999; Hoffman, 2006; Olds etÂ€al., 1999;). leaves them vulnerable to the same economic difficulties as
teenage mothers (Martinez etÂ€al., 2006).
Reba Jackson is 15â•›years old and a new mom. She tells her Teen fathers who do not graduate from high school usu-
clinic nurse, Sally Arnold, that she has not been seeing her ally have lower paying jobs than teens and young men who
friends as much. Reba complains, “When they talk about the delay parenthood (ACOG, 2010; NCPTP, 2002). Hoffman
weekend's great party, I get mad and sad.” She feels out of (2006) estimated the cost to the public sector as $3.1 billion
place because her mother makes her stay home to care for per year in lost taxes as a result of those lower paying jobs
her new baby. “Don't get me wrong, I love Sam with all my among young fathers.
heart, but I feel so sad when I hear my friends talk about There is a renewed interest in fathers and the role fathers
where they are going on spring break.” Reba reports that she play in child rearing. Because most fathers of babies born
is also worried about keeping her grades up and about what to teen mothers are young, they are less able psychologi-
she would do if she had to move out of her mother's house. cally and financially to contribute much to their children's
upbringing (Elfenbein & Felice, 2003). Before delivery,
Effects of Pregnancy on Family Dynamics most unwed fathers plan to contribute financially to the
Pregnancy affects both the teenager and the members of her support of the mother and the child, but only a few follow
family. Pregnancy represents added economic and emotional through.
pressure and often is a burden which the family is not equipped Fathers generally are available to the pregnant teenager
to deal with. In some cases, grandparents become the infant's before delivery, but their relationship with the mother and
primary caregiver. Because of this, their usual pattern or routine infant weakens over time. Studies indicate that most are still
might be drastically changed. involved at delivery. Fathers of young babies see their infants
regularly (daily or weekly) (Gavin etÂ€al., 2002; Rhein etÂ€al.,
1997). By the time the child is 5â•›years old, however, only a
Reba Jackson's mother, Tania, is feeling stressed by the
handful of fathers have regular contact with their child, and
demands of the new baby in the house. She tells Sally Arnold,
absent teen fathers pay less than $800 per year in child sup-
the nurse who is making a home visit, “My husband and I
port (NCPTP, 2002). Most teen fathers (80%) do not marry
worked all our lives so that we could travel in our retirement.
the mothers of their children (Kaye et al., 2009).
Instead, we are taking care of our grandson while my daugh-
The health care system has devoted most of its attention
ter finishes high school. We were lucky; our health insurance
to caring for the adolescent mother, and the adolescent or
policy paid for some of Reba's expenses, but we have had to
young adult father has been largely ignored. Much work
pay for some. Our savings are slowly sinking, and I'm look-
needs to be done to address adolescent male health, sexuality,
ing at working for another 10â•›years, if my health holds up.”
and responsible sexual behavior, and the father's role in
teenage pregnancy (NCPTP, 2006). The following initiatives and other medical services. Two states, Texas and Utah, passed
appear promising: legislation that limits a minor's access to birth control and STD
• Primary prevention stressing male responsibilities in birth treatment by refusing to pay for these services with state funds
control if the minor does not have parental consent (Jones & Boonstra,
• Secondary prevention geared toward increasing the young 2005). Services provided with federal funds are not limited in
fathers’ role in pregnancy and child care this fashion.
• Tertiary prevention directed at improving parenting skills
and supporting lifestyle changes (e.g., education, job train- Restrictions on Abortion Consent
ing) that increase the possibility of financial stability and Access to abortion services is treated differently than access to
independence. other reproductive health care. This is an area of Â�continued
and ongoing legislative effort. Currently, parental Â�involvement
LEGAL ISSUES AND TEEN ACCESS TO in abortion decisions is mandated by 36 states (GI, 2011c).
REPRODUCTIVE HEALTH SERVICES Some states require parental notification, and others require
parental consent. All states with parental consent laws are
With respect to the right to privacy and confidentiality, there required by a Supreme Court decision to have some type of
are conflicting laws affecting minors. The Supreme Court has judicial bypass mechanism. Adolescents who are fearful of
acknowledged a minor's right to privacy, including privacy in obtaining or unable to obtain parental consent may seek a
medical service needs. Nevertheless, a minor's access to repro- judicial review and bypass parental consent, if they show ade-
ductive health services is limited. Consent for medical care is quate reasons.
governed primarily by state laws. Most states allow adolescents
to obtain reproductive health services such as contraceptive Legal Ambiguity Prevails
services, treatment for STDs, and pregnancy testing without Plan B (Levonorgestrel, the medication to prevent conception)
parental consent. Many states have passed explicit laws that is currently approved for over-the-counter emergency con-
allow access to certain medical services (BoxÂ€24-2). Some states traceptive use in the United States. However, access to Plan B
restrict the types of health care that minors may receive with- without a prescription is restricted to adults 17â•›years or older,
out parental authorization. For example, treatment for STDs is who must provide proof of age to buy the medication. Plan B
allowed, but contraceptive services require parental approval. remains a prescription-only drug for girls age 16 and younger
(GI, 2009).
Exceptions to Parental Consent Requirements Many states allow adolescents to make certain life decisions,
Certain minors are considered legally “mature” for the pur- for example, leaving school or marrying, at a younger age than
pose of making decisions, including obtaining medical ser- they can independently make certain medical decisions. In 38
vices. States define these adolescents as “emancipated.” Married states and the District of Columbia, a minor may place her
minors, members of the armed forces, and teens who live apart child for adoption without parental consent (GI, 2011d). Thirty
from their parents are most often considered legally mature by states allow adolescent parents to consent to medical treatment
state standards (see ChapterÂ€6). for their child while still restricting their ability to consent to
medical services for themselves. It is important for community
State and Federal Efforts at Influencing Consent Laws health nurses to be familiar with the laws in their states concern-
There have been efforts at both the state and federal levels to ing adolescent health services and to be aware of any restrictions
create legislation requiring parental consent for contraceptive that would necessitate parental approval.
NURSING ROLE IN ADDRESSING TEENAGE

BOXÂ€24-2â•…â•‡STATE LAWS GOVERNING SEXUAL ACTIVITY AND PREGNANCY
ADOLESCENT ACCESS TO Community health nurses providing care to sexually active and
REPRODUCTIVE SERVICES pregnant teenagers should use a balanced approach. A compre-
• Adolescents may obtain contraceptive services in 46 states and the hensive intervention program should address all prevention lev-
District of Columbia (some restrictions may apply). els: primary, secondary, and tertiary. A strategy that encourages
• Pregnant adolescents may obtain prenatal care and delivery ser- abstinence, delayed initiation of sexual activity, and responsible
vices in 32 states and the District of Columbia. contraception for those who choose to be sexually active is part
• Teens may seek diagnosis and treatment of sexually transmitted of a comprehensive approach to primary prevention. Primary
diseases in all 50 states and the District of Columbia. prevention is a crucial component of any intervention program.
• Abortion services: If young girls become pregnant, however, it is imperative that
• 36 states have some type of parental consent or parental notifi- they receive adequate prenatal care coupled with long-term
cation requirement. postpartum follow-up to ensure a healthy outcome for both the
• 23 states require parental consent; 4 of these require consent of mothers and their children.
both parents. Community health nurses, because of their expertise in
• 11 states require parental notification. assessment, health teaching, and program development, are
• Most states that require parental involvement make exceptions well suited to this task. Their accessibility to adolescent popula-
for medical emergencies and teens who have been abused. tions places them in a pivotal position to play a significant role
Adapted from Guttmacher Institute. (2011). Selected fact sheets. in the delivery of care before initiation of sexual activity, dur-
Retrieved July 13, 2011 from http://www.guttmacher.org. ing contraceptive use, during pregnancy, and during long-term
follow-up with the parents and child. Community Resources for BOXÂ€24-3â•…â•‡CHARACTERISTICS OF
Practice at the end of this chapter can help nurses plan and pro- EFFECTIVE SEX AND HIV
vide care for all three prevention levels.
EDUCATION PROGRAMS
PRIMARY PREVENTION • Focus on reducing one or more sexual behaviors that lead to unin-
tended pregnancy, human immunodeficiency virus (HIV) infection,
It is apparent that pregnancy during the teen years presents or sexually transmitted diseases (STDs)
some unique risks and special needs for the teen, her pregnancy, • Are based on theoretic approaches that have been demonstrated to
and her infant. The best choice for most young girls is to delay influence other health-related behavior and identify specific impor-
pregnancy until they are physically and emotionally mature. tant sexual antecedents to be targeted
Primary prevention has three focuses: • Deliver and consistently reinforce a clear message about abstain-
1. To delay or stop participation in sexual activity ing from sexual activity and/or using condoms or other forms of
2. To provide access to contraceptives contraception*
• Provide basic, accurate information about the risks of teen sexual
3. To strengthen future life goals
activity and about ways to avoid intercourse or use methods of pro-
Most experts believe that a comprehensive primary preven-
tection against pregnancy and STDs
tion program should include sex education, family life educa-
• Include activities that address social pressures that influence sex-
tion, family planning, and some form of life-planning program ual behavior
that stresses identification of future goals and steps to those • Provide examples of and practice with communication, negotiation,
goals (Boonstra, 2009; Lindberg et al., 2006a). An effective sex and refusal skills
education program encourages self-esteem and responsible • Employ teaching methods designed to involve participants and
decision making in addition to containing specific information have them personalize the information
on sexual matters. Most of the available primary prevention • Incorporate behavioral goals, teaching methods, and materials that
programs address one or two but not all aspects of a compre- are appropriate to the age, sexual experience, and culture of the
hensive program. students
• Last a sufficient length of time (i.e., more than a few hours)
Educational Programs • Select teachers or peer leaders who believe in the program and
Most educational efforts are school based. Sex education is pro- then provide them with adequate training
vided by some private schools and by public schools in approxi-
*Appears to be one of the most important characteristics
mately 65% of the states (GI, 2011e). Only 20 states and the distinguishing effective from ineffective programs.
District of Columbia require sex education in public schools. From Kirby, D. (2007). Emerging answers: Research findings on
Many programs are limited in the content they may present. For programs to reduce teen pregnancy and sexually transmitted diseases.
example, 33 states and the District of Columbia require educa- Washington, DC: National Campaign to Prevent Teen and Unplanned
tion about STDs and HIV infection, but 28 states require that Pregnancy; and Manlove, J., Papillio, A., & Ikramullah, E. (2004).
Not yet: Programs to delay first sex among teens. Washington, DC:
the content on abstinence be stressed, if sex education is pro-
National Campaign to Prevent Teen Pregnancy.
vided, and 10 states mandate that the topic of abstinence be cov-
ered (GI, 2011e). Only 18 states and the District of Columbia
mandate that education about STDs and HIV require programs received instruction based on the abstinence-only approach,
to include contraceptive education. excluding birth control information (GI, 2011b). Because there
In 37 states and the District of Columbia parental involve- is dissention on the appropriateness of sex education in schools,
ment is required in education about sex and HIV. All but two school districts are reluctant to improve or add to existing con-
of those states allow parents the option not to enroll their chil- tent because it might generate renewed public interest and
dren in sex education. A typical sex education effort consists opposition. Teachers feel constrained by community opposi-
of fewer than 10 class periods scattered throughout a student's tion, and some stick to a prepared script rather than risk discus-
12â•›years of education. Only 1 in 10 programs is a comprehensive sion and exploration of sexual topics.
sexuality education program (USDHHS, 1995). The National Most of the public appears to support sex education with
Campaign to Prevent Teen Pregnancy has identified 10 charac- content aimed at reducing teenage pregnancies (Albert, 2010;
teristics of effective sexual education programs (BoxÂ€24-3). Bleakley etÂ€al., 2006). About 9% of parents surveyed support
the abstinence-only programs. The remainder feel either that
Sex and Contraception Content abstinence should be included in a comprehensive approach or
Sex education contains, at the very least, information about the that abstinence is not an important element of a sex education
anatomy and physiology of reproduction in males and females. program (Albert, 2010).
Beyond this narrow focus, there is little agreement and much The best way to reduce concern and increase community
controversy about appropriate content for sex education classes. support of sex education is to expand the content to address
Some programs include information on sexual orientation, community concerns, whenever possible. Although a compre-
STDs, and contraception. These topics are the most contentious hensive sex education curriculum cannot ignore contraceptive
and engender public debate and opposition by parents or com- information, there are legitimate issues related to abstinence,
munity groups. When faced with protest, school districts are the advantages of delayed sexual activity, and the medical risks
reluctant to go against parental wishes. Of states with sex educa- of teenage sexual conduct (e.g., exposure to STDs) that should
tion content, only 50% require the inclusion of pregnancy pre- be addressed. A program that provides such an approach is
vention content (GI, 2011e). Approximately 60% of teens have comprehensive and has the additional advantage of increasing
received formal education about birth control, and 25% have community support.
Abstinence-Only Curriculum sexual activity in teens, reduce the frequency of sex, reduce
Abstinence-only programs, sexual education programs the frequency of unprotected sexual activity and increase the
that teach abstinence as the only option for the unmarried use of contraceptives among sexually active teens, reduce the
and adolescents, have the support of an active minority of teen pregnancy rate, and lower the number of sex partners
Americans. Abstinence-only programs had received empha- (Bleakley etÂ€al., 2006; GI, 2006c ; Kirby, 2007). Several such
sis in federally funded projects during the Bush presidency. successful programs are listed in BoxÂ€24-4, which also gives
Federally funded abstinence programs do not allow mention some examples of other innovative primary and tertiary pre-
of contraceptives except to cite their failure rates (Bleakley vention efforts.
etÂ€al., 2006).
The federal government funded abstinence-only programs Family Life Programs
at the level of $176 million for 2006 (GI, 2006c). To qualify Family life programs offer information on family systems
for grant money, education programs had to meet eight des- and the interactions and influences among family members.
ignated criteria, including teaching that sexual activity out- Topics include marriage, divorce, separation, and birth. Most
side of marriage is likely to have harmful psychological and family life programs are offered at the junior or senior high
physical effects (GI, 2002a). Several studies (Boonstra, 2010; school level as an elective course, which means that they do
Santelli etÂ€al., 2008; U.S. House of Representatives, 2004) have not reach many teenagers and cannot target those at great-
found errors in abstinence education programs, including the est risk. Family life programs use a variety of teaching tech-
following: niques, including simulation and game playing, that help
• False claims about the physical and psychological risks of concrete thinkers consider the rigors as well as the delights
abortion of parenting. One popular technique requires students to
• Misinformation on the incidence and transmission of STDs assume full-time personal responsibility for the welfare of a
• Religious and moral views in place of scientific facts baby simulator or raw egg for 1â•›week. Students must ensure
• Distorted medical evidence and basic scientific facts that the baby substitute is always in the presence of a respon-
There is little evidence to suggest that abstinence-only pro- sible person and comes to no harm. They are then graded on
grams are successful in curtailing sexual activity before mar- how well they accomplish this task.
riage or in reducing STDs or pregnancy among adolescents
(Bleakley etÂ€al., 2006; Boonstra, 2010; GI, 2006c; Kirby, 2007). Role of the Nurse in Education
Health care and educational professionals have asked for strin- In some school systems with school nurses, the nurse is involved
gent review of abstinence-only programs and comparison of in both sex education and family life education. If family life
their results with those of other types of sex education pro- courses are not available in the school system or are not reach-
grams. The Minnesota Department of Health evaluated an ing at-risk teenagers, nurses might consider implementing
abstinence-only program and reported that there was an such a program with their community agency's support or in
increase in the rate at which teens engaged in sexual activity conjunction with other community organizations such as the
1â•›year after they attended the program (“Can abstinence pro- Young Men's Christian Association (YMCA) or Young Women's
grams lead to more sex?”, 2004). In response to public concern, Christian Association (YWCA).
the USDHHS conducted a study of abstinence-only programs Community health nurses can provide factual sex education
and released the results in April 2007. That study followed to teenagers in class as they provide other health care services.
teens for 4 to 6â•›years after receiving abstinence-only education Most sex education teachers have little training in sex educa-
and found that those teens engaged in sexual activity, initiated tion. Many have asked for additional training in how to edu-
sexual activity, had the same number of sexual partners, and cate students about pregnancy, HIV infection, and other STDs
engaged in unprotected sex as often as teens who received other (GI, 2002a). Nurses make effective sex educators because they
types of sex education. are equipped to provide sexual content in a factual and nonsen-
Studies of adolescent virginity pledgers (teens who comÂ� sational approach. They are also proficient at encouraging and
mitted to delay sexual activity until marriage) found that these guiding client discussion, characteristics helpful in addressing
teens are just as likely to have sex as those who did not pledge, sex education with teenagers.
had lower use of condoms at the time of first sexual activity,
and were less likely to seek care for STDs (Bruckner & Bearman, Screening for Risk Behaviors
2003, 2005; Rosenbaum, 2009). Virginity pledgers had the same Adolescents who use health care services should be screened for
rates of STDs as other teens and substituted anal or oral sex for potential risky behaviors (ACOG, 2009). Areas to assess include
sexual intercourse at higher rates compared with other teens. sexual activity, symptoms of HIV infection and other STDs, and
knowledge and use of barrier protection if sexually active. In
Comprehensive Sex Education—Most Effective one study, health care providers missed opportunities to coun-
Data indicate that programs that provide a comprehensive sex sel students on sexual health behaviors on more than 50% of the
education (discussion of abstinence, contraception, STDs) visits monitored during the study (Burnstein etÂ€al., 2003). The
with a more balanced approach are more successful and do CDC (2010) found that less than half of those who should be
not encourage sexual activity (Boonstra, 2010; GI, 2006c; screened are screened for STDs.
Kirby, 2007). Sex education teachers who teach the effective-
ness of contraceptives in their programs are more likely to Adolescent Counseling
include information about preventing unintended pregnan- The aim of counseling and education for teens should be
cies and STDs and the correct use of birth control methods. to delay the start of sexual activity and to provide accurate
Comprehensive sex education programs delay the onset of information to reduce the risk of STDs and pregnancy for
BOXÂ€24-4â•…â•‡SELECTED EXAMPLES OF PREVENTION PROGRAMS

PRIMARY PREVENTION Â�
outcomes, lower repeat pregnancy risk, improve parenting skills, and
Teen incentives program. A pregnancy prevention program using skill support educational programs for young mothers (Ford etÂ€al., 2002;
development to promote healthy behaviors and improve self-percep- Harris & Franklin, 2003).
tion and decision-making behaviors, especially regarding sexual activity
and pregnancy prevention. It showed statistically significant results in COMPREHENSIVE PROGRAMS
decreasing sexual activity and increasing contraceptive use (Smith, 1994). Safer choices intervention program. A comprehensive school-
Becoming a Responsible Teen (BART). A community-based pro- based program developed with teacher, parent, child, and community
gram aimed at prevention of human immunodeficiency virus infec- input. The program included use of peer educators, curriculum and staff
tion/acquired immunodeficiency syndrome (HIV/AIDS), which includes development activities, and school and community links for activities
information about pregnancy prevention and abstinence. The program and services (Coyle etÂ€al., 1996). It was implemented in California and
emphasizes decision-making skills and communication regarding sexual Texas high schools. Teens in the program were 43% less likely to initiate
behavior. In a 1-year follow-up, participants had lower levels of sexual sexual intercourse than teens who did not participate in the program.
activity and were more likely to use condoms if sexually active than Sexually active teens in the program were more likely to use contracep-
teens not in the program (Kirby, 2007; Manlove etÂ€al., 2004). tives than other teens during a 3-year follow-up (Manlove etÂ€al., 2004).
School-based clinics contraceptive services—Minneapolis. A California's Adolescent Sibling Pregnancy Prevention
program that includes both school-based contraceptive services and a Program. A program targeting high-risk teens who have siblings who
voucher system to provide students with contraceptives. The vouchers were adolescent parents (male or female). It provides comprehensive
are given at school for community clinics. At schools, the program found services, including case management, academic guidance, promotion of
there was a similar demand for contraceptives, but the on-site programs decision-making skills, job placement, self-esteem enhancement, con-
increased access and use of contraceptives (Sidebottom etÂ€al., 2003). traceptive services, and sex education. The results are promising: preg-
SIHLE: Sistas, Informing, Healing, Living. This program was nancy rates are lower, there is delay in initiating or abstinence from
designed for young African American teens and implemented in health sexual activity, contraceptive use is higher, and school truancy is lower
clinics. It focused on preventing STDs and did so but was found to than in a comparable peer group (East etÂ€al., 2003).
reduce the number of sex partners, increase condom use, and reduce Children's Aid Society–Carrera Program. An intensive long-term
unprotected sex and pregnancy rates. (Kirby, 2007). after-school program for high-risk students in New York City that empha-
sizes planning for the future. Students stay in the program throughout
SECONDARY PREVENTION high school. Components include employment and academic assistance,
Teenage mothers–grandmothers program. A program for teens and family life and sex education, performing arts participation, sports train-
their mothers that includes group meetings and counseling about paring, physical health, mentoring, and ongoing counseling. Females in the
enting and other concerns of participants. Teens whose mothers partici- program were less likely to have sexual intercourse or become pregnant
pated were less likely to drop out of school and had better self-esteem and two times more likely to use two types of contraceptives than were
than those whose mothers did not participate (Roye & Balk, 1996). control teens. Males in the program were more likely to use two types
Prepregnancy and postpregnancy intervention programs. of contraceptives than were control teens. The program is expanding to
Programs developed for adolescent teens and those who have already Nebraska, Florida, New York State, New Mexico, and Baltimore, MD
given birth. Programs provide education to improve child health (Philliber etÂ€al., 2001; Philliber etÂ€al., 2003).
Data from Barnett, J. E., & Hurst, C. S. (2003). Abstinence education for rural youth: An evaluation of the Life's Walk Program. Journal of School
Health, 73(7), 264-268; Coyle, K., Kirby, D., Parcel, G., etÂ€al. (1996). Safer choices: A multicomponent school-based HIV/STD and pregnancy
prevention program for adolescents. Journal of School Health, 66(3), 89-94; East, P., Kiernan, E., & Chavez, G. (2003). An evaluation of California's
Sibling Pregnancy Prevention Program. Perspectives on Sexual and Reproductive Health, 35(20), 62-70; Ford, K., Weglicki, L., Kershaw, T., etÂ€al.
(2002). Effects of a prenatal care intervention for adolescent mothers on birth weight, repeat pregnancy, and educational outcomes at one year
postpartum. Journal of Perinatal Education, 11(1), 35-38; Harris, M. B., & Franklin, C. G. (2003). Effects of a cognitive-behavioral, school-based,
group intervention with Mexican American pregnant and parenting adolescents. Social Work Research, 27(2), 71-83; Kirby, D. (2007). Emerging
answers: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, DC : The Campaign to Prevent
Teen and Unplanned Pregnancy; Manlove, J., Papillio, A., & Ikramullah, E. (2004). Not yet: Programs to delay first sex among teens. Washington,
DC: Campaign to Prevent Teen Pregnancy; Meadows, M., Sadler, L. S., & Reitmeyer, G. D. (2000). School-based support for urban adolescent
mothers. Journal of Pediatric Health Care, 14(5), 221-227; Philliber, S., Kaye, J., & Herrling, S. (2001). The national evaluation of the Children's Aid
Society Carrera-model program to prevent teen pregnancy. Accord, NY: Philliber Research Associates; Philliber, S., Brooks, L., Lehrer, L. P., etÂ€al.
(2003). Outcomes of teen pregnancy programs in New Mexico. Adolescents, 38(151), 535-553; Roye, C. F., & Balk, S. J. (1996). Evaluation of an
intergenerational program for pregnant and parenting adolescents. Maternal-Child Nursing Journal, 24(1), 32-40; Sidebottom, A., Birnbaum, A. S.,
& Nafstad, S. S. (2003). Decreasing barriers for teens: Evaluation of a new pregnancy prevention strategy in school-based clinics. American Journal
of Public Health, 93(11), 1890-1892; St. Lawrence, J. S. (1998). Becoming a responsible teen: An HIV risk reduction program for adolescents. Santa
Cruz, CA: ETR Associates; and Smith, M. A. B. (1994). Teen incentive program: Evaluation of a health promotion model for adolescent pregnancy
prevention. Journal of Health Education, 25(1), 24-29.
sexually active teens. Most publically funded family plan- Contraceptive Services
ning clinics counsel new teen clients about the benefits of Access to and regular use of birth control is the goal of contraceptive
abstinence and Â�encourage them to discuss sexual issues services for adolescents. Family planning clinics and private physi-
with their parents (Lindberg et al., 2006b). About half of cians are one source; school-based clinics are a more recent effort.
these clinics also have education programs on related top- In 2010, there were 1909 school-based clinics, but it is unclear
ics that are provided at the clinic or in schools and youth how many provide contraceptive services (GAO, 2010b). BoxÂ€24-4
centers. provides examples of school-based contraceptive programs.
Community health nurses can encourage clinic atten- Community health nurses have a unique opportunity to
dance, promote access to contraception, and provide refer- affect teenage pregnancy rates and reduce the health risks for
rals to appropriate contraceptive services when counseling both the pregnant adolescent and her infant. Care should be
individuals or teaching sex education classes. The nurse must directed toward providing a satisfactory and healthy outcome.
Â�emphasize the importance of contraceptive use by all sexually The critical elements of any program include the following:
active adolescents. • Early detection of pregnancy
The key to compliance with birth control methods by teenag- • Pregnancy resolution services
ers is regular, continued attendance at a clinic site and the use of • Prenatal health care
long-acting contraceptives. Although much progress has been • Childbirth education
made, teens are still less likely to use contraception regularly • Parenting education
and more likely to rely on condoms as their primary method
of birth control (Abma etÂ€al., 2010; Santelli etÂ€al., 2007). Clinic Early Detection
programs should provide regular contact and monitor compli- Early detection provides more time to decide what to do about
ance; school-based programs have been particularly success- the pregnancy and a longer period of prenatal care if the ado-
ful in this effort (Sidebottom etÂ€al., 2003). Community health lescent decides to continue the pregnancy. Community health
nurses are adept at monitoring and improving adolescent com- nurses can facilitate early detection by considering the possi-
pliance with birth control measures because they provide clear, bility of pregnancy during the initial assessment of physical
direct, and nonjudgmental guidance. complaints by female adolescents. Complaints such as fatigue,
appetite loss, nausea and vomiting, weight loss, or missed men-
Life Options or Youth Development Programs strual periods, coupled with a history of sexual activity and
Life options programs are comprehensive programs that pro- inadequate birth control, should be clues to pursue additional
vide a broad range of support services for adolescents. These questioning.
programs attempt to expand an adolescent's future goals and Sensitive but direct questioning is important. The commu-
expectations by improving educational and employment pros- nity health nurse must be accepting of the teenager, or the teen-
pects. The aim is to increase a teen's self-worth and ease the ager will be reluctant to share information, ask questions, and
teen's transition to adulthood. Because future-oriented, goal- express concerns. It is not uncommon for a teenager to deny or
directed adolescents are less likely to become pregnant, the attempt to hide a pregnancy. If the nurse is brusque, it is unlikely
expected result is a reduction in the rate of teenage pregnancies. the teenager will feel comfortable seeking or volunteering
Programs might be school or community based and target information of an intimate nature. Previous experience with
especially risky populations such as teens from low-income nurses and other health care providers has an impact on a teen-
families. Efforts are directed toward reducing social factors ager's willingness to seek care or to trust the nurse. All nurses
associated with increased pregnancy rates (Klerman, 2002). Life should take care to ensure that young clients are treated with
option programs offer a variety of structures and strategies, respect and dignity and receive culturally competent care (see
including the following: ChapterÂ€10).
• One-on-one mentoring and role modeling by successful
adults Pregnancy Resolution Services
• Community service participation Once pregnancy is confirmed, the teenager faces an important
• Remedial education decision. The American College of Obstetrics and Gynecology
• Tutoring services (ACOG), Planned Parenthood, the American Nurses Association
• Counseling, by both professionals and peers (ANA), and numerous other professional health care organiza-
• Self-worth enhancement techniques tions take the position that a comprehensive program should
• Exposure to new experiences (e.g., concerts, museums, and include all possible pregnancy options: abortion, adoption, and
travel) to expand life options keeping the baby.
These are relatively new programs intended to provide long- • Approximately 6 of every 10 pregnant adolescents choose
term intensive support to targeted teenagers. The results take childbirth.
years to achieve. Data suggest these programs have been suc- • Three in 10 teen pregnancies end in abortion.
cessful in delaying sexual initiation, increasing condom use, and • About 10% of adolescent pregnancies end in miscarriage.
reducing rates of STDs (Kirby, 2007; Lonczak etÂ€al., 2002). • Choosing adoption is rare.
SECONDARY PREVENTION: THE CARE Abortion

OF PREGNANT TEENAGERS Adolescents choose abortion more frequently than adults
and wait longer to do so. Approximately 27% of adolescent
Since 1991, there has been a renewed public effort to address the pregnancies are terminated by abortion (GI, 2010b). The
serious problem of teen pregnancy, which has resulted in a 37% most common reasons teenagers give for choosing abortion
decline in the pregnancy rate (Ventura & Hamilton, 2011). The are the following (Andrews & Boyle, 2003; Finer etÂ€al., 2005;
NCPTP has been instrumental in addressing the problem of GI,Â€2011a):
teenage pregnancy in the United States. This nonprofit, nonpar- • Too young to be a mother
tisan, broad-based group of social and religious leaders, health • Baby would change her life
care professionals, researchers, politicians, and concerned citi- • Cannot afford a child now
zens is supported by private donations. Its mission is the reduc- • Parents want her to have an abortion
tion of teen pregnancy in the United States. • Partner is unreliable
Abortion is a controversial issue. Both supporters and oppo- supports this position (Andrews & Boyle, 2003; Pope etÂ€al.,
nents are vocal and strident. For the past four decades, abortion 2001). In general, teenagers feel they made the best personal
opponents have attempted to reduce access to and availability choice at the time.
of abortion services. Both federal and state efforts are aimed
at reducing funding and tightening regulations for programs Prenatal Health Care
receiving public money. Federal funding for Medicaid abor- Once a teenager decides to continue the pregnancy, effort is
tion services was eliminated, although there are some excep- directed toward ensuring a healthy outcome for the mother
tions such as abortions in cases of rape or incest (GI, 2011c). and infant. Early initiation and regular continuation of prena-
Any state that wanted to continue funding had to assume all the tal care significantly reduce the risk for both adolescents and
costs for abortion services. Some states (17) chose to continue their infants, although complication rates remain above those in
funding, but most (32) chose not to do so (GI, 2011c). Because other age groups (ACOG, 2009; Martin etÂ€al., 2006; Mummert
many pregnant teenagers are served by publicly supported pro- etÂ€al., 2007). Short gestation, low birth weight of the infant, and neo-
grams, their access to abortion services was directly affected by natal mortality are all reduced with regular prenatal care (ACOG,
the changes. 2009; Ford etÂ€al., 2002). Home visits by community health nurses
State efforts have targeted changes to the legal criteria for improve pregnancy outcomes and infant health status (Children's
abortion services for teens (e.g., parental notification, waiting Defense Fund [CDF], 2005; Olds etÂ€al., 1999, 2004). The Nurse–
periods, and mandatory counseling). These restrictions are Family Partnership program started by David Olds, a commu-
costly, and there is some question as to their effectiveness. The nity health nurse, has expanded to 263 counties in 28 states and
Supreme Court has upheld some but not all of the state initia- serves more than 17,000 families (Boonstra, 2009; CDF, 2005).
tives on parental notification and waiting periods (GI, 2003).
In general, state initiatives that allow teenagers an alternative Special Needs of Pregnant Adolescents
to parental notification or do not impose an “undue burden” An estimated 33% of adolescent mothers receive inadequate
in waiting time have been upheld; the remainder have been prenatal care (GI, 2011a; Philliber etÂ€al., 2003). A standard
struck down. obstetrics text should serve as the basis for a prenatal plan of
It is difficult to determine whether abortion restrictions care. There are some special concerns that the community
have an impact on teenage abortion. Nationally, there has been health nurse must be aware of when planning prenatal care for
a decline in the rate at which teenagers seek abortion services, pregnant teenagers. As previously noted, adolescent mothers
but there has also been a decline in the rate of teenage pregnan- and their infants are at greater risk for serious medical Â�problems
cies. The unresolved question is whether abortion rates would than are older mothers and their infants. Age alone is not the
be higher without the legal and financial obstacles. Some sug- problem. The risk associated with early pregnancy has been cor-
gest that limited access to Medicaid funding increases the hard- related with factors such as lower socioeconomic status, poor
ships for low-income women who choose the abortion option. prenatal care, inadequate nutrition, and unhealthy lifestyle
Further studies are needed to determine the exact impact of practices (Martin etÂ€al., 2003, 2006; NCPTP, 2010c). When care
funding reductions and legal limitations on abortion choices of is taken to reduce the associated risks, teenage pregnancy is less
adolescent females. problematic.
The essential components of a prenatal program to reduce
Adoption the incidence of low birth weight in infants should include the
Placement for adoption is less controversial but is an infrequent following:
choice for teenagers. Few teenagers or other pregnant women • Screening for harmful behaviors
choose this option (ACOG, 2009; Finer etÂ€al., 2005). Adolescents • Ongoing risk assessment
who choose adoption are older, farther along in their schooling, • Individual care and case management
and more future oriented with respect to educational goals than • Nutritional counseling
are teenagers who keep their infants. There is some evidence • Health education aimed at reducing poor health habits
that parental support influences a teen's decision to place her • Social support services
child for adoption. Good prenatal programs also should include preparation for
A federal effort directed by the Office of Adolescent Pregnancy labor and delivery, introduction to newborn care, and exploration
Programs to encourage the adoption option among pregnant of birth control options for postdelivery use. Adolescents have
teenagers began in the 1980s. Funding was provided for research some special health needs and concerns associated with preg-
studies that were intended to increase the likelihood of adop- nancy related to their developmental age, nutrition, and health
tion and to identify factors that influenced the adoption choice. habits. Website Resource 24A identifies for the nurse some
In 2000, legislation provided funding to support the training important areas of concern for assessment and investigation.
of family planning and other health providers in how to pro-
vide information on adoption to women reluctant to continue a Prenatal Programs Available to Teenagers
pregnancy (Dailard, 2004). No appreciable change has occurred Three types of programs offer prenatal care to adolescents:
in the adoption rate, although efforts continue to increase the clinic programs, private medical services, and school-based pro-
rate of adoption, especially as an alternative to abortion. grams. The choice of program depends on accessibility and the
financial circumstances of the teenager and her family.
Teen Satisfaction with Choice Private medical service is available only to people who are
Adolescents appear satisfied with their pregnancy decisions. covered by a medical insurance plan or can afford to pay. Most
Despite assertions that teenagers who choose abortion or adop- family insurance plans limit coverage to children younger than
tion suffer negative psychological consequences, no evidence 18â•›years of age, although some plans provide coverage until age
21 or 23 if the child is a full-time college student. Parents might other community groups, and clubs and organizations in which
be surprised to find that their child is not insured, and they are the teenager has participated. If the teenager is separated from
unprepared to meet the expenses of pregnancy when their child her family, social services can arrange financial assistance for
is not a full-time student. housing or, for younger teenagers, foster care.
For families without insurance or the financial resources to For adolescents, pregnancy often accompanies other per-
pay for prenatal care, there are several options: sonal problems or emotional issues. Failure to address related
• Medical assistance or public health insurance through problems and issues in a supportive, caring atmosphere is
Medicaid or CHIP equivalent to providing only partial care to the pregnant ado-
• Prenatal and obstetric clinics associated with publicly funded lescent. Persistent home visitation by the community health
hospitals that accept medical assistance clients and people nurse is one way to provide long-term support. Studies have
with limited financial means, who are offered a sliding-scale demonstrated that pregnant adolescents who are visited at
fee program home by community health nurses have better employment
• Prenatal clinic care provided through state and county health records, have fewer pregnancies, and delay a second pregnancy
departments longer, and their children have fewer hospitalizations and bet-
• Satellite clinics operated by some hospitals and health ter immunizations, compared with adolescents who do not
departments in low-income neighborhoods with high rates receive home visits (Boonstra, 2009; Koniak-Griffin etÂ€al., 1999;
of adolescent pregnancy. Olds etÂ€al., 1999, 2004).
Because socioeconomic status has been associated with
a greater number of potential complications, clinics serving The Adolescent and the Young Adult Father
low-income teenagers expect to have a larger number of cli- Secondary prevention efforts aim to improve parental partici-
ents requiring intense supervision. Recent reforms have limited pation in prenatal care, childbirth preparation, and parenting
care options for low-income pregnant teens. States require most activities. Programs are intended to improve the quality and
medical assistance recipients to use managed care organiza- duration of the relationship between the father and the child.
tions. At the same time, many health departments have dropped The more successful efforts have been those that engage fathers
or restricted prenatal programs (see ChapterÂ€29). early, no later than the birth of the baby (McLanahan & Carlson,
Prenatal care services provided through comprehensive com- 2002; Schuyler Center, 2008). Community health nurses can
munity-based programs achieve the best results with pregnant assist in these efforts by encouraging the father's participation
teens. These programs have a heavy outreach and educational
Â� in prenatal visits. The community health nurse should invite the
emphasis, use multidisciplinary health care teams with an father to prenatal classes, encourage questions and participation
emphasis on community health nurse involvement, and do in prenatal visits, and acknowledge the father's role as a partner
home visiting (Klima, 2003; Montgomery, 2003). The commu- in the birth process.
nity health nurse acts as the broker or case manager for prenatal
care and sees that clients are provided with needed services. The Childbirth Education
nurse is usually the team member who spends the most time Teenagers are likely to get information about labor and deliv-
with the adolescent, providing health screening, counseling, and ery from their peers, much of which may be erroneous.
education for pregnant clients. Assessment of the teenager's knowledge base, correction of
School-based prenatal services are offered in conjunction misconceptions, and reinforcement of valid information is
with other school clinic services or in separate schools designed key. If the adolescent's mother or other relative is involved, the
for the exclusive use of pregnant teenagers. School-based pre- nurse should include that person in the dialogue. The mother's
natal services employ a comprehensive approach and are usu- knowledge base might be incorrect or outdated if it consists
ally found in large school districts with high rates of adolescent solely of her own personal experiences. Including the mother
pregnancy. School-based prenatal programs are associated in the interview allows the nurse to correct misinformation,
with a high level of compliance with appointments and the care acknowledge the mother's contribution to her daughter's care,
regimen, a reduction in the number of complications, and the and facilitate the mother's cooperation with the prenatal and
secondary benefit of increased school attendance both before postpartum programs.
and after delivery (Barnet etÂ€al., 2004; Strunk, 2008). The delivery of a child usually represents a pregnant ado-
lescent's first experience with hospitalization. Most hospitals or
Support Systems and Nurse Home Visits birthing centers provide tours and orientation prior to delivery.
Adolescent pregnancy is often associated with or hastens a fam- Whenever possible, teenagers should be encouraged to attend
ily crisis. During pregnancy, the expectant teenager looks for an orientation program. Most facilities allow a support person
emotional, financial, and physical support from family mem- to remain with the teenager during delivery. The nurse might
bers. The community health nurse and other caregivers should have to help the teenager choose her support person, especially
take care to assess the degree of support available from fam- if a number of persons are available. This decision should be
ily and others. Most pregnant teens live with their parents. The made as soon as possible. If the teenager has opted for natu-
amount of support (financial, physical, and psychological) var- ral childbirth classes, the person who will support her in labor
ies with families. Many adolescent mothers live in households should attend classes with her, if possible.
in which poverty and other problems are common (GI, 2002b;
NCPTP, 2010c). If families are unable or unwilling to provide Postpartum and Newborn Care
support, the teenager will need help identifying other support Changes in the delivery of health services have reduced the
sources. Examples of potential support include other relatives, amount of in-hospital time mothers are allowed by their
the father of the infant and his family, church organizations, health insurance providers. These changes affect the amount of
Â�
education and monitoring delivered by hospital staff and make addition to her other obligations. The first task, and one that
it crucial that monitoring be provided in the home and com- might best be accomplished on a home visit, is to assess the sup-
munity. Postdelivery care varies widely in scope and duration of port systems available to the teenage mother. If the adolescent
services. All prenatal programs provide a postpartum check for is involved in a comprehensive prenatal and postpartum pro-
the mother, and a well-baby check is included in most services. gram, health care professionals have already assessed available
The most extensive postpartum care is delivered in community support. If not, the nurse should look at the immediate family,
programs that rely heavily on nurses. These programs usually other relatives, significant others, and the father of the infant
include the following: and his family. Even if support systems are adequate, the fam-
• Health assessment of both the mother and the infant ily might need some help in understanding and supporting the
• Newborn care education and supervision adolescent as a maturing individual.
• Parental education on growth and development and parent- Role conflict is a common problem in families. Family mem-
ing skills bers might expect the teenager to instantly become an adult and
• Review of role adjustments and available supports mother, or expect the opposite, that she will remain a child and
• Sex education and birth control information allow her parents to assume all the responsibilities. Neither situa-
One valuable component of these programs is the empha- tion is especially healthy for the adolescent or infant. Ideally, both
sis on regular contact with the new mother, starting the first parents should be encouraged to continue developing as individ-
week after delivery. This is especially relevant for adolescent uals (e.g., continue their education, participate in some social
mothers, who have little experience in caring for a newborn activities, explore relationships with peers) and at the same time
and distinguishing between normal and abnormal physi- increase their proficiency and confidence in parenting.
cal conditions for both themselves and their new infants. When support is minimal or lacking, the community health
Regular nurse visits reduce anxiety and increase infant health nurse might be able to refer the teenager to other possible
(Olds etÂ€al., 1999). Mothers experience many concerns or resources such as parenting programs, cooperative daycare,
problems before the first scheduled clinic or physician visit. or programs that pair the new mother with an older adoles-
Earlier contacts allow the teenager and nurse to address these cent mother who has had a successful experience. One such
issues and reduce anxiety. Contact need not always be in per- program, the Taking Charge Program, paired small groups of
son; some care can be provided by telephone monitoring of pregnant or parenting girls with young women who had been
the new mother. pregnant adolescents. They helped the teenagers improve par-
enting skills and problem solving (Harris & Franklin, 2003).
Health Status of the New Mother AÂ€mother-Â�grandmother program provides support and encour-
At a minimum, the new mother should have a postpartum agement to both the teen mother and her mother, the baby's
examination at week 6. Some community health programs start grandmother (Roye & Balk, 1997).
home visits at about 2â•›weeks after delivery. The physical assess- Adequate support is an important concern, because adoles-
ment should focus on the standard postpartum areas as well cent mothers have rates of child abuse and neglect twice as high
as on specific concerns of the adolescent. Consistent with teen- as those of young mothers in their twenties (Hoffman, 2006).
agers’ concern about body image, they have frequent questions Adequate physical and emotional support, along with health
about weight loss and figure restoration. teaching and realistic expectations for their children, success-
fully reduces the incidence of abuse and neglect in at-risk moth-
Dorothea Collins is a new 16-year-old mother. When Tom ers (CDF, 2005; Olds etÂ€al., 1999, 2004) (see ChapterÂ€23).
Dresher, the community health nurse, made his first post-
partum visit, he found that Dorothea was successfully coping Health Status of the Newborn
with baby feedings and changes. However, the primary issue In addition to performing the usual newborn assessment, the
on Dorothea's mind was her prom dress, which she had pur- community health nurse should look for signs of adequate
chased during her pregnancy and promptly tried on as soon maternal and infant bonding. Evidence of attachment includes
as she left the hospital. Dorothea told Tom, “I'm going to have calling the child by its given name, cuddling the infant, talk-
to crash diet because I don't fit into the dress. This is the dress ing to the infant, and demonstrating an interest in infant care
size I wore before I became pregnant. I don't understand why and development. Sometimes, teenagers demonstrate difficulty
it doesn't fit. I am only 5 pounds heavier than I was before I in bonding, simply because they have had no previous expe-
got pregnant.” Tom spent some time helping Dorothea under- rience with infants and are afraid to do anything. Sometimes,
stand that her shape would continue to change for some time another person has assumed the role of caregiver, and the teen-
after delivery. He reviewed her eating habits, and together ager becomes an observer rather than the caregiver. Bonding
they worked on a balanced diet plan designed to help her lose can be evaluated in clinic situations, but home visits allow the
about one pound per week. He also encouraged her to begin nurse a more accurate picture of the teen and infant relationship
some moderate exercise, such as walking. because the nurse can observe for a longer time and evaluate the
interaction among the infant, teenager, and other caregivers.
Role Adjustment and Emotional Support When another person assumes most of the responsibilities
Adjusting to the role of a parent during adolescence is partic- for infant care, the nurse should explore the adolescent's wishes.
ularly difficult. The adolescent mother needs support as she The teenager might want to care for her infant and might sim-
attempts to integrate her new responsibilities into her daily ply require encouragement, demonstration, and supervision to
routine. The teenager might be juggling school and infant become confident in infant care. The nurse might have to sug-
care. Fatigue and stress are common and can be exacerbated gest that family members help by supporting the teenager as she
if the new mother attempts to resume her social activities in attempts to establish a relationship with her child.
Nancy Riley is making a home visit to Jamie Schult, who When Maria Gomez makes her first home visit to Karena
delivered her baby 2â•›weeks ago. Jamie is 16â•›years old and lives Hernandez after her delivery, she finds Karena crying. Karena
with her mother, grandmother, and three siblings. She still is reports, “My baby won't eat anything. I've tried everything,
involved in a relationship with the father of her child, but he including formula, toast soaked in milk, and oatmeal. She
lives with his brother and his family. During the visit, Nancy just won't eat.” Maria sits down to talk with Karena and help
asks Jamie how the baby is doing, and Jamie has little to say. her to position the baby for a formula feed. The baby is fussy
Her mother, Delores, answers all the questions. She is also but slowly takes the formula. During the visit, Maria takes
the one holding the baby, and she feeds the baby during the the opportunity to find out why Karena felt that toast or oat-
nurse's visit. When Nancy sees Jamie at the clinic for her post- meal would be appropriate for a 1-week-old infant. She dis-
partum check, she asks how things are going at home. Jamie covers that Karena's grandmother had suggested she start
says, “I don't take care of my baby. My mother thinks I can't the infant right away on more substantial food so she would
do anything right. I want to feed her, but my mother says I sleep through the night. Maria spends some time reviewing
just give her gas because I don't know how to hold the bottle.” the appropriate age-related food schedule and leaves several
pamphlets with Karena. She also suggests that Karena call the
Health Teaching Regarding Newborn Care clinic if she runs into other problems that cannot wait until
the next home visit.
Most prenatal care includes basic information about child
care, although the extent of the content varies. Adolescents
will have more formalized classroom instruction if they par- An important point to remember is that people vary in child
ticipate in a school-based prenatal program. Even if the teen- care customs and practices. Child care techniques common to
ager has received extensive preparation, she usually needs a culture or family tradition need not be discouraged or elimi-
health teaching reinforced after delivery. The most common nated if they do no harm. For example, some families swaddle
topics teenagers identify for review and reinforcement are (tightly wrap) infants, whereas others do not; some introduce
listed in BoxÂ€24-5. solid foods early, and others do not; some use an umbilical
Because teenagers usually focus on the present, they fre- band, and others do not; some pierce the infant's ears, but
quently do not pay attention to information that has no others do not. When the nurse sees child care practices con-
immediate relevance. When the infant arrives, problems then trary to his or her agency's standard protocol or teaching plan,
develop. It is very frightening to be caring for a tiny infant and or to her or his own personal habits or values, the practices
be presented with a crisis. Under these circumstances, the teen- should be evaluated in terms of harmfulness. Any health care
age mother becomes very receptive to reviewing and discussing professional who discourages or disapproves of practices that
child care issues. Community health nurses should take advan- pose no harm runs an unnecessary risk of altering the family–
tage of the adolescent's concern to teach healthy infant care and provider relationship or alienating the family. An important
distinguish between normal and abnormal infant behavior. question to ask is, “Is this care issue worth jeopardizing my
ability to continue to provide health care to this mother and
her infant?” If the answer is no, then clearly the nurse is better
BOXÂ€24-5â•…â•‡SUGGESTED HEALTH off not running the risk.
TEACHING TOPICS AND
CONTENT FOR TEENAGE
MOTHERS TERTIARY PREVENTION
POSITIONING AND HANDLING OF INFANT Tertiary prevention is rehabilitative. With respect to teen-
• Nutrition: Breast-feeding and bottle-feeding techniques (encourage pregnancy, prevention should be designed to improve the
age breast-feeding when possible), feeding schedule, dietary chances of self-sufficiency for adolescent mothers and fathers
recommendations for the first 6â•›months, and vitamin and iron while ensuring a healthy, supportive environment for their chil-
supplements dren. None of the interventions are unique to tertiary preven-
• Hygiene: Skin care and bathing, care of diaper rash, nail care, and tion, aside from those aimed at enhancing child welfare.
umbilical and circumcision care
• Elimination: Diapering and frequency of changes, bowel move- Birth Control
ments (frequency and appearance), constipation, and recognition of Ideally, contraception should be addressed as part of the prena-
problems tal program. After delivery, the adolescent must decide if she will
• Growth and development: Normal growth and development, continue sexual activity. If so, the nurse should review her con-
chart of developmental milestones, and suggested techniques to traceptive options. Some girls are opposed to contraception on
encourage development religious grounds. If this is the case, the nurse should accept the
adolescent's decision but caution her about the risks involved in
APPROPRIATE DISCIPLINE TECHNIQUES unprotected sexual activity. Even if there is no immediate need,
• Immunization schedule: Recommended schedule, rationale for contraception should be reviewed. If the adolescent has already
administration, and possible side effects used birth control, it is helpful to identify what the method was,
• Health care issues: Behaviors that signal distress or discomfort,
how it was used, and why it was discontinued. Such a review helps
thermometer reading and normal versus abnormal readings, com-
to determine whether contraception was used properly and to
mon symptoms (e.g., upper respiratory tract infection, dehydration,
correct any misconceptions or faulty technique. The nurse should
and diarrhea), teenager's health coverage, and selection of a clinic
or private physician ensure that the teenager is aware of community resources (family
planning clinics) where she may be supplied with contraceptives.
Preventing or delaying another pregnancy is a priority. guidance, Â�parenting support, and child care services are all
Statistics show that teenagers (both boys and girls) who are par- parts of comprehensive programs. Most evaluation efforts have
ents run a significant risk for having another child while they been short-term ones and have appraised selected segments
are still teenagers (Abma etÂ€al., 2010; Raneri & Wiemann, 2007). rather than a total program. Some success has been noted. For
The same strategies employed in primary prevention to avoid example, one study found reduced adolescent pregnancy rates
pregnancy can be used to prevent repeat pregnancy. Accurate among participants in life options programs targeting at-risk
information, accessible contraceptive services, regular clinic vis- teens (Tabi, 2002). Evaluation efforts need to continue and to
its, and monitored compliance with contraceptive use are effec- focus on long-term results. One long-term study, the Seattle
tive in reducing the incidence of a second or third pregnancy in Social Development Project, followed children from fifth grade
adolescent parents. through age 21â•›years. When evaluated at age 21, those enrolled
in that project were found to have delayed initiation of sexual
Parenting Skills activity, to have had fewer sexual partners, to use contraceptives
Parenting support, ideally started during and immediately more frequently, and to be less likely to have had an STD than a
after delivery, is continued on a long-term basis, sometimes comparison group of peers.
for 2 or 3â•›years. Parenting classes, individual counseling, and Olds and colleagues (1999) reported on the effects over time
peer support groups are all successful interventions. Home (20â•›years) of the Nurse Home Visiting Program. The short-term
visits by community health nurses and trained community intervention occurred only from prenatal care through an infant's
parent aides provide young mothers and fathers (when pres- second birthday; however, the results appeared to continue over
ent) with encouragement and monitoring (Boonstra, 2009; a long period. Women who participated in the program deferred
Olds etÂ€al., 1999, 2004). School-based infant and child care subsequent pregnancies and improved their workforce participa-
programs are beneficial to young mothers and their chil- tion, and their children were less likely to experience childhood
dren. They increase the likelihood that the mother will com- injuries or learning delays (Olds etÂ€al., 2002). A follow-up study
plete high school while providing support and guidance for at 4â•›years indicated that study participants increased the interval
her parenting efforts (Key etÂ€al., 2001; Meadows etÂ€al., 2000; between pregnancies, experienced less domestic violence, and
Sadler, 2007). Infants and children are ensured quality child continued to show improvement in mother–child relationships
care, educational companionship, and a head start on learn- and the early childhood development of their children (Olds
ing opportunities. etÂ€al., 2004). At age 15â•›years, the children of the teen mothers in
the study had fewer arrests and convictions, smoked and drank
Comprehensive Programs less, and had fewer sexual partners compared with their peers.
A number of innovative interventions have combined vari- Continued long-term studies are needed to determine what strat-
ous strategies into comprehensive support programs (see egies are the most effective. It might be that regular, consistent
BoxÂ€24-4). Sex education, birth control support, life options support of any type is beneficial and effective.
KEY IDEAS
1. The pregnancy, abortion, and birth rates for Â�adolescents are 8. Government funding and policy changes affect services
higher in the United States than in other developed Â�countries, provided to sexually active and pregnant teens.
although the rate of sexual activity is Â� approximately 9. Primary prevention programs that include sex education,
theÂ€same. contraceptive information, and access to contraceptive ser-
2. Adolescents who participate in sexual activity at an early vices can delay sexual activity and increase contraceptive
age are more likely to have multiple sex partners and a use in sexually active teenagers. The evidence suggests that
higher risk for contracting STDs. abstinence-only programs are not successful when used as
3. Many teens substitute oral sex for intercourse and often do the sole method of primary prevention.
not view oral sex as “real” sexual activity. 10. Secondary prevention programs that include early initia-
4. The pregnancy rate is higher among adolescents from racial tion of adequate, regular prenatal care have been proven to
and ethnic minority groups, but the largest number of reduce medical complications and improve the health sta-
babies are born to white adolescents. tus of both pregnant teenagers and their newborn infants.
5. There is no single cause of teenage pregnancies; instead, 11. Tertiary prevention programs that provide a variety of
aÂ€combination of social and personal factors is responsible. support services for new mothers and their infants reduce
6. Adolescents who have children are more likely to discon- health risks for both the mother and child and increase the
tinue education, need public assistance, continue on public chances that the mother will continue her education.
assistance for a longer period, and have a poorer work his- 12. Community/public health nurses have an enormous oppor-
tory over time than are adolescents who postpone child- tunity to affect teens by doing the following:
bearing to later years. • Encouraging abstinence or delay of sexual activity
7. Pregnant teenagers and their infants are at greater risk for • Providing factual information on sex education, contra-
medical complications (e.g., hypertension, toxemia, ane- ception, and STDs
mia, low birth weight, stillbirth, infant mortality) com- • Assisting pregnant teens with health care and parenting
pared with older women and their infants. skills

A Pregnant Adolescent Jennifer Maurer Kliphouse
Ann Jones is a 16-year-old girl who comes to the family planning clinic Additional Areas for Further Assessment
for a pregnancy test. She is 5â•›months pregnant. She tells the commu- • Progress and satisfaction at school, including expected schedule for
nity health nurse that she delayed coming to the clinic because she graduation
was afraid her mother would talk her into an abortion. In the initial • Experience with birth control, birth control plans after delivery, and
interview, the nurse learns the following: accuracy of sexual knowledge
• Ann is happy she is pregnant and wants to keep her infant. • Experience with child care, accuracy of information, skill level, and
• She feels fine. education related to deficient areas
• She does not need maternity clothes because, she says, “I am • Knowledge of growth and development
watching my weight and have not gained one pound yet.” • Use of community support referrals or resources to provide ongoing
• Is not sure she can continue to live with her mother because her support after delivery
mother is “mad I got knocked up and is not talking to me right now.”
• Is one grade behind but is doing “okay” in school. Nursing Diagnoses
She also tells the nurse that the father of the infant, Bob, is a sopho- • Imbalanced nutrition—less than body requirement related to grow-
more in high school, lives with his parents, and is willing to help with ing fetus, lack of knowledge, and body-image concerns as evidenced
finances. Bob works 15 hours per week at a fast-food restaurant after by Ann's weight watching and lack of weight gain
school. His parents are not yet aware that Ann is pregnant, and Bob • Disabled family coping related to situational crises of teen pregnancy
thinks they will be very angry with both him and Ann. and lack of parental support as evidenced by lack of communication
between Ann and her mother
Assessment • Ineffective health maintenance related to young maternal age and
• Compare actual weight gain with expected weight gain for 20â•›weeks delay in initiation of prenatal care as evidenced by first prenatal
of pregnancy medical visit at 5â•›months
• Review dietary intake • Supplemental Food Programs Division
• Ascertain what financial assets and health insurance, if any, are • Deficient knowledge related to pregnancy, infant growth and devel-
available to the client opment, and parenting as evidenced by expressed weight watching
• Determine the presence of risk factors associated with poor and avoidance of medical attention
maternal and infant outcomes
• Ascertain the client's knowledge level related to pregnancy,
childbirth, and child care
Imbalanced nutrition—less Adequate dietary intake for a The nurse provided teaching on Normal weight gain during pregnancy is 30 to
than body requirement related pregnant woman normal weight gain and its relationship 35â•›lb. Ann's initial weight was 110â•›lb, and her
to lack of knowledge and body Normal weight gain during to positive infant outcome. weight increased by 1â•›lb per week during the
image concerns as evidenced pregnancy The nurse contracted with Ann to remainder of her pregnancy.
by Ann's weight watching and gain at least 1â•›lb per week during
lack of weight gain pregnancy. Since she registered late,
Ann was scheduled for weekly visits to
monitor weight gain progression during
her pregnancy.
The nurse performed routine Blood laboratory results determined Ann's blood type
prenatal blood tests. (O positive) and indicated that she was anemic.
The nurse provided prenatal vitamins. Prenatal vitamins were provided free of charge
TheÂ€nurse asked Ann to perform a by the clinic. Ann verbalized understanding
72-hour diet recall. of nutritional changes during pregnancy and
reported with each subsequent visit, “IÂ€always
take my vitamins.” The 72-hour diet recall
revealed deficiencies in caloric intake and
intake of fruits and vegetables and dairy
products.
The nurse arranged for nutritional Together with the dietitian, Ann modified Ann's
consultation with a registered dietitian. diet to increase the amount of fresh fruits and
vegetables as well as drink four glasses of
whole milk a day. Ann reported that she was
able to stick to the diet for a few weeks, but at
her fifth appointment, she stated, “It's hard to
remember to drink so much milk.” The dietitian
listed other sources of calcium such as broccoli
and other green, leafy vegetables.
1. Discuss with adolescents their feelings about sexual activity, per- Identify the proponents and opponents of these measures,
ception of risks, and educational and future goals. Encourage their arguments, and their stated goals. Identify your own
them to share their personal experiences related to how they values and positions.
acquired sexual information and conversations they might have 4. Review the sex education and family life lesson plans in
had with others regarding sexual activity or risky behavior. your school district, if they exist. Describe the content and
2. Identify a client who is a teenage mother in your clinical area teaching strategies. Do you think they are adequate? When
and explore with her what she finds rewarding and what is was the last time the content was changed or upgraded?
difficult about her situation. Review her educational prog- What are the qualifications of the teachers? Do teachers
ress, her child care, and her living arrangements. use a prepared script? Are teachers comfortable allowing
3. Become familiar with a specific community's values regard- discussion and statements of views by children or adoles-
ing sex education and contraceptive services for adolescents. cents in class?

Advocates for Youth: http://www.advocatesforyouth.org/ Office of Public Health and Science (Office of Population
Commodity Supplemental Food Program: http://www.fns.usda. Affairs, Office of Adolescent Pregnancy Programs, Office of
gov/fdd/programs/csfp/ Family Planning and Reproductive Health): http://www.hhs.
Food and Nutrition Service: http://www.fns.usda.gov/fns/ gov/opa/
Goodwill Industries International: http://www.goodwill.org/ Salvation Army National Headquarters: http://www.salvationar-
March of Dimes Birth Defects Foundation: http://www. myusa.org/usn/www_usn_2.nsf
marchofdimes.com/ U.S. Department of Agriculture: http://www.usda.gov/wps/
National Campaign to Prevent Teen and Unplanned Pregnancy: portal/usda/usdahome
http://www.thenationalcampaign.org/ Women, Infants, and Children Program: http://www.fns.usda.
Planned Parenthood Federation of America: http://www. gov/wic/
plannedparenthood.org/
WEBSITE

• NCLEX Review Questions 24A: Nutrition and Health Habits: Special Importance in
• Critical Thinking Questions and Answers for Case Studies Adolescent Pregnancy
• Care Plans
• Glossary
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Teen Pregnancy. of office-based physicians and Title X clinics— paraprofessionals and by nurses: Follow-up
Martin, J. A., Hamilton, B. E., Sutton, P. D., etÂ€al. United States, 2009–2010. Morbidity and results of a randomized controlled trial.
(2003). Births: Final data for 2002. National Mortality Weekly Report, 60(1), 1-4. Pediatrics, 114(6), 1560-1568.
Vital Statistics Reports, 52(10). Hyattsville, MD: Morbidity and Mortality Weekly Report. (2011c). Ott, M. A., Millstein, S. G., Ofner, S., et al. (2006).
National Center for Health Statistics. Summary of notifiable diseases—United States, Greater expectations: Adolescents’ positive
Martin, J. A., Hamilton, B. E., Ventura, S. J., etÂ€al. 2009. Morbidity and Mortality Weekly Report, motivations for sex. Perspectives on Sexual and
(2006). Births: Final data for 2004. National Vital 58(53), 1-100. Reproductive Health, 38(2), 84-89.
Statistics Reports, 55(1). Hyattsville, MD: National Mummert, A., Nagamine, M., & Myers, M. (2007). Perper, J., Peterson, K., & Manlove, J. (2010). Diploma
Center for Health Statistics. Childbirth-related hospitalizations among attachment among teen mothers, fact sheet. Child
Martin, J. A., Hamilton, B. E., Sutton, P. D., etÂ€al. adolescent girls, 2004 (Statistical Brief No. 31). Trends. Retrieved July 10, 2010 from http://www.
(2007). Births: Final data for 2005. National Vital Washington, DC: Agency for Healthcare Research childtrends.org/Files/Child_Trends-2010_01_22_
Statistics Reports, 56(6), 1-103. and Quality. FS_DiplomaAttachment.pdf.
Philliber, S., Brooks, L., Lehrer, L. P., etÂ€al. (2003). Scarr, E. M. (2002). Effective prenatal care for Ventura, S. J., & Hamilton, B. E. (2011). U.S. teenage
Outcomes of teen pregnancy programs in adolescent girls. Nursing Clinics of North America, birth rate resumes decline. National Center for
New Mexico. Adolescents, 38(151), 535-553. 37(3), 513-521. Health Statistics Data Brief No. 58, February 2011.
Phipps, M. G., Sowers, M., & DeMonner, S. M. Schuyler Center. (2008). Teenage births: Outcomes for Hyattsville,Â€MD: National Center for Health
(2002). The risk for infant mortality among young parents and their children. Albany, NY: Author. Statistics.
adolescent childbearing groups. Journal of Shearer, D. L., Mulvihill, B. A., Klermen, L. V., etÂ€al. Wiemann, C., & Berenson, A. (1998). Factors
Women's Health, 11(10), 889-897. (2002). Association of early childbearing and associated with recent and discontinued alcohol
Pope, L. M., Adler, N. E., & Tschann, J. M. (2001). low cognitive ability. Perspectives on Sexual and use by pregnant adolescents. Journal of Adolescent
Postabortion psychological adjustment: Are Reproductive Health, 34(5), 236-243. Health, 22(5), 417-423.
minors at increased risk? Journal of Adolescent Sidebottom, A., Birnbaum, A. S., & Nafstad, S. S. World Health Organization. (2011). Adolescent
Health, 29(1), 211. (2003). Decreasing barriers for teens: Evaluation pregnancy: The facts. Retrieved August 11, 2011
Prado, G., Pantin, H., Briones, E., etÂ€al. (2007). of a new pregnancy prevention strategy in from http://www.who.int/making_pregnancy_
A randomized controlled trial of a parent- school-based clinics. American Journal of Public safer/topics/adolescent_pregnancy/en/index.htm.
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and HIV risk behaviours in Hispanic adolescents. Strunk, J. A. (2008). The effects of school-based Examining external and internal poverty as
Journal of Clinical Psychology, 75(1), 914-926. health clinics on teenage pregnancy and antecedents of teen pregnancy. American Journal
Raneri, L. G., & Wiemann, C. M. (2007). Social parenting outcomes: An integrated literature of Health Behaviors, 28(4), 361-373.
ecological predictors of repeat adolescent review. Journal of School Nursing, 24(1), 13-20.
pregnancy. Perspectives on Sexual and Substance Abuse and Mental Health Services SUGGESTED READINGS
Reproductive Health, 39(1), 39-47. Administration. (2010). Pregnant teen
Rector, R. E., Johnson, K. A., & Noyes, L. R. (2003). admissions to substance abuse treatment: Abma, J. C., Martinez, G. M., & Copen, C. E. (2010).
Sexually active teenagers are more likely to be 1992–2007. The TEDS Report, March 18, 108. Teenagers in the United States: Sexual activity,
depressed and to attempt suicide (Center for Data Tabi, M. M. (2002). Community perspective on a contraceptive use, and childbearing, National
Analysis Report No. 03-04). Washington, DC: model to reduce teenage pregnancy. Journal of Survey of Family Growth. Vital and Health
Heritage Foundation. Advanced Nursing, 40(3), 275-284. Statistics Series 23, No. 30.
Rhein, L. M., Ginsburg, K. R., Schwartz, D. F., etÂ€al. Treffers, P., Olukoya, A., & Ferguson, B. (2001). Albert, B. (2010). With one voice: America's adults
(1997). Teen father participation in child rearing: Care for adolescent pregnancy and childbirth. and teens sound off about teen pregnancy: A
family perspectives. Journal of Adolescent Health, International Journal of Gynecology and Obstetrics, periodic national survey. Washington, DC:
21(1), 244-252. 75(2), 111-121. National Campaign to Prevent Teen Pregnancy.
Rosenbaum, J. E. (2009). Patient teenagers? United Nations. (2008). Demographic Yearbook. Hoffman, S. D. (2006). By the numbers: The public
A comparison of the sexual behavior of virginity NewÂ€York: Author. costs of teen childbearing. Washington, DC:
pledgers and matched nonpledgers. Pediatrics, U.S. Census Bureau. (2010). Income poverty and National Campaign to Prevent Teen Pregnancy.
123(1), e110-e120. Retrieved August 25, 2011 health insurance coverage in the U.S.: 2009. Manlove, J., Papillio, A., & Ikramullah, E. (2004).
from http://www.pediatrics.aappublications.org/ Current Population Reports P60-238. Not yet: Programs to delay first sex among teens.
content/123/1/e110.full. U.S. Census Bureau. (2011). Census Bureau Reports Washington, DC: National Campaign to Prevent
Roye, C. F., & Balk, S. J. (1997). Caring for pregnant 64% increase in the number of children living with Teen Pregnancy.
teens and their mothers, too. American Journal of grandparents over the last two decades. Retrieved Maynard, R. A. (Ed.). (2007). Kids having kids:
Maternal/Child Nursing, 22(3), 153-157. August 7, 2011 from http://www.census.gov/ Economic costs and social consequences of teen
Sadler, L. S., Swartz, M. K., Ryan-Krause, P., etÂ€al. prod/2011pubs/p70-126.pdf. pregnancy. Washington, DC: Urban Institute.
(2007). Promising outcomes in teen mothers U.S. Department of Health and Human Services. Olds, D. L., Henderson, C. R., Jr., Tatelbaum, R.,
enrolled in a school-based parent support (1995). Healthy people 2000: Midcourse review. etÂ€al. (1988). Improving the life course
program and child care center. Journal of School Washington, DC: U.S. Government Printing Office. development of socially disadvantaged mothers:
Health, 77(30), 121-130. U.S. Department of Health and Human Services. A randomized trial of nursing home visitations.
Santelli, J. S., Ott, M. A., Lyon, M., etÂ€al. (2006a). (2000). Healthy people 2010: Understanding and American Journal of Public Health, 78, 1435-1445.
Abstinence and abstinence-only education: improving health (2nd ed.). Washington, DC: U.S. Olds, D. L., Robinson, K., Pettitt, L. M.,
AÂ€review of U.S. policies and programs. Journal of Government Printing Office. etÂ€al. (2004). Effects of home visits by
Adolescent Health, 38(1), 72-81. U.S. Department of Health and Human Services. paraprofessionals and by nurses: Follow-up
Santelli, J. S., Morrow, B., Anderson, J. E., et al. (2007). Impacts of four Title V, SectionÂ€510 abstinence results of a randomized controlled trial.
(2006b). Contraceptive use and pregnancy risk education programs: Final report. Washington, DC: Pediatrics, 114(6), 1560-1568.
among U.S. high school students, 1991–2003. U.S. Government Printing Office. Boonstra, H. D. (2009). Home visiting for at
Perspectives on Sexual and Reproductive Health, U.S. Department of Health and Human Services. risk families: A primer on a major Obama
38(2), 106-111. (2010). Healthy People 2010. Washington, DC: administration initiative. Guttmacher Policy
Santelli, J. S., Lindberg, L. D., Finer, L. B., Author. Retrieved July 16, 2011 from http://www. Review, 12(3), 105.
etÂ€al. (2007). Explaining recent declines in healthypeople.gov. Kay, K., Suellentrop, K., & Sloup, C. (2009). The fog
adolescent pregnancy in the United States: U.S. House of Representative. (2004). The content zone: How misperceptions, magical thinking, and
The contribution of abstinence and improved of federally funded abstinence-only education ambivalence put young adults at risk for unplanned
contraceptive use. American Journal of Public programs. Washington, DC: United States House pregnancy. Washington, DC: The Campaign to
Health, 97(1), 1-7. of Representatives, Committee on Government Prevent Teen and Unplanned Pregnancy.
Santelli, J. S., Dandfort, T., & Orr, M. (2008). Reform. Kirby, D. (2007). Emerging answers 2007: Research
Transnational comparisons of adolescent Ventura, S. J., Mathews, T. J., Hamilton, B. E., etÂ€al. findings on programs to reduce teen pregnancy and
contraceptive use: What can we learn from these (2011). Adolescent pregnancy and childbirth— sexually transmitted diseases. Washington, DC:
comparisons? Archives of Pediatric Adolescent United States 1991–2008. MMWR Supplements The Campaign to Prevent Teen and Unplanned
Medicine, 162(1), 92-98. 60(01), 105-108. Pregnancy.
CHAPTER
25
Substance Use Disorders
Charon Burda*
FOCUS QUESTIONS
How are substance abuse and dependence defined? What behavior patterns alert the nurse to the presence of
What is the process of addiction? addiction and suggest specific interventions?
What theory of addiction is most relevant to community/ How can community/public health nurses assist individuals
public health nursing practice? and families recovering from addictions?
What is the extent of substance use disorders (SUDs)? What community resources exist to help with addiction
How can community/public health nurses help prevent problems and how is this picture changing?
addictions?
How can community/public health nurses help prevent fetal
alcohol syndrome and related disorders?
CHAPTER OUTLINE
Background of Addiction Stigma and Language
Impact of Substance Use on Society Impact of Substance Use Disorders on Individuals
Healthy People 2020 Objectives andÂ€Family Members
Definitions Infants and Children of Mothers with Prenatal Substance
Theories of Addiction Use Disorders
The Process of Addiction Children and Teens
Effects of Alcohol and Drugs on the Body Family Dysfunction and Co-dependence
Common Drugs Addictions and Communicable Diseases
Monitoring Incidence and Prevalence Responsibilities of the Community/Public Health Nurse
Prevalence of Drug Use and Drug-Related Problems Importance of Primary Prevention and Health Promotion
Demographic Distribution of Substance Use and Abuse Topics in Health Promotion and Prevention
Co-occurring Disorders Secondary Prevention
Substance Use in the Workplace Tertiary Prevention
Prevalence of Substance Abuse among Registered Community and Professional Resources
Nurses Funding Issues and Access to Care
KEY TERMS
Abstinence Fetal alcohol spectrum disorders (FASDs) Recovery-oriented systems of care
Addiction Impaired nurses (ROSC)
Brief interventions Medication-assisted treatment (MAT) Substance abuse
Co-dependence Overdose Substance dependence
Compulsive drug-seeking behavior Person first language Substance use disorders (SUDs)
Co-occurring disorders (Comorbidity) Pseudoaddiction Tolerance
Detoxification Recovery Withdrawal
*This chapter incorporates material written for the second edition by Karen Allen, for the third edition by Katherine High, and for the fourth edition by Mary R. Haack.
631
632 CHAPTER 25â•… Substance Use Disorders
Community public health nurses are on the forefront of iden- Since the “War on Drugs,” declared by President Richard
tifying individuals who require specialized help. Nurses need to Nixon in the 1970s and continued by President George H. W.
be knowledgeable about the latest evidence-based care as well as Bush, public policy has shifted away from an illness model to a
implement the most effective interventions available for those deterrence model. This shift resulted in the Crime Bill signed by
with substance use disorders (SUDs). This vulnerable popula- President Bill Clinton in 1994, which called for life imprisonment
tion imposes a high level of need for informed, culturally sensi- for those committing three consecutive drug offenses (“three
tive, professional nursing care. Nurses need to be aware of the strikes”). President George W. Bush continued the effort by reau-
signs and symptoms of SUDs and develop relationships with thorizing the Drug-free Communities Act, which concentrated
appropriate referral sources. Clients should be carefully guided the prevention efforts in the most drug-ridden communities. He
to appropriate, cooperating facilities, with follow-up by staff to also created a national drug control strategy that included efforts
ensure that they receive appropriate care. The most important to limit drug supplies, reduce substance demands, and provide
principle in addiction treatment is “No wrong door” (Center effective treatment to individuals with SUDs.
for Substance Abuse Treatment [CSAT], 2000). The health care As of 2011, President Obama's pledge was to treat illegal
delivery system, and every provider in it, has a responsibility to drug use more as a public health issue than a criminal jus-
address the range of client need, wherever and whenever a client tice problem. While the evidence-based solutions for SUDs
presents for care. Every “door” of the health care delivery sys- require increased prevention and treatment, the funding of
tem should be the right door to receive assistance and referral. such efforts lags behind. For example, in 2009, the budget of
Community/public health nurses need to continue advocating the Office of National Drug Control Policy (ONDCP) allotted
for appropriate treatment and resource allocations for this vul- 35% for prevention and treatment research to reduce demand,
nerable and stigmatized population. while law enforcement to reduce supply received 65% (The
White House, 2008).
BACKGROUND OF ADDICTION Budget allocation is a reflection of priority. When treat-
ment and prevention are not the central focus, the current out-
Many psychoactive substances are plant made (nicotine, caffeine, comes of increasing substance use and low rates of treatment
morphine, cocaine, mescaline, and tetrahydrocannabinol); alco- availability for addiction recur in society. Since we are not pay-
hol is a natural product of sugar fermentation by yeast. Due to ing for prevention, it is not readily accessible (Fornili, 2009).
the accessibility of these substances in nature, the use of psycho- DiClemente (2006) articulated the current challenge in think-
active drugs has been a part of the human experience since antiq- ing about addiction and how one's thoughts change the offered
uity. Major events that have influenced our attitude and behavior responses. He stated:
regarding drug use have occurred historically. For example,
“If addiction is seen as a moral failing, it will be condemned.
tobacco export played an important part in the economy of the
If seen as a deficit in knowledge, it will be educated. If the
United States early in its history. The invention of the matchstick,
addiction is viewed as an acceptable aberration, it will be
which allowed portable fire, and machines that could roll thou-
tolerated. If the addiction is considered illegal, it will be pros-
sands of cigarettes quickly fueled the tobacco industry.
ecuted. If addiction is viewed as an illness, it will be treated.”
During the nineteenth century, advances in chemistry made
it possible to purify the active ingredient of opium (morphine) (DiClemente 2006, p. vii)
and coca (cocaine) allowing these drugs to be taken in more
concentrated form, thus increasing their addictive potential. Impact of Substance Use on Society
The hypodermic syringe had already been developed in 1858 Drug addiction is a chronic, relapsing, compulsive disorder.
and helped spread the use of morphine in treating wounded Addiction presents a major burden on the health and financial
and ill soldiers during the Civil War. Early pharmaceuticals and resources of our society. Damage to human life is described in
patent medicines, tonics, and elixirs sold over the counter con- terms of loss of “disability-adjusted life years” (DALYs). This
tained liberal amounts of opium, cocaine, or alcohol and were measure takes into account the number of years lost due to pre-
not regulated at all until 1906 when the Pure Food and Drug Act mature deaths as well as the years spent living with disability.
created the U.S. Food and Drug Administration (FDA) to regu- Worldwide, psychoactive drugs are responsible for 8.9% of all
late labeling and assess the potential hazards and benefits of all DALYs lost. The main impact is not due to illicit drugs (0.8% of
new medications. DALYs) but to alcohol (4%) and tobacco (4.1%).
In contrast, the behavior and methods of drug use fuel leg- For years the United States has been spending tens of bil-
islation and society's perspective on addiction. For example, in lions of dollars a year in an attempt to control the trafficking
1914, roughly 1 of every 400 Americans was an opiate addict. and use of illicit drugs. Most of those dollars have been used
AtÂ€that time, the Harrison Act was passed, regulating the dispens- to support stricter enforcement. When calculating the actual
ing and use of opioid drugs and cocaine. Prior to the Harrison cost of addiction on society, there are many factors to con-
Act, users procured drugs from their physicians; consequently, sider. Increased chronic illnesses that jeopardize public health
this Act gave rise to street dealers and illegal drug trade. and resources include, but are not limited to, related cases of
Medicalization of drug addiction began in the second half human immunodeficiency virus/acquired immunodeficiency
of the twentieth century but was not taken seriously until the syndrome (HIV/AIDS), hepatitis, asthma, diabetes, cancer,
1950s when the World Health Organization (WHO), followed and mental illnesses. The most recent cost analysis by the
by the American Medical Association (AMA), declared alco- Department of Justice's National Drug Intelligence Center
holism to be a disease. In 1970, the Controlled Substances Act (NDIC) included health care, crime, and the associated loss
replaced or updated all previous federal legislation and led to of productivity for drug abuse which were estimated at $193
the creation of the Drug Enforcement Agency (DEA). Â�billion in 2007 (NDIC, 2011).
CHAPTER 25â•… Substance Use Disorders 633
A further complexity is the realization that approximately is to discourage the initial use of substances such as alcohol,
25% of individuals with an SUD are also diagnosed with a con- tobacco, and illicit drugs among adolescents and children. (See
current mental health diagnoses (Substance Abuse and Mental Healthy People 2020 Objectives box.)
Health Services Administration [SAMHSA], 2007). Substance
use significantly affects not only the user but also his or her Definitions
immediate and extended family as well as the health and safety Distinguishing between the terms abuse, dependence, and
of that person's community. The full impact of substance use addiction has been difficult because they are often used inter-
is evident when assessing teenage pregnancy rates, HIV/AIDS, changeably and incorrectly. For purposes of clarification in
sexually transmitted infections (STIs), domestic violence, child this chapter, definitions are provided. Substance use disorder
abuse, motor vehicle accidents, aggression, crime, homicide and is an overarching term used to encompass both substance
suicide (SAMHSA, 2006). abuse and substance dependence. The gold standard for iden-
Understanding these far-reaching negative consequences is tifying and diagnosing clusters of behaviors is the Diagnostic
the key for health care professionals in educating and develop- and Statistical Manual of Mental Disorders (DSM-IV-TR).
ing solutions to move forward. This chapter presents a broad Published by the American Psychiatric Association (APA), it
overview of substance use and addiction. Theories of addiction, includes criteria for all recognized mental health disorders for
interventions, and community resources addressing problems both children and adults. Accurate assessment of a diagnosis
relevant to community/public health nursing are discussed. directs treatment options.
Substance abuse as defined in the DSM-IV-TR refers to a mal-
Healthy People 2020 Objectives adaptive pattern of substance use manifested by recurrent and
The Healthy People 2020 objectives place a strong emphasis on significant adverse consequences occurring within a 12-month
education at the earliest ages to support prevention efforts and period. Individuals may repeatedly fail to fulfill major role obli-
maintaining cost containment in the future. A primary focus gations, repeatedly use a substance in a situation in which it is
HEALTHY PEOPLE 2020

Substance Abuse Objectives
Health Status Objectives Service and Protection Objectives
1. Reduce alcohol-related motor vehicle crash deaths to 0.38 per 8. Increase the proportion of persons age 12â•›years and older who
100,000 population (baseline: 0.4 per 100,000 in 2008). need alcohol and/or illicit drug treatment and who received spe-
2. Reduce cirrhosis deaths to no more than 8.2 per 100,000 popula- cialty treatment for abuse or dependence in the past year.
tion (baseline: 9.1 cirrhosis deaths per 100,000 population in 2007;
2008 2020
American Indians and Alaska Natives, 25.9; Hispanics, 15.4; males,
Treatment Baseline Target
13.4; in 1998).
3. Reduce drug-induced deaths to no more than 11.3 per 100,000 popu- Illicit drug treatment 16% 17.6%
lation (baseline: 12.6 in 2007). Alcohol and illicit drug treatment 9.9% 10.9%
4. Reduce the occurrence of fetal alcohol spectrum disorders (FASDs) 9. Increase the proportion of persons who are referred for follow-
(baseline: 3.6 per 10,000 live births in 2006). up care for alcohol problems and drug problems after diagnosis
Risk Reduction Objectives or treatment for one of these conditions in a hospital emergency
5. Increase to 94.4% the proportion of adolescents aged 12 to 17â•›years department (developmental: no baseline).
who report no alcohol or illicit drug use in the past 30â•›days (baseline: 10. Increase to 17.6% the number of persons who need illicit drug
85.8% in 2008). treatment and to 16% the number of people who need alcohol
6. Reduce the proportion of persons engaging in binge drinking of alco- treatment who receive specialty treatment for abuse or dependen-
holic beverages during the past 2 weeks. cies in the past year (baseline: 16% of persons with illicit drug
and 10.9%of persons with alcohol abuse or dependencies received
Group 2008 Baseline 2020 Target treatment in 2008).
High school students 25.2% 22.7% 11. Extend to all states and the District of Columbia the number of
College students 40% 36% states with mandatory ignition interlock laws for first and repeat
Note: Binge drinking is defined as having five or more drinks on the impaired driving offenses in the United States (baseline: 15 states
same occasion. in 2009).
12. Increase the number of drug, driving while impaired (DWI), and
7. Increase the percentage of 12- to 17-year-olds who perceive great
other specialty courts in the United States (developmental: no
risk associated with substance abuse.
baseline).
Behavior Perceived 2008 2020
as a Great Risk Baseline Target
Having five or more drinks on a single 40.5% 44.6%
occasion once or twice per week
Smoking marijuana once per month 33.9% 37.3%
Using cocaine once per month 49.7% 54.7%
From U.S. Department of Health and Human Services. (2010). Healthy people 2020. Washington, DC: Author. Retrieved March 23, 2012 from http://www.
healthypeople.gov.
physically hazardous (such as driving while intoxicated), have Age

INDIVIDUAL
multiple legal problems, or have recurrent social or interper- Favorable attitudes
sonal problems because of their substance use (APA, 2000). HOST toward drug use
Substance dependence refers to a cluster of cognitive, Susceptibiltiy to peer
behavioral, and physiological symptoms indicating that the influence
individual continues to use a substance despite significant sub- Possible genetic
susceptibility
stance-related problems. Unlike substance abuse, substance
Prenatal drug use/
dependence also includes symptoms of tolerance, withdrawal,
in utero damage
and a pattern of compulsive use. Dependence includes symp-
Dual diagnosis
toms of taking larger amounts of drugs than intended. There
Brain changes
is often marked difficulty in being able to decrease drug intake.
A majority of a person's time revolves around the activities to
AGENT ENVIRONMENT
obtain and maintain their drug use. Finally, despite acknowl-
Type of drug* Cultural norms and standards
edgement that the drug use is a danger to their individual regarding drugs; public policy
Manufacture and
health, relationships, employment, and social well-being, they mixture of drugs Friends who use drugs
continue to use (APA, 2000). Adulterants and Family history of alcohol and drug use
The APA is in the process of developing a national consen- contaminants Family functioning
sus updating the DSM-V. The new DSM-V will refer to “addic- Strength of drug Extreme wealth or economic
tions and related disorders,” and will eliminate the category deprivation
of dependence to better differentiate between the compulsive Lack of employment opportunities and
community involvement
drug-seeking behavior of addiction and normal responses of
Availability of drugs
tolerance and withdrawal that some experience when using
*Drug refers to alcohol and other drugs.
prescribed medications.
Addiction, is defined by the National Institute on Drug FIGUREÂ€25-1â•‡ Public health model of addiction.
Abuse (NIDA, 2010) as a chronic, relapsing brain disease char-
acterized by compulsive drug seeking despite negative conse-
quences. The definition of a brain disease acknowledges that the The biopsychosocial model of addiction that best fits com-
brain undergoes significant changes in its structure and func- munity/public health nursing is that of the public health model
tion because of illicit substances. Some of these neurochemi- (Figure 25-1). The public health model of addiction stresses
cal and molecular changes may be permanent. As defined by that biological, psychological, pharmacological, and social fac-
the American Society of Addiction Medicine (ASAM), addic- tors constantly interact and influence the problem of addic-
tion also encompasses the genetic, psychosocial, and environ- tion in any person or group of people. As described by Mosher
mental influences in the development of substance use, abuse, (1996), in the public health model, the host is the person who
and dependence (West, 2001). This definition conceptualizes has the addiction; the agent is the alcohol or other drug suffi-
addiction as a chronic disease similar to hypertension or dia- cient in quantity to cause harm to the host; and the environment
betes. As with all chronic diseases, addiction is a pathological includes the social, economic, physical, political, and cultural
condition that has a clearly measurable, characteristic physiol- settings in which the host and agent interact. The environment
ogy and neurobiology. This definition of addiction is consis- also includes the meanings, values, and norms assigned to a
tent with research that has identified genetic factors as well as drug by its culture, community, and society.
environmental factors that precipitate relapse. It is true that alcohol and other drug addictions could not
Another important distinction in addiction is pseudoad- exist if the alcohol or illicit drugs were not available. Therefore,
diction, which includes the characteristics of drug-seeking the role of addicting drugs and alcohol is that of the agent in
compulsive behaviors that are consistent with addiction. The the public health model. The addiction does not occur solely
behaviors are the same but the underlying cause is different. because of the agent. Some host and environmental factors also
Pseudoaddiction occurs in people experiencing inadequate contribute to the development of addiction.
medication management for pain relief. Once the pain is ade- Many of the repetitive behaviors associated with addictions
quately treated, the person no longer abuses the medication. involve multiple brain reward regions and neurotransmitters
This is a very important concept for all health care practitioners that regulate normal consumptive behaviors necessary for sur-
to understand as ineffective pain management directly affects vival, for example, eating and drinking (Guardia etÂ€al., 2000;
the person's ability to heal (Savage, 2003). NIDA, 1994). Scientists are involved in a widely publicized
search for genes that predispose persons to alcoholism and
Theories of Addiction other addictions by regulating brain function. Changes in the
Alcohol and drug addictions appear to be part of a larger con- brain are a major cause of alcohol and other drug addictions.
stellation of related disorders, thought to be clustered around Prescott and colleagues (1999) and other researchers have con-
some underlying biological or genetic mechanism, or multi- ducted twin studies that demonstrate a genetic vulnerability to
factorial cause that is yet to be discovered. A recent trend has alcoholism. Identical twins of alcoholic parents have more than
been to create models of addiction within a biopsychosocial a 60% chance and fraternal twins a 30% chance of becoming
framework that provides a broader, more holistic perspective alcoholics.
on addiction and its prevention, treatment, and research. This Numerous environmental conditions such as physical and
model is being accepted more widely because it can more ade- emotional trauma also play a part in the expression of addic-
quately explain the complex nature of addiction. tions (Sansone et al., 2009). Other environmental risk factors
include economic and social deprivation, low neighborhood A second type of progression involves changes in the
attachment, community norms that facilitate drug use and amount, pattern, and consequences of drug use. The first stage
abuse, and availability of alcohol and other drugs (Trigoboff & in the process of addiction may involve experimental and social
Wilson, 2004). use but, in the second stage, use becomes a regular occurrence
Genetic vulnerability and environmental factors inter- and begins to affect the user's health and well-being. Use might
act to produce addiction; however, addiction can apparently occur during the day and while alone or with others. Substances
be induced without genetic vulnerability through the impact may be used to manipulate varying emotions.
of the environment alone. Mosher (1996, p. 244) stated, Behavioral indicators in the second stage can include a
“Environmental factors—the forces that bring the agent into decline in school or work performance, mood swings, personal-
injurious contact with the host—are critical in the public health ity changes, lying and conning, change in friendships, decrease
model of addiction. A high-risk environment creates a myriad in extracurricular activities, adoption of a drug culture appear-
of opportunities for public health harm.” High-risk environ- ance, conflicts with family members, and preoccupation with
ments can be found in the family, workplace, school, commu- procuring and using alcohol and other drugs. As continued and
nity, and war zones (Table 25-1). increased use progresses, dependency develops. Alcohol and
drugs may be used daily or continuously to avoid negative emo-
The Process of Addiction tions. Use becomes unmanageable as the individual attempts to
There are two types of progression in drug use. In one type, achieve homeostasis and feel normal. Behavioral indicators of
known as the gateway theory of drug use, adolescents begin exper- dependence include physical deterioration, cognitive changes,
imenting with alcohol or tobacco, sometimes later progressing to lack of concern over being discovered, and absence from home,
marijuana. In a small percentage of cases, they move on to other job, or other places of responsibility (SAMHSA, 1994).
types of drugs as they get older. The initial lure may be curiosity, Addiction is a disease of the brain. Abused substances activate
peer pressure, stressors, or simply mimicking adult behaviors. the same brain circuits as do behaviors of basic survival such as
TABLEÂ€25-1â•…â•‡RISK AND PROTECTIVE FACTORS FOR SUBSTANCE USE

RISK FACTORS PROTECTIVE FACTORS
Individual
• Early antisocial behavior • Self-control
• Alienation and rebelliousness • Involvement in religious activities
• Favorable attitudes toward drug use • High self-esteem
• Susceptibility to peer influence • Conventional peer values
• Friends or siblings who use tobacco, alcohol, and drugs • Parental monitoring of peers
• Low academic achievement and absence from school • Academic confidence
• Low self-esteem • Commitment to school
• Delinquent behavior • Attachment to teachers
• Early substance use
Family
• Child abuse and neglect • Parent–child attachment
• Poor parenting skills • Authoritative parenting style, not authoritarian or permissive
• Lack of clear behavioral expectations • Parental educational expectations
• Lack of monitoring and supervision • Parental monitoring
• Lack of caring
• Inconsistent or excessively severe discipline
• History of alcohol and other drug abuse
• Positive parental attitudes toward alcohol and other drug abuse
• Low expectations for children's success
• Family history of alcoholism and substance abuse
Community
• Economic and social deprivation • School antidrug policies
• Low neighborhood attachment • High neighborhood attachment
• Community norms that facilitate drug use, abuse, and trafficking • Laws and penalties
• Availability of alcohol and other drugs • Employment opportunities for youth
• Lack of employment opportunities • Opportunities for community involvement
• Extreme wealth
• Few opportunities for youth involvement in community
• Violence
Risk factors adapted from Comerci, G. D. (2002). The role of the primary care physician. In Schydlower, M. (Ed.). Substance abuse: A guide for
health professionals (pp. 21-41). Elk Grove Village, IL: American Academy of Pediatrics; and Daugherty, R. P., & Leukefeld, C. (1998). Reducing the
risk for substance abuse: A lifespan approach. New York: Plenum Press; Protective factors from Charon Burda.
eating and sex. During repeated drug use, the brain registers the behavior in motion. This knowledge questions the thinking
increased pleasure, which corresponds with increases in a neu- that addiction is related to willpower and free choice (Burns
rotransmitter called dopamine. Dopamine is one of many neu- & Bechara, 2007).
rotransmitters, and it is responsible for feelings of pleasure and Researchers can now visualize and compare brain changes
euphoria. The route it travels in the brain is called the pleasure using brain imaging. Studies show that the brains of heavy
pathway. Once this system is activated, the brain wants to keep chronic drinkers shrink, specifically the frontal lobe, which is
the dopamine levels high to enhance the feelings of intense plea- responsible for decision making and judgment. The cerebellum
sure. The user is then placed in a chronic “cycle of distress” to that governs gait and balance also shrinks. Withdrawal symp-
keep the drug available. Once the pleasure has diminished, the toms occur because the body and the brain have been trying to
need to decrease the anticipated distress of not having the drug create a balance with the continual use of a drug. When the drug
is activated. Drugs that are abused provide very large amounts is no longer available, the systems of the body become overcom-
of dopamine to the brain. In response to the increased dopa- pensated and unbalanced.
mine, the brain regulates itself by decreasing the normal pro-
duction of dopamine. Over time, dopamine regulation becomes EFFECTS OF ALCOHOL AND DRUGS ON THE BODY
altered, and the user is unable to experience pleasure even from
the drugs they crave. The abilities to control decision making Drugs are often categorized by the effects they have on the
and judgment and to manage desires and emotion are all nega- human body (Table 25-2). (See also National Institute on Drug
tively impacted. Abuse, 2011 at http://www.nida.nih.gov/consequences/.) Two
Researchers now believe that the drug-seeking behavior major categories of addictive drugs are central nervous sys-
is a primitive response that occurs prior to conscious aware- tem (CNS) depressants and CNS stimulants. CNS depressants
ness. The limbic system, specifically the nucleus accumbens, include alcohol and certain drugs (see Table 25-2). These drugs
is the area of the brain that starts the drug-seeking addictive depress CNS function and behavior to cause a sense of Â�relaxation
TABLEÂ€25-2â•…â•‡EFFECTS OF SELECTED DRUGS AND ALCOHOL

DESIRED EFFECTS HEALTH CONSEQUENCES
Central Nervous System (CNS) Depressants
Alcohol, barbiturates, Relaxation, euphoria, disinhibition, Death from overdose, alone or in combination with other CNS
benzodiazepines,Â€nonbarbiturates sedation, compliance with social depressants; illnesses resulting from damage caused by chronic
custom, decreased tension and exposure of tissues in every organ and system of the body due to
anxiety, decreased inhibition, toxic effects; irreversible brain damage and resultant cognitive
mental relaxation difficulties, fetal alcohol spectrum disorders, trauma and
accidents, respiratory depression, seizures, coma, death
Narcotics (morphine sulfate, Euphoria, a thrill similar to orgasm, Respiratory failure, coma, death, trauma, and accidents
Percodan,Â€Dilaudid, Damerol, diminished response to pain, during drug-seeking behavior; increased risk for human
Dolophine, Darvon, Talwin, Stadol, drowsiness, decreased anxiety, immunodeficiency virus (HIV) and hepatitis, and localized and
heroin, codeine) and fear systemic infections; convulsions associated with withdrawal
Central Nervous System Stimulants

Cocaine, amphetamines, Ecstasy, Elevated mood, enhanced sexual Hypertension, increased alertness, local anesthesia, cerebral
3-4-methylenedioxy-N- stimulation, euphoria, relief of vascular accident, paranoia, hallucinations, seizures, death, toxic
methamphetamine (MDMA) fatigue, increase in alertness, effects to fetus, increased heart and respiratory rates, irregular
loss of appetite heartbeat, physical collapse, high fever, cardiovascular accident
and cardiac arrest, psychosis
Nicotine (cigarettes, snuff, Relaxation, relief from compliance Increased illness and absence from work, chronic obstructive pulmonary
chewing tobacco, pipes, cigars) with social custom, appetite diseases (emphysema and bronchitis associated with shortness of
control, increase in energy breath, cough, excessive phlegm), coronary heart disease, cancers of
the mouth and lungs, interaction of tobacco smoke with medications
leading to decreased effectiveness of medications
Caffeine (coffee, tea, cola, Relaxation, compliance with social Muscle twitching, rambling thoughts and speech, heart
other soft drinks, chocolate) custom, increased wakefulness, arrhythmias, motor agitation, ringing in the ears, flashes of light,
increased alertness, diminished stomach complaints, breast cysts, spontaneous fetal loss
sense of fatigue, blocked
drowsiness, facilitated mental
activity
Hallucinogens
LSD, PCP, STP, DOM, mescaline, Altered perceptions, heightened Violence and self-inflicted injuries, memory loss and illusions,
psilocybin, or MDMA and MDA awareness, sense of spiritual speech difficulty, convulsions, coma, ruptured blood vessels in
(Ecstasy) insight, increased sexual the brain, cardiac and respiratory failure, psychotic episodes,
pleasure flashbacks
TABLEÂ€25-2â•…â•‡EFFECTS OF SELECTED DRUGS AND ALCOHOL—CONT'D

DESIRED EFFECTS HEALTH CONSEQUENCES
Cannabis, hashish, delta-9- Compliance with social custom, Marijuana: dry mouth, sore throat, increased heart rate, orthostatic
tetrahydrocannabinol (THC) sense of well-being, relaxation, hypotension, bronchitis, immunosuppression, reduction in
altered perceptions, euphoria, testosterone and sperm count, disruption of menstrual periods
increased appetite, relief of nausea and ovulation, anxiety and extreme self-consciousness, paranoia
and vomiting, heightened sensory and panic, impaired judgment, decreased REM sleep, impaired
awareness, enhanced sociability ability to carry out goal-directed tasks, apathy, social withdrawal,
decreased concentration, hallucinations, and delusions
Inhalants
Acetone, benzene, amyl and Disorientation, increased euphoria Mouth ulcers, gastrointestinal problems, anorexia, confusion,
butyl nitrate, nitrous oxide, headache, ataxia, convulsions, death from asphyxiation,
gasoline, toluene permanent brain damage, memory interference, damage to
airways, lungs, kidneys, and liver, and nose bleeds
Anabolic Steroids Maintenance of or improvement Liver damage and liver cancer, endocrine abnormalities (e.g.,
of athletic performance, decreased plasma testosterone, decreased luteinizing hormone,
increased muscle size and strength, atrophy of testes), decreased libido, acne, water and salt
increased aggressiveness retention, stunting of bone growth in children, impotence, mood
swings with paranoia, violent behavior
and Â�drowsiness. At high doses, mental clouding occurs, along can develop tolerance, for example, heroin, there is really no
with a loss of coordination, intoxication, and coma. Analgesics predictable or standardized dose that can be considered “too
frequently have CNS-depressant qualities, although their prin- much” for everyone. Tolerance and experience are the predic-
cipal effect is to reduce the perception of pain. Narcotics or tors of the effects. An overdose amount for a novice user may
opiate-like drugs produce relaxation and sleep. They may not produce any desired effect in an experienced user. In the
also produce a sense of euphoria and a desire to keep tak- public health context, an overdose is generally defined as exhi-
ing the drug. Drugs in this class also include oxycodone (e.g., bition of symptoms that indicate an individual has taken a level
Oxycontin) and hydrocodone (e.g., Vicodin). CNS stimulants of a drug (or combination of drugs) that exceeds the person's
produce increased electrical activity in the brain and behavioral individual tolerance. In the case of heroin, which is a respira-
arousal, alertness, and a sense of well-being. Drugs in this class tory depressant, these symptoms include loss of consciousness;
include amphetamines (e.g., Adderal), cocaine, caffeine, meth- breathing that slows significantly or stops; and the person's lips,
ylphenidate (e.g., Ritalin, Concerta), and 3-4-methylenedioxy- skin or nails turning blue from lack of oxygen.
N-Â�methamphetamine (MDMA; “Ecstasy”).
Hallucinogens, or mind-altering drugs, including marijuana, Common Drugs
alter one's perception of reality. LSD (lysergic acid diethylamide) Alcohol
is the most potent hallucinogen. Ecstasy, popular among chil- Alcohol is one of the most frequently used problematic drugs.
dren and adolescents, has the properties of both a stimulant and Ethyl alcohol, or ethanol, is an intoxicating ingredient found
a hallucinogen. Inhalant use is most common among children in beer, wine, and liquor. A standard drink equals 0.6 ounces
and adolescents because inhalants are affordable and accessible. of pure ethanol, or 12 ounces of beer; 8 ounces of malt liquor;
Inhalants include aerosols, gasoline, correction fluid, cleaning 5Â€ounces of wine; or 1.5 ounces (a “shot”) of 80-proof distilled
solutions, and other commonly used chemicals. Irreversible spirits or liquor (e.g., gin, rum, vodka, or whiskey). Alcohol is
effects can be hearing loss, limb spasms, CNS or brain damage, absorbed through the digestive tract into the bloodstream, and
or bone marrow damage. Death from heart failure or suffoca- some of the factors that affect absorption include the amount
tion (inhalants displace oxygen in the lungs) can occur. consumed in a given time, the type and amount of food in the
Tolerance is the capacity to ingest more of the substance than stomach, the drinker's size, and the drinker's gender.
other persons without showing impaired function. Because tol- Alcohol is not excreted from or stored anywhere in the body
erance develops with repeated use over a period of time, tol- before metabolism; it is distributed throughout the body flu-
erance can be an early sign that the person is developing an ids. It does not distribute much into fatty tissues; therefore, at a
addiction. In the United States, alcohol tolerance often remains given weight, a female who has a higher proportion of body fat
unrecognized because of the cultural myth that a man should be than a male has less volume in which to distribute the alcohol.
able to “hold his liquor.” The consequence is that signs of toler- This explains why the blood alcohol levels (BAC) are higher for
ance that could lead to early intervention are often overlooked, females than males of the same weight.
and the addiction progresses. A late-developing symptom of Alcohol is toxic. A self-protective vomiting reflex occurs at
chronic addiction is a reduced tolerance for high blood levels of a BAC level of about 0.12% but only if consumption is rapid.
alcohol or other drugs, which develops when the diseased liver However, if BAC levels are increased gradually, the vomiting
can no longer process the ingested substance efficiently. center is depressed, and the individual can drink up to lethal
Most people would define an overdose as taking too much concentrations. Death from acute alcohol intoxication is often
of a drug. How much is “too much”? For a drug to which one the result of respiratory failure.
Marijuana Amphetamines, synthesized in 1932, were first used via

The most commonly used illegal drug is marijuana, which is inhalation to dilate nasal and bronchial passages of asthmat-
prepared from the leafy materials of the cannabis plant. Delta- ics and in products for treatment of stuffy noses. However,
9-tetrahydrocannabinol (THC) is one of the psychoactive com- in the 1970s, they went from being widely used and accepted
ponents found in the flowering tops, leaves, and stalks. Hashish to being tightly restricted and associated with drug abusing
is the most potent plant preparation, as it is pure concen- “hippies.” As a reaction, illicit, clandestine laboratories began
trated plant resin. When smoked, THC is rapidly absorbed in making methamphetamine. Use of the smoked form, known
the blood. Once distributed to the brain, it influences pleasure, as “ice” or “crystal meth,” quickly spread from the west coast
memory, thought, concentration, sensory and time perception, to the rural midwest of the United States. Methamphetamine
and coordinated movement. increases wakefulness and physical activity, produces rapid
Marijuana also affects the heart. Some studies show that heart rate, irregular heartbeat, and increased blood pressure
a marijuana users’ risk of heart attack more than quadru- and body temperature.
ples in the first hour after smoking the drug. This could be
a result of marijuana's effects on blood pressure, heart rate, Club Drugs
and oxygen-carrying capacity of blood. Even infrequent use Teenagers and young adults at bars, nightclubs, concerts,
can cause burning and stinging of the mouth and the throat, and parties most often use “club drugs.” Club drugs include
which is often accompanied by a heavy cough. Regular use MDMA (Ecstasy), gamma-hydroxybutyric acid (GHB), fluni-
may have similar effects on the lungs as those of smoking trazepam (Rohypnol), ketamine, and others. They have vary-
cigarettes. Marijuana smoke contains 50% to 70% more caring effects. MDMA is a synthetic drug that has stimulant and
cinogenic hydrocarbons than does tobacco smoke, and mar- psychoactive properties. It is taken orally as a capsule or tab-
ijuana users inhale more deeply than do tobacco smokers let. Negative effects experienced on consumption of the drug
(Mayo Clinic, 2006). Ecstasy include blurred vision, muscle tension, nausea, invol-
In addition to being a social drug, marijuana has also been untary teeth clenching, and sweating as well as psychological
studied for its therapeutic abilities. Some of its potential ben- effects such as anxiety, depression, paranoia, memory loss, and
efits are alleviation of nausea, vomiting, and the loss of appetite insomnia. Users, specifically those in raves and clubs, may also
resulting from chemotherapy; reduction of intraocular pressure experience acute dehydration if they are active and are not con-
in glaucoma; reduction of muscle spasms; and relief from mild suming enough water. MDMA, by itself, is not fatal but can lead
to moderate chronic pain. A legal form is available by prescrip- to death when accompanied by overheating and dehydration
tion in some states. and by inhibiting urine production leading to fatal buildup of
fluid in the tissues. MDMA is one of two drugs, the other being
Opiates alcohol, for which there is significant evidence that it destroys
Opiates (e.g., morphine and codeine) are derived from the brain cells. Ketamine distorts perception and produces feelings
opium poppy. The major therapeutic indication for this drug of detachment from the environment and self, while GHB and
group is pain relief. However, because this group of drugs can Rohypnol have sedating effects. GHB abuse can cause coma and
also cause constipation, it has saved the lives of many people seizures. High doses of ketamine can cause delirium and amne-
with dysentery. Narcotics have been used to counteract diarrhea sia. Rohypnol can incapacitate the users and cause amnesia and
and the resulting dehydration in both young and older per- can be lethal, especially when mixed with alcohol.
sons in developing countries. Heroin is two to three times more
potent than morphine because heroin's additional two acetyl Prescription Drugs
groups permit it to penetrate the blood–brain barrier more Misuse of prescription drugs is becoming an increasing prob-
readily. Heroin users live on a cyclic schedule, requiring a dose lem, especially among America's youth. Second only to mari-
every 4 to 6 hours. The short-term effects of heroin include a juana, it is the most prevalent form of illegal drug use among
surge of euphoria and clouded thinking, followed by alternating adolescents and young adults (SAMHSA, 2007). There are
wakeful and drowsy states. two types of misuse: Prescription medication misuse, which
is defined as an intentional, risk behavior that involves the
Stimulants improper use of one's own prescription medications, moti-
Cocaine and amphetamines are considered the most addictive vated by a desire to treat one's symptoms or experiment, or
drugs consumed by man. Stimulants keep the user mentally for any other reason. It is a form of nonadherence because the
and physically alert. Cocaine has multiple routes of administra- user either fails to use the medication exactly as prescribed
tion: orally, by injection, or by inhalation. Its form often dictates (e.g., taking the medication too frequently, or increasing the
administration. For example, coca leaves contain between 0.1% medication dose without supervision). Another form of mis-
and 0.9% cocaine, and chewing cocaine rarely causes any social use is a risky behavior that involves the intentional use of
or medical problems for the user. Drinking coca tea tends to someone else's prescription medication motivated only by the
soothe the stomach. While powder cocaine, which has come to desire to alleviate symptoms that may be related to an actual
symbolize the rich and famous, is expensive, cocaine in its lump or perceived health problem, to experiment, to get high, or to
form (“crack”) is very inexpensive. There is great variability in create an altered state.
the uptake and metabolism of cocaine, so a lethal dose is diffi- Drug diversion and sources of nonmedical prescription drug
cult to estimate. Cocaine can trigger cardiac changes and aller- use include “doctor shopping,” leftover supplies from physi-
gic reactions to the drug or to other additives found in street cal illness, friends and peers, buying prescription drugs on the
cocaine. Chronic toxicity may lead to malnourishment, and streets, pharmacy and hospital thefts, and stealing from fam-
bingers can experience irritability and paranoia to the extent of ily member's medicine cabinet (Boyd etÂ€al., 2007; Inciardi etÂ€al.,
experiencing hallucinations. 2007; Johnston etÂ€al., 2008).
Over-the-Counter Medications
MONITORING INCIDENCE AND PREVALENCE
The abuse of over-the-counter (OTC) cold medications by ado-
lescents is also on the rise in the United States. There has been In the United States, data on drug use and problems are collected
a 10-fold increase in cold medicine abuse during 1990 to 2004, from various sources. The National Survey on Drug Use and
with a 15-fold increase among those aged 9 to 17â•›years (Levine, Health (https://nsduhweb.rti.org/RespWeb/homepage2.cfm) pro-
2007). An ingredient in many cough and cold remedies, dextro- vides national-level and state-level estimates of drug use (includ-
methorphan hydrobromide, or more commonly known by its ing nonmedical use of prescription drugs) and alcohol use as
street name DXM, is the most popular antitussive medication well as patterns and consequences of drug use in the general U.S.
in the United States. Intoxication by DXM occurs by consuming civilian population aged 12â•›years and older. Scientific random
large doses which can lead to different affects ranging from mild samples of households are selected across the United States, and
distortions of color or sound to “out of body” dissociative sen- the data from these surveys provide current, relevant informa-
sations, visual hallucinations, and total loss of motor control. tion on drug use in the country. (See other secondary resources
Other OTC products used for weight control and sleep aids in this text's website). In addition, major epidemiological stud-
are monitored by the FDA for their toxicity and abuse potential; ies such as the National Comorbidity Studies and the National
however, herbal products that may also have some psychoactive Epidemiologic Survey on Alcohol and Related Conditions, find
properties are not (SAMHSA, 2007). Energy drinks and many consistent comorbidity patterns of SUDs with other psychiat-
nonprescription drugs contain large amounts of caffeine. The ric disorders in the U.S. civilian, noninstitutionalized population
absorption is rapid after oral intake, with peak levels occurring aged 18â•›years and older (Compton etÂ€al, 2007; Kessler etÂ€al, 2005).
30 minutes after ingestion. Caffeine is not extremely toxic, and Two additional minority-specific psychiatric epidemiology stud-
overdoses are rare but can happen. Death occurs from convul- ies conducted in the United States, using nationally representative
sions, which lead to respiratory arrest. While many people enjoy samples, are the National Survey of African Americans (NSAA) and
the stimulating effects of caffeine, its unpleasant symptoms the National Latino and Asian American Study (NLAAS). Disclosing
such as irritability, nervousness, insomnia, heart arrhythmias, the use of drugs is, understandably, a sensitive issue. Thus, every
and gastrointestinal disturbances are often overlooked. effort, including assurance of anonymity, is made to encourage hon-
esty. Large surveys must rely on self-reported behaviors.
Drug Combinations
A particularly dangerous, and not uncommon, practice is com- Prevalence of Drug Use and Drug-Related Problems
bining alcohol with drugs or combining multiple drugs. The In 2009, an estimated 22.5 million persons (8.9% of the pop-
practice ranges from the coadministration of legal drugs such as ulation aged 12â•›years or older) were classified with substance
alcohol and nicotine, to the dangerous random mixing of pre- dependence or abuse in the past year based on DSM-IV-TR
scription drugs, to the deadly combination of heroin or cocaine criteria (Figure 25-2). Of these, 3.2 million were classified
with fentanyl (an opioid pain medication). Whatever the con- with dependence on or abuse of both alcohol and illicit drugs,
text, it is critical to realize that because of drug–drug interac- 3.9Â€million were dependent on or abused illicit drugs but not
tions, such practices often pose significantly higher risks than alcohol, and 15.4 million were dependent on or abused alcohol
the individual risks of the already harmful drugs. but not illicit drugs (SAMHSA, 2010).
25
22.5 22.2 22.6 22.3 22.2 22.5
22.0 21.6
20
Numbers in Millions
15
10
0
2002 2003 2004 2005 2006 2007 2008 2009
Both Alcohol and Illicit Drugs Illicit Drugs Only Alcohol Only
FIGUREÂ€25-2â•‡ Substance dependence or abuse in the past year among persons aged 12â•›years or
older: 2002–2009. (From Substance Abuse and Mental Health Services Administration. [2010]. Results from
the 2009 National Survey on Drug Abuse and Health: National findings. Rockville, MD: Author.)
Of nearly 4.6 million drug-related emergency department current use of tobacco products and cigarettes among young
(ED) visits, half were attributed to adverse reactions to phar- adults; in 2002, the rates were 45.3% and 40.8%, respectively.
maceuticals, and almost one-half (45.1%, or 2.1 million) were The percentage of cigarette smokers among 12- and 13-year-
attributed to drug misuse or abuse. ED visits involving misuse olds also dropped from 2.1% in 2008 to 1.4% in 2009. About
or abuse of pharmaceuticals increased by 98.4% between 2004 one-fifth (20.4%) of persons aged 35â•›years or older in 2009 had
and 2009, from 627,291 visits in 2004 to1,244,679 visits in 2009 smoked cigarettes in the past month.
(SAMHSA [DAWN], 2010). Current use of a tobacco product among persons aged
12â•›years or older was reported by a higher percentage of males
Demographic Distribution of Substance Use and Abuse (33.5% and females 22.2%). Among 12- to 17-year-olds, the
Distribution of Alcohol Use rate was slightly higher for males, but the difference was not sta-
According to the 2009 National Survey on Drug Use and Health tistically significant.
NSDUH (SAMHSA, 2010), of Americans aged 12â•›years or older, In 2009, the prevalence of current use of a tobacco prod-
51.9% (more than 130 million people) are current drinkers of uct among persons aged 12â•›years or older was 11.9% for Asian
alcohol (consumed at least one drink in the past 30â•›days). Of Americans, 23.2% for Hispanic Americans, 26.5% for African
Americans aged 12â•›years or older, nearly one-Â�quarter (23.7%, or Americans, 29.6% for whites, 36.6% for persons who reported
almost 60 million people) participated in binge drinking (five or two or more races, and 41.8% for American Indians or Alaska
more drinks on the same occasion) at least once in the 30â•›days Natives. After increasing from 0.7% in 2007 to 1.4% in 2008,
prior to the survey, and 6.8% (more than 17 million people) use of smokeless tobacco in the past month among African
reported heavy drinking (five or more drinks on the same occa- Americans decreased to 0.9% in 2009.
sion, on 5 or more days in the past month). As observed from 2002 onward, cigarette smoking in the
Rates of alcohol use vary by age; 3.5% among persons aged 12 past month was less prevalent among adults who were college
to 13â•›years; 13% among those aged 14 to 15â•›years; 26.3% among graduates compared with those with less education. Among
those aged 16 to 17â•›years; 49.7% among those aged 18 to 20â•›years; adults aged 18â•›years or older, current cigarette use in 2009 was
and 70.2% among those aged 21 to 25â•›years. Underage drinking reported by 35.4% of those who had not completed high school,
is particularly problematic for many reasons. An estimated 6.3% 30% of high school graduates who did not attend college, 25.4%
of 16- to 17-year-olds and 16.6% of 18- to 20-year-olds report of persons with some college, and 13.1% of college graduates
driving under the influence (DUI) of alcohol in the past year, but (SAMSHA, 2010).
the rate is higher for persons aged 21 to 25â•›years (24.8%).
Among older age groups, the prevalence of current alcohol Distribution of Illicit Drug Use
use decreases with increasing age, from 66.4% among 26- to The National Survey on Drug Use and Health (NSDUH)
29-year-olds, to 50.3% among 60- to 64-year-olds, and 39.1% obtains information on the use of illicit drugs, including mar-
among those aged 65â•›years or older (SAMHSA, 2010). ijuana/hashish, powdered and crack cocaine, heroin, halluci-
More males drink (57.6%) compared with females (46.5%), nogens (including among others, LSD, phencyclidine [PCP],
but among younger current drinkers aged 12 to 17â•›years, the rates mushrooms and MDMA or “Ecstasy”), and inhalants (such as
are more similar (15.1% for males, 14.3% for females). Males nitrous oxide, amyl nitrite, gasoline, and various other clean-
aged 12 to 20â•›years report more current, binge drinking and heavy ing fluids, and solvents). The NSDUH also collects information
alcohol use (28.5%, 20.5%, and 7%, respectively) compared with on the nonmedical use of prescription-type pain relievers, tran-
females in that age group (25.8%, 15.5%, and 3.7%). quilizers, stimulants, and sedatives, including drugs which are,
Whites are more likely than any other racial or ethnic group or have been, available by prescription, as well as those which
to report current use of alcohol (56.7%), compared with 47.6% may be manufactured and distributed illegally, such as the stim-
for persons reporting two or more races, 42.8% for African ulant methamphetamine.
Americans, 41.7% for Hispanic Americans, 37.6% for Asian In 2009, an estimated 8.7% of the population aged 12â•›years or
Americans, and 37.1% for American Indians or Alaska Natives. older (21.8 million Americans) were current (past month) illicit
Binge drinking was lowest among Asian Americans (11.1%), drug users, which represents an increase from 8% in 2008 and
and highest among whites and Hispanic Americans (24.8% and 7.9% in 2004 (SAMHSA, 2010). Illicit drug use was most preva-
25%, respectively), with African Americans, American Indians/ lent among those 18 to 20â•›years of age (Figure 25-3). Marijuana
Alaska Natives, and individuals reporting two or more races was the most commonly used illicit drug (76.6%, or 16.7
falling in the middle (19.8%, 22.2%, and 24.1%, respectively) million past month users). Of illicit drug users over age 12â•›years,
(SAMHSA, 2010). 58% used only marijuana.
Approximately 9.2 million people over age 12â•›years were cur-
Distribution of Tobacco Use rent users of illicit drugs other than marijuana in 2009. Of these,
Annually, tobacco use results in more deaths (443,000 per year) the majority (7 million persons, or 2.8% of the population)
compared with deaths from AIDS, unintentional injuries, suicide, used psychotherapeutic drugs nonmedically in the past month.
homicide, and alcohol and drug use combined (SAMHSA, 2010). An estimated 5.3 million persons used pain relievers nonmedi-
The rate of current use of any tobacco product among cally in the past month, 2 million used tranquilizers, 1.3 million
persons aged 12â•›years or older remained steady from 2008 to used stimulants, and 370,000 used sedatives (SAMHSA, 2010).
2009 (28.4% and 27.7%, respectively). Young adults aged 18 to Males were more likely to use specific drugs compared with
25â•›years had the highest rate of current use of a tobacco product females, for example, marijuana (8.6% versus 4.8%), psy-
(41.6%) compared with youth aged 12 to 17â•›years and adults chotherapeutics (3.1% versus 2.4% for nonmedical use) and
aged 26â•›years or older (11.6% and 27.3%, respectively). Between cocaine (0.9% versus 0.4%). However, for nonmedical use of
2002 and 2009, there was a significant decrease in the rates of tranquilizers, the rate of 0.8% was found in both groups.
25
23.1
22.2
2009
20.5
20.5
2010
20
16.7
16.6
Percent Using in Past Month
14.8
14.4
15
12.9
10.5
9.0
9.3
10
8.1
8.0
7.2
7.2
6.9
6.9
6.5
6.5
5.4
4.1
3.6
4.0
3.1
2.7
1.1
0.9
0
14–15 18–20 26–29 35–39 45–49 55–59 65
12–13 16–17 21–25 30–34 40–44 50–54 60–64
Age in Years
FIGUREÂ€25-3â•‡Past month illicit drug use among persons aged 12â•›years or older, by age: 2009
and 2010. (From Substance Abuse and Mental Health Services Administration. [2010] Results from the 2009
National Survey on Drug Abuse and Health: National findings. Rockville, MD: Author.)
In 2009, the rates of illicit drug use according to race or eth- diagnosed with an antisocial personality or conduct disorder
nicity varied. The lowest use was found among Asian Americans increases one's risk factors for addiction (Compton etÂ€al., 2005).
(3.7%). Rates were highest for American Indians or Alaska SUDs and psychiatric disorders are complex combinations
Natives (18.3%), 9.6% for African Americans, 8.8% for whites, of behaviors that are the result of maladaptive brain changes,
and 7.9% for Hispanic Americans. genetic vulnerabilities, and/or environmental exposures. EnviÂ�
The rate of substance use is lower among college gradu- ronÂ�mental exposures in early brain development involv-
ates (6.1%) than among those who do not graduate from high ing increased stress, negative psychosocial experiences, or
school (10.2%). However, college graduates were more likely to trauma are the current focus of many research investigations.
have tried illicit drug use in their lifetime compared with adults Traumatic experiences, either physical or emotional, increase
who had not graduated from high school (51.8% versus 39.7%) the risk of substance use of both illicit drugs and prescription
drugs (National Institutes of Health, National Institute on Drug
Distribution of Poly-Drug Users Abuse [NIH/NIDA], 2010.) One special population that is iden-
Alcohol users often also smoke tobacco and use other drugs. tified as having experienced trauma and is vulnerable to psychi-
Among heavy alcohol users aged 12â•›years and older, 56.3% atric disorders and increased substance misuse are veterans who
smoked cigarettes in the past month, whereas only 18.5% have seen combat. Soldiers returning from Iraq and Afghanistan
of current non–binge drinkers, and 15.9% of those who did report posttraumatic stress disorder (PTSD) or major depres-
not drink alcohol in the past month were current smokers sion at a rate of 1 in 5. More research is needed to find the causes
(SAMHSA, 2010). According to the 2009 NSDUH, persons aged and the effective treatments for individuals suffering from these
12â•›years or older with no current alcohol use were less likely to devastating co-occurring conditions.
have used illicit drugs (3.7%), compared with those who cur- Although SUDs commonly occur with other mental ill-
rently used alcohol (5.6%) and those with binge alcohol use nesses, this does not mean that one causes the other, even if
(17.9%) or heavy use (33.2%). Underage drinkers are more one behavior is observed first. In fact, establishing which came
likely (17.5%) than those aged 21â•›years or older (5%) to have first or why can be difficult. Current research suggests the fol-
used illicit drugs within 2 hours of their last reported drinking lowing possibilities for this common co-occurrence: (1) Drug
occasion (SAMHSA, 2010). abuse may bring about symptoms of another mental illness (for
example, increased risk of psychosis in vulnerable marijuana
Co-occurring Disorders users); or (2) those suffering from anxiety or depression may
Some people may exhibit psychiatric disorders and SUDs, a con- rely on alcohol, tobacco, and other substances to alleviate their
dition called co-occurring disorders, or comorbidity. Persons symptoms. Therefore, some propose that mental illness can
who suffer from a mood disorder or anxiety are twice as likely to lead to drug abuse through self-medication (NIH/NIDA, 2010).
use or abuse illicit drugs compared with persons without these Other comorbid conditions include SUDs with a co-occurring
disorders (Conway etÂ€al., 2006). Some persons with diagnosed medical condition. Diseases that are strongly linked to abuse of
personality disorders also have higher incidence of SUDs. Being alcohol, tobacco, and drugs are extensive.
Substance Use in the Workplace Currently, many serious barriers to reporting impaired health
Problems related to alcohol and drug abuse cost American care professionals continue to exist. Many states have mandatory
businesses roughly $81 billion in lost productivity in just reporting laws that may hold colleagues responsible for harm
1â•›year. Nearly 75% of all adult illicit drug users are employed, to patients if they fail to report a co-worker who is suspected
as are most binge and heavy alcohol users (USDHHS, 1995). to be abusing substances. In states with alternative programs,
Studies show that when compared with non–substance abusers, confidential reporting to the programs absolves the colleague
substance-abusing employees are more likely to change jobs from reporting to the nursing regulatory board. In a survey by
frequently, be late to or absent from work, be less productive DesRoches etÂ€al. (2010), 64% of physicians agreed that there was
employees, be involved in a workplace accident, and file a a professional obligation to report; however, despite observation
workers’ compensation claim. of impaired colleagues, few reports are actually made. Findings
Work roles with little or no supervision and those character- by Bettinardi-Angres & Bologeorges (2011) found similar results
ized by high mobility are associated with increased rates of prob- among nurses with regard to reporting. Both physician and
lem drinking. Studies suggest a significant relationship between nurse groups reported an assumption that someone else should
work stress and access to alcohol and the development of drug be responsible for monitoring job performance; they believed
and drinking problems. The workplace culture may also encour- that less-than-optimal accommodations would ultimately result,
age the use of alcohol or drugs at lunchtimes or after work. and some feared retaliation for their personal involvement.
Some places of employment conduct drug testing. There are Nurses, who actively use substances at work, can endan-
a number of ways this can be done, including preemployment ger clients by diverting pain relief medications to themselves,
testing, random testing, reasonable suspicion/cause testing, neglecting client care, committing errors, and focusing on their
postaccident testing, and follow-up testing. Typically, a drug own needs. These situations can also risk the safety of other
panel tests for marijuana, cocaine, opioids, amphetamines, and staff. Trinkoff and colleagues (1991) examined a large sam-
PCP, but other drugs can be added. The tests are very accurate ple of nurses and reported that although alcohol abuse was
but not 100% accurate. Usually, samples are divided, so a pos- low, nurses had higher rates of prescription drug use. Nurses
itive result can be confirmed on the replicate sample. Federal have easy access to prescription drugs such as tranquilizers,
guidelines are in place to ensure accuracy and fairness in drug amphetamines, opiates, and sedatives. These drugs may be used
testing programs. Signs of drug use in the workplace include at higher doses or more often than prescribed, or for nonap-
the following: proved reasons (Trinkoff & Storr, 1998). Some researchers have
• Increased short-term sickness and absenteeism found a strong link between symptoms that precede depression
• Deterioration in relationships with colleagues, customers, or and substance abuse. Trinkoff and colleagues (2000) identi-
management fied contributory conditions that increase substance abuse risk
• Altered and slow reactions in nurses, including easy access to prescription-type drugs, job
• Unusual irritability or aggression stress or role strain, and depressive symptoms.
• Poor quality of work Several professional organizations have developed resources
• Low productivity for impaired nurses. One leader in this area is the American
• Increased workload for colleagues Association of Nurse Anesthetists, which has its own Peer
• Increased levels of accidents and mistakes Assistance Program. Other nursing specialty resources include
• Increases in petty theft the Association of Perioperative Registered Nurses and the
Emergency Nurses Association.
Prevalence of Substance Abuse among The National Council of State Boards of Nursing (NCSBN)
RegisteredÂ€Nurses is the culminating body of all 50 state boards of nursing. They
Substance use among health care professionals is of concern have set model guidelines for nondisciplinary alternative pro-
because of the ramifications to the safety of patients entrusted grams for impaired nurses. These alternative programs allow
to their care. Health care professionals potentially have nurses to engage in recovery and retain their professional lives.
greater access to medicines and drugs; therefore, increased Substance use by health care professionals is a public health
use among them is possible. Use in the nursing population is problem. All nurses should be educated on SUDs and be aware
believed to be similar to use in the general population, which of workplace policies that address substance use by staff. Nurses
is 10%. Some report that the actual prevalence could be as should become familiar with and use the nursing professional
high as 20%, taking underreporting into account (Monroe & organizations for assistance. When nurses are educated and
Kenaga, 2010). nonjudgmental in their approach, they enhance recovery with
Impaired nurses and their peers may be negatively affected evidence-based practices and compassion.
by stigma in their professional lives. Ineffective punitive atti-
tudes and policies decrease the ability to seek assistance and STIGMA AND LANGUAGE
become a barrier to treatment access. The American Nurses
Association (ANA) defines impaired nurses as those who are There are cultural differences in alcohol and illicit drug use,
actively using brain-altering chemicals while treating clients. as well as socioeconomic differences within cultural groups.
This activity affects one's cognitive, interpersonal, and psycho- Awareness of specific cultural and regional differences will
motor skills that are required to perform job responsibilities increase community/public health nurses’ ability to engage
optimally. The ANA (2001) mandates that all nurses, regard- individuals seeking assistance. Advocating for clients requires
less of their specialty or role, take an active part in reporting an awareness of subtle stereotypes, which can be stigmatiz-
impaired colleagues. The ANA considers reporting an ethical ing and can become a barrier to treatment. Professional nurses
obligation. must be vigilant not to judge an individual based on his or her
actual or potential alcohol and illicit drug use. Nurses must rec- Prenatal tobacco, alcohol, and/or drug exposure can have
ognize that alcohol and illicit drug addiction are identified in serious consequences for the infant. Different substances pro-
every area and social group. Community/public health nurses duce different effects, and the developing fetus is often exposed
should also realize that one abused drug is not worse than to multiple substances during pregnancy if the mother has
another. They all have similar devastating effects on the indian SUD. For example, the developing fetus is exposed to the
vidual, the family, and the community. Stigma has been identi- nicotine, hydrogen cyanide, and carbon monoxide in a smok-
fied as one of the major treatment barriers for persons with an ing mother's bloodstream, and this can result in significant
SUD. Stigma focuses on a person's difference, not on common- negative consequences such as premature birth and low birth
ality, and on personal challenge not on strength. Preventing and weight. Not all women who abuse alcohol or drugs give birth to
reducing negative stereotyping of persons with SUDs requires babies with serious health problems. The amount of damage,
the willingness of nurses to assess their personal underlying which is highly variable, is related to the quantity, frequency,
perceptions and attitudes. and timing of exposure; both maternal and fetal metabolism;
Stigma is often hidden in language and in the terminology individual susceptibility; and probably differences in Â�maternal
used. The terminology individuals use reflects their regard for health. Why some women manage to have healthy pregnancies
another. People are not their behavior, disability, or disorder. despite substance abuse is unknown (Haack, 1997). Beyond
This recognition requires the purposeful use of person first fetal exposure, children of impaired mothers experience a lack
language. Terminology that reflects nonjudgmental and cul- of emotional attachment or bonding. They are apt to have
turally sensitive responses will allow for therapeutic alliances higher levels of stress and inconsistency in their day-to-day
to enhance communication. Some negative terminology in the lives. Brain development depends on the child's experience.
medical field is habitual and requires vigilance: for example, Healthy emotional bonds with an unstressed adult are optimal
when referring to laboratory results, use of the words “clean” for neurobiological brain development. Many impaired par-
and “dirty” are implied negative reflections on the individual. ents experiencing SUDs are unable to be emotionally available
These words should be replaced with “negative,” “positive,” or to their offspring, which can negatively affect immature brain
“substance free.” Another example is the uninformed habit of development (Mate, 2010).
identifying an individual as their disorder. Calling someone a
“junkie” or “addict” identifies the whole person; it is better to Effects of Prenatal Alcohol Exposure
say “a person with a substance use disorder,” which identifies No level of maternal alcohol use is known to be safe for the devel-
substance use as a part of a person's behavior. oping fetus. In 2009, an estimated 10% of pregnant women aged
According to the National Alliance of Advocates for 15 to 44â•›years reported current use of alcohol, 4.4% reported
Bupernorphine Treatment (NAABT, 2008), the declaration of binge drinking, and 0.8% reported heavy drinking. These rates
the nation's “War on Drugs” included the use of derogatory were significantly lower compared with those for nonpregnant
terms as a deterrent to drug use. At that time, the science and women in the same age groups (54.4% current use, 24.5% binge
evidenced-based practices related to addiction were compara- drinking, and 5.5% heavy use). The rate of binge drinking in the
tively limited. A national solution to addiction was identified in first trimester of pregnancy was estimated to be 11.9% of preg-
a simple slogan, “Just say no.” Currently, a wealth of research that nant women aged 15 to 44â•›years in 2009, up from 6.6% in 2006
speaks to the complexity and science of addiction is available. to 2007 (SAMHSA, 2010, p. 31).
Public health nurses are change agents. They implement the Chronic alcohol use in women places their children at risk
most effective nursing interventions with individuals, fami- of developing addictive disorders. Binge drinking also plays a
lies, and communities. The words and actions they model in major role in risk, exposing the fetus to high levels of alcohol
the community create attitudes of positive regard and can build within short periods. Several alcohol-related developmental
self-esteem and create motivation for growth. Healthy modeling disorders are recognized under the umbrella term fetal alcohol
directly impacts the daily lives and health of the people served. spectrum disorders (FASDs):
The dynamic scientific advances made in understanding addic- • Fetal alcohol syndrome (FAS)
tion must be reflected in the very words each professional uses. • Alcohol-related neurodevelopmental disorders (ARNDs)
• Alcohol-related birth defects (ARBDs)
IMPACT OF SUBSTANCE USE DISORDERS The incidence of FAS in the United States is estimated to be
1 to 2 per 1000 births. The combined incidence of FAS, ARND,
ONÂ€INDIVIDUALS AND FAMILY MEMBERS and ARBD is 10 per 1000 births (May & Gossage, 2001).
The public health impact of addiction affects all citizens and Unfortunately, the incidence rate has not improved over
their families. Some of the social and human costs are outlined the years. The Institute of Medicine has defined the diagnos-
in the sections that follow. tic characteristics of these disorders, which are based on his-
tory of maternal alcohol use during pregnancy, facial features,
Infants and Children of Mothers with Prenatal small gestational age, abnormalities in the CNS, and failure to
Substance Use Disorders thrive that is not related to poor nutrition. Figure 25-4 shows an
infant with FAS. A child with FASD or ARND may not have the
“If our society were truly to appreciate the significance of physical features of FAS but have behavioral or cognitive abnor-
children's emotional ties throughout the first years of life, malities. New research uses neuroimaging to demonstrate per-
it would no longer tolerate children growing up, or parents manent structural brain abnormalities. Some changes include
having to struggle, in situations that cannot possibly nourish smaller-than-normal brain size and decreased white matter.
healthy growth.” Other observations include malfunctioning in various regions
(Stanley Greenspan, MD, 1997, p. 37) of the brain (Norman etÂ€al., 2009).
Effects of Prenatal Cocaine and Heroin Exposure

Problems connected with cocaine abuse include intracranial
hemorrhage in the fetus and serious complications of preg-
nancy such as abruptio placentae. During the first 4â•›months
of life, cocaine-exposed infants can continue to experience an
abstinence syndrome and exhibit abnormal behaviors, includ-
ing rapid mood changes and tremulousness. Infants exposed to
cocaine in utero may have great difficulty bonding. Although
emotionally labile, they can be difficult to soothe, hold, and
cuddle, which further hampers positive interactions with their
mothers. If the mother does not receive guidance in parent-
ing her baby and/or treatment for her cocaine use disorder,
she may be at risk for abusing and/or neglecting her child (see
ChapterÂ€23). Community/public health nurses can play a key
role in providing or facilitating access to parenting skills train-
ing and substance abuse treatment.
Infants of mothers dependent on heroin or methadone may
experience withdrawal symptoms after birth and compromised
growth and development patterns. For pregnant women depen-
dent on heroin, the policy in the United States is that it is safer
for the fetus if the woman is maintained on methadone or
buprenorphine. Attempts to withdraw from heroin should not
be made without prescribed pharmaceutical intervention.
FIGUREÂ€25-4â•‡Infant with fetal alcohol syndrome. Note the Community/public health nurses need to continue to build
long, smooth philtrum, thin upper lip, short nose, and flat mid- trust and educate adolescents and women of childbearing age
face. (From Markiewicz M, Abrahamson E. (1999). Diagnosis in color: about the risks of substance use and abuse during pregnancy.
Neonatology. St. Louis: Mosby.) Early intervention is key.
Children and Teens

Some common symptoms observed may include learning The National Survey on Drug Use and Health surveys chil-
disabilities, intellectual disabilities or low IQ (intelligence quo- dren 12â•›years of age and older. However, a growing number
tient), speech and language delays, poor reasoning and judgment of children even younger are using alcohol and illicit drugs
skills, attention deficits, poor memory, and poor coordination. in all regions of the country (Monitoring the Future, 2011).
These behaviors are on a spectrum of severity, depending on There are regional differences in degree of risk and availability
the individual. There is no cure for FASD, but there are protec- of substances. Children of parents who misuse substances are
tive factors. According to the Centers for Disease Control and at higher risk to use at younger ages and are more vulnerable
Prevention (CDC, 2011), the protective factors include diagno- to addiction in their lifetime. Current estimates are that over
sis and early intervention before age 6â•›years; provision of a lov- 28Â€million Americans have parents with alcoholism, and many
ing, stable home environment; involvement in special education more have parents addicted to other substances (Adult Children
and social services; as well as protection from any experience of of Alcoholics [ACOA], n.d.). Experiences and common themes
violence. Developmental disabilities related to maternal alcohol for adult children of alcoholics were described by a few pioneer-
consumption are serious but preventable. ing authors (Wegscheider, 1981; Woititz, 1983).
The lives of infants and children with FASDs can be The children of impaired parents experience certain com-
improved through early identification and treatment. Early mon characteristics, including feelings of low self-esteem,
intervention is important for infants whose mothers abused impaired attention disorders, difficulty with authority figures,
alcohol prenatally. Once maternal alcohol use during preg- social inadequacy, and a heightened sense of responsibility.
nancy is documented and a diagnosis is established, the child is They have a higher risk of exposure to domestic violence, both
eligible for early intervention services under Part C of the fed- in observation and in experience. Physical and sexual abuses,
eral Individuals with Disabilities Education Act (IDEA). These which can result in traumatic stress and significantly impact
services are critical to helping the child achieve optimal func- functioning in later years, are not uncommon. The inattention
tioning during his or her lifetime (Welch-Carre, 2005). (See of the affected parent can cause alterations in parental attach-
ChapterÂ€30.) It should be noted that it is not easy to detect FAS ment and trust that may affect the ability of the child to form
during the neonatal period because the facial features associ- healthy relationships in the future (Barnard & McKeganey
ated with the syndrome are difficult to recognize, and the CNS 2004). As mentioned in previous sections, the genetic compo-
dysfunction might not be identified until several years after nents and in utero exposure place these children at an increased
birth. Often, students with FASD are misdiagnosed as hav- risk of addiction in their lifetimes. With regard to their envi-
ing attention-deficit hyperactivity disorder (ADHD) and are ronment, they experience unpredictable parental responses
improperly medicated. Current scientific evidence suggests and inconsistent parenting practices. This can prove confus-
that although persons with FASDs have attention or arousal ing and anxiety provoking, causing an overwhelming com-
regulation problems, their difficulties are not the same as those pulsion to please. There is often increased family conflict and
characterizing ADHD. chaos, secondary to financial difficulty and legal involvements
(Haggerty etÂ€al., 2008; Skinner etÂ€al., 2011). Children learn by Recovery from addiction can be a long course of learning
example and mimic the behavior of their peer group and/or the and implementing new behaviors, for both the person with
adults in their environments. One major effect on these chil- the SUD and the family members. In the majority of peo-
dren is that they often have to guess about what normal behav- ple who seek assistance, recovery is experienced as a chronic,
ior is when observing the behavior of other people. relapsing process. This complex chronicity and relapse has
SUDs are found in every geographical area and economy. been compared to three chronic medical illnesses: type II dia-
Children are the most vulnerable and are severely impacted betes, hypertension, and asthma (McLellan etÂ€al., 2000). Long
by impaired adults who cannot be depended on for consistent recoveries underline the importance of continuing assessment,
care. Maladaptive learned behaviors in the family can contrib- ongoing family intervention, and appropriate referrals, when
ute to the generational transmission of substance misuse and necessary, to address emotional and physical problems. When
unhealthy relationships that impact our communities well a person's recovery is complicated by a personality disorder or
into the future. a psychiatric disorder, an even longer period of intervention
and healing is needed. The community/public health nurse can
Family Dysfunction and Co-dependence assist such families by encouraging active participation in self-
Family dysfunction and appropriate interventions are addressed help groups, helping to establish social support systems, rec-
in detail in ChaptersÂ€12 through 14. Families with members ommending counseling and intervening to bring dysfunctional
who have addictions exhibit characteristic dysfunctional family family patterns into balance. The SAMHSA has established a
patterns. A full elaboration of the family dynamics associated National Registry of Evidence-Based Programs and Practices
with addiction is not possible in this text due to constraints of (NREPP). The registry includes a searchable database of inter-
space. These dysfunctional patterns in relationships are some- ventions for the prevention and treatment of mental disor-
times characterized as co-dependent. Co-dependence is a term ders and SUDs and organizations to implement programs and
used to describe the relationship between a person with an SUD practices in communities. Further information can be found at
and one or more persons who attempt to assist through empa- http://www.nrepp.samhsa.gov.
thy and encouragement. This support person works to limit or
eliminate the harmful consequences of the substance misuse. ADDICTIONS AND COMMUNICABLE DISEASES
Unfortunately, at times the abuser is enabled to continue the
addiction pattern because he or she does not have to confront Communicable diseases that are linked with alcohol and other
the negative consequences of the addiction behaviors. drug addictions include tuberculosis (TB), sexually transmitted
One pattern identified by family theorists involves labeling infections (STIs), and serum-transmitted diseases, especially
or blaming (scapegoating) an individual as the sole source of HIV infection and hepatitis B and C. These communicable dis-
the family's problems. For example, an adolescent who smokes eases are discussed at length in ChaptersÂ€7 and 8.
marijuana at school is often the index case in a family with other Coexistence of an alcohol disorder and TB places people
members who have alcohol and drug problems. Nonaddicted at higher risk for poor health outcomes and death. In chronic
family members are frequently “overfunctioners”; their overre- alcohol use, the immune system is suppressed, and alcohol
sponsible behaviors compensate for the irresponsible behaviors hepatitis can gravely complicate TB treatment. Oeltmann etÂ€al.
exhibited by the family member with the SUD. If the overre- (2009) found that roughly one in five people with TB in the
sponsible individuals are able to stop taking on responsibili- United States reported abusing alcohol or other drugs, mak-
ties that belong to the affected family member, then that person ing addiction a leading risk factor for the disease. Screening
will be more easily recruited into treatment (see Secondary for SUDs is not a common standard in primary care practices,
Prevention later). which can further increase risk of poor outcomes. Treatment
Sometimes, families coping with addiction reorganize and for comorbid diseases cannot be implemented in isolation. All
exclude the addicted person (often a parent). The parent–child of a person's comorbid states must be addressed to maximize
or parent–spouse subsystem is left in a weaker position as a positive results.
result. A strong alliance may develop between the nonaddicted Homeless persons with addictions live in environmentally
partner and that partner's parent or other extended family mem- compromising conditions (see ChapterÂ€21). Interactions with
ber. Another pattern that may emerge is overcloseness between a someone who has TB or HIV infection are highly possible, par-
grandparent and one or more grandchildren. This strong bond ticularly if that person is under the influence of alcohol and/
results in weakened parental authority and permits the addicted or other drugs. Overcrowded environments, unprotected sex,
parent to underfunction in the parental role. Inner city fami- and intravenous drug use with needle sharing contribute to
lies with addicted members often exhibit this pattern—a strong increased infection. The spread of chronic diseases such as TB
grandparent caring for the grandchild and an impaired, drug- and HIV/AIDS are a major public health concern.
addicted parent. Both the impaired parent and the grandchild are According to the National Survey on Drug use and Health
treated as children by the grandparent. If a nonaddicted parent (SAMHSA, 2010) the estimated annual average of diagnosed
is present, that parent is closer to the children, as a general rule. HIV/AIDS cases in the United States is 420,000 among persons
Children triangled into the parental relationship and caught up aged 12â•›years and older. This average was calculated using data
in a pattern of increased intimacy with one parent and distanced from 2005 to 2009. Of these, 16% had used intravenous drugs,
from the other parent often are deterred from achieving their 64% had used drugs but not intravenously, and 23% were in
normal developmental tasks. They grow up either overfunc- need of professional treatment for alcohol or drug use in the
tioning and overachieving, therefore acting as parents to their past year prior to diagnosis.
parents, or significantly underfunctioning, therefore becoming Sex with an infected intravenous drug user can also play
unsuccessful, inadequate adults. an important role (see the Ethics in Practice box). High-risk
ETHICS IN PRACTICE
Conflict among Community Values Gail Ann DeLuca Havens, PhD, RN
Tom sits and listens to the rancor and divisiveness apparent in the people in the United States. The sharing of drug paraphernalia and
remarks of some of the city's residents at a forum called to discuss unprotected sexual intercourse are associated with the majority of all
the implementation of the syringe exchange program in the city next reported cases of AIDS (Centers for Disease Control and Prevention
month. He feels a momentary twinge of regret for having brought the [CDC], 2010a). The CDC estimates that more than one million people
issue to this point. Tom is a community/public health nurse and clinical are living with HIV in the United States (CDC, 2010b), with one in five
director of the municipally operated community-based health care cen- (21%) unaware of their infection.
ter with the largest caseload of human immunodeficiency virus (HIV)– Historically, the concept of syringe exchange programs has been
infected clients in the city. He understands that the critical nature of controversial in this country (DesJarlais etÂ€al., 2009), perceived as a
the near-epidemic proportions of the incidence of acquired immunode- major threat to the integrity of our societal norms. They have been
ficiency syndrome (AIDS) in the community requires proven interven- Â�characterized as an affront to society (Shaw, 2006).
tions if the spread of HIV is to be controlled. Unfortunately, a syringe In addressing this dilemma, several fundamental questions might be
exchange program, although shown to be a very effective deterrent posed. What obligations does society have to its individual members?
to the spread of the virus, comes with a large price tag: polarization Are they obligations that apply to every member of society? Do the
of community residents because of the moral questions it raises. It is benefits to individual members of a society to be derived from a syringe
Tom's turn to speak. exchange program outweigh the harm to society, collectively, that is
“I'm pleased to see so many of our city's residents participating in inherent in such a program? Which harm is the community willing to
the forums about the syringe exchange program. I understand that the tolerate: The potential for harm to the community's moral norms by
program is very controversial. It is viewed by many as sending a mes- condoning illegal drug use and by creating a situation that might pre-
sage that this city condones drug addiction. It is feared that it will cipitate drug use? Or the certain harm that will befall drug users who
contribute to an increase in drug addiction. And from a practical view- are exposed to HIV infection through needle sharing?
point, it was in direct violation of one of our city ordinances, namely, When we speak about obligations, we are implying that correspond-
the prohibition against possession of intravenous injection parapher- ing rights exist. Certain obligations fall to a society to ensure that the
nalia. As a point of information, the law has been amended to allow rights of its individual members are met. Individual rights were not con-
an exception such as this. ceived as having infinite dimensions. Rather, they are defined by the
“I understand that for many of you this program represents a deg- rules and norms imposed on them by society. It is the existence of pre-
radation of the prevailing moral norms that exist in this city. You are vailing norms of a society and its general moral code that frequently
afraid that clean needles will encourage drug abuse. A well-conceived precipitate a moral dilemma. City residents are being asked to support
syringe exchange program, however, includes more than the exchange a program that contradicts the prevailing moral norm. Furthermore, to
of contaminated equipment for clean needles and syringes. The cor- compound the moral tension, they are being asked to support a pro-
nerstone of such a program is the educational focus on a drug-free gram for people living at the edges of society, namely, drug abusers. Do
existence. Unfortunately, in some metropolitan areas of the United the nature of the situation and the characteristics of the people who
States, drug users who decide to break the habit do not have immedi- will benefit from a syringe exchange program limit society's obligation?
ate access to counseling and support but, instead, are placed on wait- One approach to the resolution of this dilemma would be for the resi-
ing lists for instruction and rehabilitation to help them become free dents of the city to refuse to condone and support a syringe exchange
of drugs. We are fortunate in our city in that we believe we have the program, rationalizing that they have no obligation to support individu-
necessary resources dedicated to the drug treatment component of the als’ drug habits. An alternative approach of the city's residents, consid-
syringe exchange program to ensure that anyone wishing to enroll in ering the positive empirical evidence, would be to support the syringe
the program will have immediate access. exchange program, thereby fulfilling a societal obligation to its individ-
“Syringe exchange programs have been found to be very effective ual members regardless of lifestyle. The city also would be protecting
interventions, with some programs 100% effective in avoiding an the public through the control of communicable disease.
increase in HIV infection. Syringe exchange options have met with Finally, where do the nurse's moral and professional obligations lie
extraordinary success in terms of preventing or slowing HIV infection in this situation? The American Nurses Association (ANA) Code of
among intravenous drug users (Tempalski etÂ€al., 2007). This success Ethics for Nurses was modified substantially in 2001 so that the obli-
has occurred without an increase in drug abuse. I believe that if we fail gations of its members to individual members of society are clarified
to initiate such a program in our city, where the incidence of AIDS is by the corresponding rights of clients. That is, the client has a right to
significantly higher than the national average for cities of comparable nursing care that “transcends all individual differences” (ANA (2001),
size, we will be guilty of a greater moral harm. For not only do we deny p.Â€7). Furthermore, “an individual's lifestyle, value system and religious
noninfected drug users in our city the means to maintain their HIV-free beliefs should be considered in planning health care with and for each
status, but we also reduce the likelihood that they will participate in patient” (ANA (2001), p. 7). Accordingly, the nurse's practice ought to
drug abuse educational programs that have the potential to empower include nonjudgmental care and advocacy that respects the patient as
them to break their drug habit. I ask you to understand that by not ini- a person and supports the patient's right to care.
tiating this program, we condemn some fellow citizens to chronic ill- Tom has chosen this approach. What would you have done?
ness and death through the uncontrolled spread of HIV. I am here this
evening to respond to your questions and to ask for your cooperation References:
and support as we prepare to begin the syringe exchange program in American Nurses Association. (2001). Code of ethics for nurses with
our city next month.” interpretive statements. Washington, DC: Author.
The moral issues in this case have arisen because of differences Centers for Disease Control and Prevention. (2010a). Basic information
in fundamental perspectives about what ought to be societal priori- about HIV and AIDS. Retrieved May 9, 2011 from http://www.cdc.
ties for health care in the face of the growing numbers of HIV-positive gov/hiv/topics/basic/index.htm/.
Conflict among Community Values Gail Ann DeLuca Havens, PhD, RN
Centers for Disease Control and Prevention. (2010b). HIV in the United Shaw, S. J. (2006). Public citizens, marginalized communities: The
States. Retrieved May 9, 2011 from http://www.cdc.gov/hiv/ struggle for syringe exchange in Springfield, Massachusetts.
resources/factsheets/us.htm/. Medical Anthropology, 25â•›(1), 31-63.
DesJarlais, D. C., McKnight, C., Goldblatt, C., etÂ€al. (2009). Doing harm Tempalski, B., Flom, P. L., Friedman, S. R., etÂ€al. (2007). Social and political
reduction better: Syringe exchange in the United States. Addiction, factors predicting the presence of syringe exchange programs in 96 US
104, 1441-1446. metropolitan areas. American Journal of Public Health, 97, 437-447.
sexual practices are fueled by mood-altering licit or illicit Primary prevention involves the identification and modifi-
drugs because of their effects on brain function. Higher corti- cation of risk and protective factors that apply to alcohol and
cal functions involving judgment, cognition, and perception other drug use. The benefits of primary prevention include
are compromised, precautions are not taken, and riskier sexual improved health; reduced medical costs and loss of time from
behaviors occur. school and work; and greatly improved quality of life for indi-
viduals, their family members, and the community. Five gen-
RESPONSIBILITIES OF THE COMMUNITY/PUBLIC eral prevention strategies are effective in addressing alcohol and
other drug addictions in the community (Center for Substance
HEALTH NURSE Abuse Prevention, 1994a, 1994b):
Nurses with preparation in the areas of addiction are an asset 1. Information dissemination: providing education or information
in community care settings. New and exciting opportuni- 2. Promotion of personal development: developing life coping skills
ties have emerged for participation in a variety of commu- 3. Identification of alternatives: providing alternative experiences
nity settings as the treatment emphasis has shifted from acute 4. Establishment of norms and standards: advocating for a healthy
inpatient to community-based care. Approaches focused on environment
at-risk, underserved populations are essential. For all health 5. Community development: mobilizing the community
care professionals, health promotion and primary prevention These strategies can be used with individuals, families, and
should be the focus because successful interventions have the peer groups or with the community as a whole. As a nurse devel-
capacity to affect the behaviors of a large segment of the pop- ops a planned primary prevention intervention using any of the
ulation. Interventions that reduce the use of illicit drugs and strategies, it is important to build that program around risk and
increase abstinence or judicious use of alcohol save lives and protective factors. Risk factors include attitudes, beliefs, behaviors,
ultimately reduce costs to the health care system. Treatment situations, and actions that might place a person, group, orga-
needs to be flexible, integrated, comprehensive, and outcome nization, or community at risk for experiencing drug addiction
driven. The individual and the family become the central and its effects (see Table 25-1). Risk factors predict the increased
focus, and sustained recovery is the optimal outcome. Truly, probability of future addiction. Protective factors include atti-
this is a public health approach encompassing physical, men- tudes, beliefs, behaviors, situations, and actions that protect a
tal, spiritual, and social well-being. person, group, organization, or community from the effects of
drug addiction. Recognizing and targeting individuals and popu-
Importance of Primary Prevention and Health Promotion lations who are at risk is part of any primary prevention strategy.
The main focus of Healthy People 2020 (USDHHS, 2010) is
primary prevention and health promotion. The targeted audi- Community-Focused Prevention
ence is the larger percentage of the population that currently Alcohol and other drug prevention programs that are part of a
does not have addictions. Particular emphasis should be placed broader, generic effort to promote health will be more effective.
on youth because early initiation of substance use is a precur- In addition, the more comprehensive the program is, the more
sor of long-term use, dependence, and abuse (Hawkins, 2002; effective it will be. A model of a comprehensive primary preven-
Hawkins etÂ€al., 1997). Studies report that the earlier people tion program for a community is presented in Table 25-3. The
started drinking, the more likely they were to be diagnosed as coordinated effort facilitates a coming together of all key peo-
alcohol abusers. About 48% of people who began drinking at ple and places in a community setting. Community members,
age 13â•›years were diagnosed as alcohol dependent at some point employers, nurses and other health care professionals, and fam-
in their lives. Only 17% of persons who started drinking at age ily members need to be involved. In-school education about the
18â•›years and 10% of those who started drinking at age 22â•›years effects of alcohol and other drugs on driving is an outstanding
had similar diagnoses (Grant & Dawson, 1998). example of a prevention effort that has decreased teen fatalities
in motor vehicle accidents.
Topics in Health Promotion and Prevention To achieve community mobilization, a community must have
Areas to be addressed in health promotion include abstinence a sense of unity, recognize a need for action, and have the energy
or sensible limits for appropriate age groups; effects of alcohol to act to address problems or concerns. Community mobilization
and other drugs on the body (both immediate and long term); efforts should focus on the enhancement of protective factors
differences in quantity of consumption for beer, wine, and hard that will empower community members to make healthy choices
liquor; and appropriate use of prescribed and OTC medications. and lead healthy lives in relation to alcohol and other drugs. For
Sharing information specific to the individual's need enhances example, regulating the density of alcohol outlets and increasing
personal interest and builds trust. alcohol taxes are recommended community interventions (Guide
TABLEÂ€25-3â•…â•‡COMPREHENSIVE MODEL OF PRIMARY PREVENTION OF ADDICTION

TARGET GROUPS
INDIVIDUAL COMMUNITY
METHODS (ACROSSÂ€THE LIFE SPAN) FAMILY PEERS SCHOOL/WORK (CULTURE-SPECIFIC)
Education and Posters Programs Seminars Teacher and supervisor Brochure distribution
information training
Personal development Skill building Parenting training Work teams Supportive environment Wellness programs
Alternatives After-school programs Family night Mentors Company teams Park facilities
Norms and standards Alcohol, tobacco, and other Health care Peer support SAP/EAP Money to agencies
drug use principles, beliefs, coverage for programs
and behaviors treatment
Community mobilization Cleanup projects Family support Alcohol-free Coalition building Media campaign
events
EAP, Employee assistance programs; SAP, student assistance programs.
From Allen, K. (1996). Prevention. In K. Allen (Ed.), Nursing care of the addicted client (p. 94). Philadelphia: Lippincott.
to Community Prevention, 2011). The role of community/public Resources for individuals with addictions and for their
health nursing at this level of primary prevention involves help- Â�
family members need to be available and financially accessible.
ing communities identify a shared concern regarding alcohol and Unfortunately, that is often not the case (see ChaptersÂ€21 and
other drug addiction, helping them mobilize their capacity, and 33). Community/public health nurses can advocate for insur-
helping them become ready for focused action. ance coverage for treatment and increased referral sources, as
The Federal Center for Substance Abuse Prevention has well as for workplace programs.
played a major role in promoting the development of commu-
nity coalitions by providing communities with millions of dol- Screening and Detection
lars in funding to set up partnerships for developing community Public health nurses are trusted professionals within commu-
programs to prevent alcohol and other drug abuse. These part- nities who can identify children and their families in need of
nerships include community and business leaders, religious early intervention and assistance. Awareness of the most cur-
leaders, health care agencies, and law enforcement officials. rent clinical guidelines, evidence-based practices developed by
the federal government and local agencies, and referral sources
Secondary Prevention is essential in reducing ongoing suffering among undiagnosed
Early diagnosis and treatment of addictions is important. or untreated children.
Community/public health nurses should make every effort to Nurses should screen for alcohol consumption in any setting
identify at-risk clients and provide the appropriate brief inter- in which women of reproductive age are treated or where prena-
vention. According to the SAMHSA (1999), “brief interventions tal care is provided. Using nonconfrontational approaches such
are those practices that aim to investigate a potential problem as questions imbedded in regular health questionnaires is most
and motivate an individual to do something about his substance effective. Several useful instruments are available on the web-
abuse, either by natural, client-directed means or by seeking addi- site of the National Institute on Alcohol Abuse and Alcoholism
tional substance abuse treatment.” This definition, along with (NIAAA) at http://www.niaaa.nih.gov, and the NIAAA (1995)
guidelines and best practices for brief interventions, are provided clinicians’ guide.
in SAMHSA's Treatment Intervention Protocol (TIP) Series The goal of screening for alcohol and other drug abuse or
No. 34, Brief Interventions and Brief Therapies for Substance addictions is to identify persons who have or are at risk for
Abuse, which can be downloaded from http: //www.kap.samhsa. developing alcohol or drug-related problems and to engage
gov/products/manuals/tips/index.htm. them in further diagnosis and treatment of their problem.
Early detection and treatment can mitigate the problems of Biological tests as well as written questionnaires are available
addiction. Once individuals with substance use–related issues for use in screening. Although many laboratory tests can detect
are identified, community/public health nurses can act as case alcohol and other drugs in urine and blood, they measure recent
managers for these individuals. They can monitor and coordi- use rather than long-term use or dependence. Laboratory tests
nate resources and services during all stages of recovery. are best used when assessing someone to confirm a diagnosis,
It is essential that community/public health nurses take whereas questionnaires are best used for screening.
on a strong teaching and support role. Individuals and fami- Various questionnaires are available for screening for alcohol
lies need to learn about the disease concept of addictions; the and other drug abuse. If a screening result is positive, the next
symptoms and expected relapses over the course of the ill- step for the nurse is to explore the history of an individual's alco-
ness and recovery; and the management of symptoms. Nurses hol and/or drug use and problems. The nurse should observe
can also lessen the effects of addiction on all family members for any physical, psychological, and social signs of dependence
by building on the strengths of the family. Because of their and dysfunction. Communication with family members can
knowledge of community resources for addiction treatment, provide useful information.
community/public health nurses can refer family members
to appropriate treatment resources and support groups such Screening Tools
as 12-step self-help groups. Nursing efforts can be directed It is recommended that screening tools be able to detect both alco-
toward other family
Â� members and community resources if the hol and drug use and be specific to the given population. For exam-
member with the SUD is not available. ple, instruments such as CAGE-AID (Box 25-1) are appropriate
BOXÂ€25-1â•…â•‡THE CAGE AND CAGE-AID for Teenagers (POSIT) is effective for adolescents (Table 25-5).
QUESTIONS* These instruments are widely used, and their validity and reliability
have been established; that is, they detect alcohol and drug use as
1. In the last 3â•›months, have you felt you should cut down or stop intended and can be relied on to do so repeatedly.
drinking or using drugs?
 Yes  No Assessment and Diagnosis
2. In the last 3â•›months, has anyone annoyed you or gotten on your According to the DSM-IV-TR (APA, 2000) dependence can be
nerves by telling you to cut down or stop drinking or using drugs? diagnosed when at least three of the following symptoms have
 Yes  No occurred within a 12-month period:
3. In the last 3â•›months, have you felt guilty or bad about how much • Tolerance to or a marked need for increased amounts of a
you drink or use? substance to achieve the desired effect
 Yes  No • Withdrawal symptoms
4. In the last 3â•›months, have you been waking up wanting to have an
• Unsuccessful attempts to cut down or control use
alcoholic drink (eye-opener) or use drugs?
• Abandonment or reduction of important social, occupa-
 Yes  No
tional, or recreational activities due to substance use
Scoring: Each affirmative response earns one point. One point indi-
cates a possible problem. Two points indicates a probable problem. • Continuation of use despite knowledge of recurrent physical
or psychological problems
*The original CAGE questions appear in plain type. CAGE acronym
is made from bolded words. The CAGE Adapted to Include Drugs
questions are the original CAGE questions modified by the italicized text. Mary initially began to consume alcohol to relieve anxiety
From Ewing, J. (1984). Detecting alcoholism: The CAGE questionnaire. and tension. She had a family history of alcohol dependence
Journal of the American Medical Association, 252, 1905–1907, with but never thought she would become an alcoholic. At first,
permission (original CAGE questions); and Dube, C., Goldstein, she could control her drinking, limiting it to two or three
M.Â€G., & Lewis, D. C. (1989). Project ADEPT volume I: Core modules. drinks on any given occasion. As time progressed, she began
Providence, Â€RI: Brown University, with permission.
to lose the ability to predict how much alcohol she might
consume during any one episode. She would say to herself,
“I'll only have one or two drinks.” She would end up drink-
when detecting late-stage chronic use. The AUDIT-C is an effective
ing four, five, or more drinks. Sometimes, she would have
brief screening three-question tool for alcohol use in early stages of
blackouts with memory loss. It seemed that once she started
risk or dependence in adults. The geriatric version of the Michigan
to drink, she could no longer limit her intake or stop drink-
Alcoholism Screening Test (MAST-G) (Table 25-4) is appropriate
ing after consuming a predetermined amount.
for use with seniors. The Problem Oriented Screening Instrument
TABLEÂ€25-4â•…â•‡MICHIGAN ALCOHOLISM SCREENING TEST—GERIATRIC VERSION (MAST-G)

1. After drinking, have you ever noticed an increase in your heart rate or beating in your chest? Yes No
2. When talking with others, do you ever underestimate how much you actually drink? Yes No
3. Does alcohol make you sleepy so that you often fall asleep in your chair? Yes No
4. After a few drinks, have you sometimes not eaten or been able to skip a meal because you Yes No
did not feel hungry?
5. Does having a few drinks help decrease your shakiness or tremors? Yes No
6. Does alcohol sometimes make it hard for you to remember parts of the day or night? Yes No
7. Do you have rules for yourself that you will not drink before a certain time of the day? Yes No
8. Have you lost interest in hobbies or activities you used to enjoy? Yes No
9. When you wake up in morning, do you ever have trouble remembering part of the night before? Yes No
10. Does having a drink help you sleep? Yes No
1 1. Do you hide your alcohol bottles from family members? Yes No
12. After a social gathering, have you ever felt embarrassed because you drank too much? Yes No
13. Have you ever been concerned that drinking might be harmful to your health? Yes No
14. Do you like to end an evening with a nightcap? Yes No
15. Did you find your drinking increased after someone close to you died? Yes No
16. In general, would you prefer to have a few drinks at home rather than go out to social events? Yes No
17. Are you drinking more now than in the past? Yes No
18. Do you usually take a drink to relax or calm your nerves? Yes No
19. Do you drink to take your mind off your problems? Yes No
20. Have you ever increased your drinking after experiencing a loss in your life? Yes No
21. Do you sometimes drive when you have had too much to drink? Yes No
22. Has a doctor or nurse ever said they were worried or concerned about your drinking? Yes No
23. Have you ever made rules to manage your drinking? Yes No
24. When you feel lonely does having a drink help? Yes No
Scoring: 5 or more “yes” responses is indicative of an alcohol problem.
From Blow F. C., Brower, K. J., Schulenberg, J. E., etÂ€al. (1992). The Michigan Alcoholism Screening Test—Geriatric Version (MAST-G): A new elderly-
specific screening instrument. Alcoholism: Clinical and Experimental Research,â•›16, 372. The Regents of the University of Michigan, 1991.
TABLEÂ€25-5â•…â•‡SAMPLE QUESTIONS Fred works for a national packing and shipping company.
FROM PROBLEM-ORIENTED He is divorced, lives alone, and works the evening shift at
SCREENING INSTRUMENT the company's local facility. Most of his socializing is done
FOR TEENAGERS (POSIT) after work at his neighborhood bar, where he has a cadre
of friends. He drinks seven to eight cans of beer each night,
1. Do you have so much energy you do not know Yes No
what to do with it? sometimes with a shot of whiskey first. He does not drink
2. Do you brag? Yes No before going to work. His immediate family members live
3. Do you get into trouble because you use drugs Yes No out of state and are concerned about his drinking habit, but
or alcohol at school? he does not see any problem.
4. Do your friends get bored at parties when alcohol Yes No Fred states that his drinking does not affect his workplace
is not served? performance. He has received two citations for driving under
5. Is it hard for you to ask for help from others? Yes No the influence (DUI). When he received the second citation,
6. Has there been adult supervision at the parties Yes No he hired a lawyer (for $2500) and was successful in having the
you have gone to recently? charges dropped. Because he already had one DUI citation,
7. Do your parents or guardians argue a lot? Yes No a second citation would have affected his ability to drive to
8. Do you usually think about how your actions Yes No work. One day, he just woke up and started drinking. He did
will affect others? not go to work or call in sick and did not answer his phone.
9. Have you recently either lost or gained more Yes No He stayed out for 5â•›days without notifying his supervisor. He
than 10 pounds? was in danger of losing his job of 22â•›years. His supervisor
10. Have you ever had sex with someone who used Yes No discussed the problem with one of his co-workers. The co-
intravenous drugs? worker contacted his relatives out of state. One of his sib-
From National Institute of Alcohol Abuse and Alcoholism. (1995). lings flew in and was successful in convincing him to seek
Assessing alcohol problems: A guide for clinicians and researchers treatment. He entered a 30-day outpatient daily substance
(pp.Â€431-441). USDHHS Publication No. 95–3745. Bethesda, MD: abuse program, and his supervisor allowed him to resume
National Institutes of Health. work after he completed the program.
After screening and assessments are completed, the com-
munity/public health nurse or other health care professional The nurse's input can help a client at a crisis point similar
should initiate some type of intervention. A review of screen- to that experienced by Fred by supporting an intervention ses-
ing tool results and any other test results are a first step. Where sion with concerned relatives, friends, or co-workers. During
appropriate, nurses can assist individuals with nondependent a planned intervention, the interveners share critical informa-
problem drinking through education and the establishment of tion with the addict. This may include the observations of fam-
sensible drinking goals. According to the National Institute of ily members about the addictive symptoms and the personal
Alcohol Abuse and Alcoholism (NIAAA) the recommendations impact each has experienced. The impact of symptoms on job
on consumption are the following: performance and the worry this creates for family members
• Men, no more than two drinks per day may also be appropriate. The future implications of the addic-
• Women, no more than one drink per day tion for the health of all family members, the current needs for
• Those 65â•›years of age or older, no more than one drink per day treatment of the addiction, and treatment options should also
• Although it was not addressed in the guidelines, children and be explored.
adolescents up to age 18 or 21â•›years (depending on state law) In advance of the intervention session, family members or
should drink no alcohol at all significant others can be encouraged to attend support meetings
Persons with alcohol or other drug dependence should be like Al-Anon, or seek individual counseling to help understand
referred for specialized addiction treatment. For those who their role and continued relationship in this difficult process.
are not ready to modify their behavior or seek treatment, Family members are also encouraged to investigate treatment
the nurse should continue a strategy of empathy, building facilities and explore reasonable options. Multiple evidence-
trust, and supporting individual strengths and healthy goals. based resources are available for patients and families. Family
Recommendations about substance use can be integrated with members require emotional support and education. They need
health concerns and the consequences of continued use; this to hear that the problem is no one's fault. They need to know
integration enhances motivation for change in health habits. that treatment is effective and that self-help is available to help
them recover.
Treatment Engagement
Assisting individuals from referral into treatment may involve Treatment Programs
anticipation of negative circumstances such as fear of job loss Treatment programs are based on levels of need according
or faltering relationships. They may require a collaboration of to presenting symptoms of acuity and comorbidities. The
many facets of their life; family members, a partner or parent, level of care is on a continuum from most restrictive to least
a health care professional, an employer, the school system, the restrictive, and individuals can start and progress as assessed
social services system, or the legal system may be involved. by their health care provider. Placement in the least restric-
The beliefs that one has to “hit bottom” before entering treat- tive environment to enhance the individual's personal auton-
ment, has to want treatment, or has to act on his or her own to omy and personal strengths is optimal. The levels include the
get help are unfounded in current research. The ability to use following: specialty hospitals for detoxification and inpa-
judgment and clear thinking is often altered by their addiction. tient treatment, residential rehabilitation programs; Â�partial
hospitalization or day treatment programs; therapeutic voluntary, and the only requirement for membership is a
communities; outpatient care programs; “e-therapy”; and desire to stop drinking.
medication-assisted therapies. Narcotics Anonymous (NA), Gamblers Anonymous (GA), Sex
Treatment is a process, and effective treatment must address and Love Addicts Anonymous (SLAA), Overeaters Anonymous
the whole person. This entails not only the addiction but all of (OA), and Co-dependents Anonymous (CODA) are other self-
the associated medical, psychiatric, social, vocational, spiritual, help groups that have spun off from the original 12-step AA
and legal issues as well. As with all chronic disorders, treatment movement. Each addresses a particular area of need.
requires a comprehensive approach.
Self-Help Groups and Programs for Spouses and
Detoxification Co-dependents
Detoxification treatment for withdrawal from alcohol and Other 12-step programs modeled on AA include Al-Anon,
other drugs might be necessary for some substance-Â�dependent Alateen, and Alatot. Family members of impaired individu-
individuals. Although medical detoxification is available als can educate themselves about addiction and increase their
in hospitals, most detoxification treatment is provided in social supports.
community-based outpatient programs. A person experi-
Â� Groups of Adult Children of Alcoholics (ACOA) were stimu-
encing withdrawal is isolated in a quiet room and calmed lated by the written accounts of a few pioneering authors who
by nursing care that includes frequent checks of vital signs; described experiences of growing up in an addicted family and
appropriate reassurance; reality orientation to time, place, and suggested steps toward recovery. The ACOA groups are affili-
person; and pharmacotherapy as prescribed. Only a small per- ated with Al-Anon and follow the AA model. More information
centage of persons have more serious withdrawal symptoms; can be found on their websites.
1% to 3% experience seizures or delirium tremens (profound Family members can benefit greatly from regularly attending
confusion, hyperactivity, and hallucinations), usually by the self-help group meetings, both as an aid to their own recovery
second or third day of withdrawal. These complications are and as a way to mobilize social support. Perhaps most impor-
serious, however, and require medical attention. Concurrent tantly, they come to realize that the family, too, has developed
physical illnesses, recent and prolonged heavy alcohol intake, problems living with addiction. New members are often encour-
and previous episodes of withdrawal and/or seizure tend to aged to seek out a sponsor, someone further along in the group
produce more severe withdrawal symptoms. Detoxification is process. The sponsor can be of immense assistance to a family
not substance abuse treatment. member coping with a loved one with addiction.
Nurses and other health care professionals need to focus on The co-dependence movement and CODA have created yet
the goals for treatment of substance-related problems. The goals another type of 12-step self-help group for partners. Whereas
of treatment vary depending on the client, reducing alcohol and Al-Anon groups encourage self-focus, these groups are likely
other drug use or complete abstinence from it; increasing func- to focus on relationships with others by incorporating the lan-
tioning in multiple aspects of life; and preventing or reducing guage of the co-dependence movement. These include learning
the frequency and severity of relapse. to establish personal boundaries in relationships, meeting one's
own wants and needs in a relationship, adapting to change, and
Tertiary Prevention increasing communication with one's partner.
Treatment of addictions is similar to other chronic relaps- It is important for nurses who care for substance-dependent
ing disorders in recovery. Tertiary prevention for alcohol and clients to become familiar with the support programs available
other drug addictions involves ongoing follow-up and treat- in their communities. It is helpful for them to attend meetings
ment to prevent relapses and maintain recovery. Community/ to become more familiar with these resources and the services
public health nurses should be familiar with programs for they provide.
those with addictions and self-help groups for family mem-
bers and significant others. Community/public health nurses Maintenance of Recovery
can encourage continued participation in these and other Positive social support, residence in a family setting, adequate
community support programs and advocate for substance- socioeconomic resources, and absence of a family history of
free living and leisure environments. With problems of addic- alcoholism and drug abuse have been associated with increased
tion, it is essential that nurses take on a strong teaching and recovery from all addictions.
counseling role as previously discussed. Direct nurse inter- A National Summit on Recovery through the Center for
vention during periods of relapse requires collaboration Substance Abuse Treatment (CSAT) under SAMHSA met in
with the whole healthcare team and/or referral to addiction 2005 to create a consensus on a working definition of recov-
specialists. ery and guiding principles for recovery-oriented systems of
care (ROSC). By definition, both health and recovery depend
Twelve-Step Programs on individuals experiencing wellness or well-being in addition
The first recovery program was the 12-step Alcoholics to the absence of disease or infirmity (CSAT, 2005). “Recovery
Anonymous (AA) program. The AA philosophy and inspira- from alcohol and drug problems is a process of change through
tional stories of personal recovery are found in the Big Book which an individual achieves abstinence and improved health,
(AA, 2007). AA is a self-help program with a spiritual base. wellness and quality of life” (CSAT, 2005, p5).
AA provides fellowship, social support, constructive sugges- These addiction leaders also agreed on two re-occurring
tions, methods that have proved effective, sponsorship of a themes: (1) individuals may choose to define recovery differ-
new member by an older member, and a suggested program ently; and (2) not all guiding principles apply to all people, and
of hope for recovering alcoholics. Participation is strictly different guiding principles may apply at different points in
the recovery process. These findings emphasize the complex- Â�

familiarize themselves with evidence-based prevention inter-
ity of the issue and the strong need for flexibility and individ- ventions, brief interventions, effective pharmacotherapy, and
ual considerations in the recovery process. Some individuals the different treatment and self-help groups that are available in
achieve recovery through specialty treatment, others through the communities in which their clients live and work.
self-help groups, and others through faith-based organiza- It is also important to know that in some communities, none
tions or other community-based organizations. of these support groups might exist. The nurse can advocate and
Those who are newly sober should be taught that relapse work to get these groups established by contacting the national
is common in early recovery; they should be encouraged to headquarters of the self-help organizations. Advocacy is a major
quickly resume attendance in their treatment plan. Social sup- role of community/public health nursing, and advocacy is criti-
port is instrumental in avoiding further and sustained relapses. cal when resources related to substance use disorders are not
One difficulty when recovering is the need to change the social available in clients’ communities. See Community Resources for
network if that network facilitates or encourages substance Practice at the end of the chapter for resources.
use. Changing one's circle of friends, avoiding environments The federal government provides free publications and elec-
that pose dangerous temptations, and making other changes to tronic information that summarize research findings and pro-
decrease the stimulatory effect of these factors are essential to vide guidance for developing alcohol and drug treatment and
avoid further drug use. For some people, that step may include prevention programs, including the following:
their families, partners, and their friends. There is national con- • NIDA Notes provide drug research information, and Alcohol
sensus that treatment success is not only abstinence from alco- Alert covers current alcohol research.
hol and drugs but also the following: • Join Together is a collaboration of the Boston University
• Increased employment, return to school or school retention School of Public Health and The Partnership at Drugfree.
• Decreased involvement with the legal system org and is dedicated to advancing effective drug and alcohol
• Stable housing policy, prevention, and treatment.
• Social support • SAMHSA's Center for Substance Abuse Treatment publishes
• Access to services Treatment Improvement Protocols (TIPs) for use with clients
• Retention in treatment with addictions and with their families
• Client satisfaction in care • The Center for Substance Abuse Prevention also has free
• Cost effectiveness publications, kits, and computer programs that can assist in
• Use of evidenced-based practice (CSAT, 2005) providing culturally relevant prevention for communities.
Pharmacotherapy for Substance Use Disorders

FUNDING ISSUES AND ACCESS TO CARE
Medication-assisted treatment (MAT) is a form of phar-
macotherapy and refers to any treatment for an SUD that The Uniform Alcoholism Treatment and Prevention Act of
includes a pharmacological intervention as part of a com- 1974 brought treatment under the aegis of health care. A sys-
prehensive substance abuse treatment plan. The ultimate tem of care that consisted largely of 28-day inpatient pro-
goal of the plan is patient recovery with full social function. grams was eventually developed. Very few were part of the
In the United States, MAT using FDA-approved drugs such traditional health care system because health care practitio-
as disulfiram, naltrexone, and acamprosate has been dem- ners had little training in treatment of addictions. SUD treat-
onstrated to be effective in the treatment of alcohol depen- ment programs have been funded primarily through federal
dence, and opioid dependence has been treated effectively block grants to the states, state and local taxes, and health
with methadone, naltrexone, and buprenorphine (Connock, insurance programs. Inpatient treatment centers, including
etÂ€al., 2007; Fornili & Burda-Cohee, 2006). Vivitrol, approved those in the U.S. Department of Veterans Affairs (VA) system,
by the FDA in 2006 for the treatment of opioid dependence, have decreased drastically in size and number. Most VA treat-
is a monthly injection, but the current monthly costs of ment is now concentrated in outpatient services. Hospitals
$1000 could be prohibitive. that had detoxification units have discontinued those specialty
When medication-assisted treatment was all inclusive, the units. The burden of addiction treatment has fallen back on
benefits were reported to: the more conventional outpatient system of self-help groups,
• Improve survival jails, social service agencies, and homeless shelters and some
• Increase retention in treatment specialty programs. A very high proportion of admissions to
• Decrease illicit opiate use general hospitals are persons with substance abuse problems,
• Decrease hepatitis and HIV seroconversion although hospital personnel are not adequately trained to
• Decrease criminal activities manage these problems.
• Increase employment Access to treatment for SUDs remains a critical problem
• Improve birth outcomes for those with perinatal addiction in our health care system. See ChapterÂ€33 for a discussion of
(SAMHSA, n.d.) the 2008 Wellstone and Domenici Mental Health Parity and
Addiction Equity Act. The Act does not mandate substance
COMMUNITY AND PROFESSIONAL RESOURCES abuse coverage; however, when coverage is provided by insur-
ance companies they must provide benefits equal to benefits
Community nurses have numerous community, professional, for other types of illnesses. Community/public health nurses
and federal resources available to assist them in addressing the must continue to work with others to ensure access to care
problem of abuse of alcohol and other drugs with their cli- for prevention and treatment of substance abuse and addic-
ents. To be effective, community/public health nurses must tions for all.
KEY IDEAS
1. Addiction is a brain disorder. as well as educate and refer individuals and families expe-
2. The focus of addiction treatment is the compulsive drug- riencing addictions.
seeking behavior that exists even in the face of negative 7. Effective treatment is individualized and flexible and
health and social consequences. includes all facets of an individual's life.
3. Individuals seeking help for addiction often have other 8. Access to treatment for addiction remains a critical prob-
complicating physical, psychological, or social difficulties. lem in our health care system
4. Substance abuse affects all family members, not just the 9. Recovery from substance addiction occurs over years and
user. The patterns of relationships between users and their usually involves some relapses. A strong support system,
loved ones are often unhealthy. including 12-step programs and self-help groups for family
5. Community/public health nurses can help prevent genera- members, is important.
tional transmission of addiction. 10. All health care providers need to be trained to screen, inter-
6. Community/public health nurses are front-line health care vene, and refer individuals with a substance use disorder for
professionals who can assess need and individualize care, treatment.

A Client with Alcoholism Jennifer Maurer Kliphouse
Dan is a successful 45-year-old salesman, who owns his own business. Assessment
He lives with his wife and his 18-year-old son. His problems with alco- • Assess the extent to which Dan uses alcohol and other drugs.
holism have been developing insidiously since he began to drink at the • Complete a biopsychosocial assessment of Dan and his family.
age of 21â•›years. Heavy drinking ensued a few years later. Although his • Assess the adequacy of self-care activities and strengths.
family members complain about his drinking, he denies he has a prob- • Assess Dan and his family members for signs and symptoms of emo-
lem with alcohol. Dan has experienced some impairment of his abil- tional problems and addiction patterns.
ity to perceive distance from objects; a few days ago, his car collided • Complete a family genogram of at least three generations and iden-
with another car while he was driving, and Dan was arrested for driv- tify dysfunctional patterns.
ing under the influence (DUI). He has also had episodes of memory loss • Assess the extent of the family's resources and social support to sus-
associated with drinking more heavily than usual. His preferred bever- tain Dan and the family through an acute episode of Dan's illness.
age is beer, and he can easily consume two six-packs of beer in an aver- • Assess the community resources available to Dan and the family.
age evening of drinking.
Dan's wife, Jan, has tried everything to get Dan to quit drinking and is Nursing Diagnoses
embittered over his lack of cooperation, absences from home to drink, • Ineffective denial related to family history of alcoholism, as evidenced
deteriorating work performance, failure to help around the house, and by (AEB) repetitive refusal to admit that alcohol abuse is a problem
constant conflicts with their teenage son. Jan presents as a martyr who • Dysfunctional family processes: alcoholism related to abuse of alco-
overfunctions and tries her best to selflessly care for her family but hol, AEB loss of control of drinking, broken promises, inability to
obviously neglects her own needs. She appears sad and dejected. meet emotional needs of family members and subsequent deteriora-
The community health nurse became involved in this family through tion in family relationship, disruption of family roles.
a physician referral that was associated with Dan's discharge from the • Situational low self-esteem (of wife) related to unsatisfactory spou-
local hospital; he had a second serious episode of gastric bleeding sec- sal relationship, AEB declined ability to care for his or her own needs
ondary to long-standing gastrointestinal problems and heavy alcohol Following discharge from the hospital, Dan is admitted to a detoxifica-
consumption. tion center and then referred to the community health clinic for further care.

Ineffective denial related to Dan will acknowledge Dan will perform week-long alcohol Dan recalls that prior to his hospitalization for gastric bleeding
family history of alcoholism, and acceptÂ€that he intake recall. he consumed approximately 12 beers or more per day. On two
AEB repetitive refusal to abuses alcohol. days, he also consumed 3 to 4 drinks of hard liquor in addition
admit that alcohol abuse is to beer. “That was on Friday and Saturday though, and it's not
a problem like I'm shooting heroin or some illegal drug like that.” Dan
denies using other illegal drugs but states, “I do smoke pot
from time to time.”
Dan will also perform long-term recall With the nurse, Dan relates, “I didn't use to drink as much,
of alcohol consumption for the but what's the difference? It doesn't affect me as much.”
last 24â•›years and evaluate drinking Dan also reports, “The men in my family always drink. It's
patterns. really not a big deal.” With regard to his history, Dan states
he began drinking only on the weekends, but in his late
twenties, he started to drink occasionally during the week
and currently “drinks several beers a day.” Dan does not
associate drinking with any emotional or life changes. He
says, “I just like beer.”
Continued
THE NURSING PROCESS IN PRACTICE—CONT'D

A Client with Alcoholism Jennifer Maurer Kliphouse

Dan will list recent physical changes “The doctors tell me my stomach episode was because I drank
that are a result of long-term too much, but I don't know.” He attributes visual changes
excessive alcohol consumption. and memory loss to “getting older mostly.” Also, he denies
his recent car accident was the result of intoxication. “Well,
sure I got a DUI because those breathalyzers don't account
for tolerance. Besides, I really do need new glasses.”
Dan will enroll in Dan will enroll in addictions Dan is forced to enroll in addictions counseling by the
addictions counseling counseling as mandated by the court. His attendance at Alcoholic Anonymous meetings
and adhere to court settlement. has been sporadic at best. Dan's lawyer intervenes
agreed-on actions and insists he enroll in private addictions counseling.
and goals created Dan's court settlement cites addiction counseling as
through counseling. mandatory; otherwise, he may face a jail sentence. Dan has
successfully attended addiction counseling for 1â•›month and
states, “Only two more months to go!”
Together with an addictions counselor, Dan says his three goals are, “I won't drink a lot, I won't drink
Dan will create three goals for a lot, and I won't drink a lot. What a bunch of baloney.”
himself related to keeping sober. While Dan's counseling attendance has improved, his
reluctance to actively participate exemplifies further Dan's
inability to admit to alcohol dependence.
Dan will acknowledge Both Dan's wife and son have created a After listening to the lists read by both his son and his wife,
the impact his list that details missed family events, Dan says, “I didn't know you felt this way.” HeÂ€apologizes
alcoholism has had on disappointment and/or embarrassment and states he will try to “do better by you.” However, his
his family members they have felt, and husband/father role wife Jan reports that Dan has said this before, that both she
and their relationships. disruption as a direct result of Dan's and her son have given him many of these same examples
alcohol consumption. They will read before, but “nothing ever changes.”
the list to Dan.
Dan will acknowledge past and present After this confrontation, Dan says some things seem familiar to
statements his family members him. He also states that he “felt pressured,” by this “united
have made about how his alcohol front.” “How can I work to make this better when you have
consumption has affected them. already made up your minds and are conspiring against me?”
1. Read a daily newspaper, and make note of the news reports were your initial physiological reactions? What were your
on motor vehicle accidents, episodes of domestic quarrels or feelings and thoughts about the experience? If you abstained
public violence, and legal problems that involve alcohol or from using substances, reflect on that experience. Reflect on
other drugs. What major changes in society would have to changes in the pattern of your personal experiences with
occur to decrease or eliminate such incidents? alcohol and other drugs over the years. Have your subjective,
2. Have a dialogue with a friend or relative and encourage the physiological, cognitive, and emotional perceptions changed
person to share with you his or her life experiences with alco- from those on your very first experience? Would you like to
hol or other drugs. Empathize, without judgment, as they change any patterns in the future?
share information. In what way do these experiences influ- 5. Create a family genogram for addiction in your family.
ence the kinds of choices the person makes today and his or Recall and record experiences with alcohol and other drugs
her beliefs about the use of alcohol or other drugs? that you either observed or heard about for various relatives.
3. Attend an open meeting of AA or NA after telephoning the Compare your experiences with theirs, and note similarities
local office to locate a meeting convenient for you. Note and differences. Share your thoughts and feelings with an
members’ positive and negative feelings as they share their understanding family member, friend, or significant other.
stories of substance abuse and recovery. Note how their 6. Think about your personal knowledge of and experience
experiences influence what kinds of choices they make today, with colleagues who abuse alcohol or other drugs. Become
what they believe about the use of alcohol and drugs, and aware of your school, workplace, or your State Board of
how they value life today. How has this experience changed Nursing policies and procedures related to impaired students
your previous perceptions, beliefs, and values concerning or professionals. Reflect on the information you obtain. Is
addictions? there anything you would like to change based on your expe-
4. Reflect on your personal experiences with alcohol, tobacco, riences and observations? Share your thoughts and feelings
and other drugs. When you first used these substances, what with a nurse colleague.

Information about each of the following organizations is found National Center on Birth Defects and Developmental Disabilities,
on its website. Centers for Disease Control and Prevention (CDC): http://
Alcoholics Anonymous: http://www.aa.org/?Media=PlayFlash www.cdc.gov/ncbddd/fasd/index.html (information on fetal
American Council for Drug Education: http://www.acde.org/ alcohol syndrome)
American Society of Addiction Medicine: http://www.asam.org/ National Clearinghouse for Alcohol and Drug Information:
Association for Medical Education and Research in Substance http://store.samhsa.gov/home
Abuse (AMERSA): http://www.amersa.org/ (provides educa- National Council on Alcoholism and Drug Dependence: http://
tional materials, including lecture slides, seminar and con- www.ncadd.org/
ference presentations, syllabi, curricula, workshop handouts, National Inhalant Prevention Coalition: http://www.inhalants.org/
screening tools, case studies, and much more) National Institute on Alcohol Abuse and Alcoholism: http://
Fetal Alcohol Syndrome Diagnostic and Prevention Network, www.niaaa.nih.gov/Pages/default.aspx
University of Washington, Seattle: http://depts.washington. National Institute on Drug Abuse: http://www.nida.nih.gov/
edu/fasdpn/ nidahome.html
International Nurses Society on Addictions: http://www.intnsa. Partnership for a Drug-Free America: http://www.drugfree.org/
org/home/index.asp Substance Abuse and Mental Health Services Administration
National Center on Addiction and Substance Abuse at Columbia (SAMHSA): http://www.samhsa.gov/ (information on fetal
University: http://www.casacolumbia.org/templates/Home.aspx? alcohol syndrome, treatment improvement protocols, and best-
articleid=287&zoneid=32 practice guidelines for the treatment of substance use disorders)
WEBSITE
STUDY AIDS
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U N I T
7
Support for Special Populations
26 Rehabilitation Clients in the Community
27 Children in the Community
28 Older Adults in the Community
658
CHAPTER
26
Rehabilitation Clients in the
Community
Leslie Neal-Boylan*
FOCUS QUESTIONS
What is the magnitude of disability in the United States? How does the rehabilitation client achieve community
What are concepts related to disability and reintegration?
rehabilitation? What are the responsibilities of the community/public
What are some common conditions that require health nurse in meeting the needs of rehabilitation
rehabilitation? clients?
How does legislation affect the rehabilitation process? What are community resources for individuals with
What is the role of the rehabilitation nurse? disabilities?
CHAPTER OUTLINE
Concept of Disability Catastrophic Care Act
Concept of Rehabilitation Technology-Related Assistance Act
Historical Overview Americans with Disabilities Act
Rehabilitation Nursing: A Specialty Air Carrier Access Act
The Environment and the Rehabilitation Client Family and Medical Leave Act
Magnitude of Disability in the United States Balanced Budget Act of 1997
Mental Illness and Disabilities Community Living Legislation
Chronic Illnesses and Disabilities Needs of Persons with Disabilities
Spinal Cord Injury and Traumatic Brain Injury Personal Care Needs
and Disability Employment
Veterans with Disabilities Community Living Arrangements
Children with Congenital and Traumatic Injuries Responsibilities of the Rehabilitation Nurse
or Illnesses Team Member and Case Manager
Increasing Life Span and Disabilities Educator
Disability by Employment Status and Gender Counselor
Legislation Case Finder
Employers’ Liability Laws Client Advocate
Vocational Rehabilitation Acts Community Reintegration Issues
Rehabilitation Act of 1973
KEY TERMS
Activity limitation Habilitation Impairment
Disability Handicap Rehabilitation
*This chapter incorporates material written for the fourth edition by Roslyn P. Corasaniti and Donna S. Raimondi.
659
660 CHAPTER 26â•… Rehabilitation Clients in the Community
CONCEPT OF DISABILITY 35 million Americans have difficulty hearing, and 19 million

have trouble seeing (CDC, 2011).
The Americans with Disabilities Act (ADA) of 1990 (Public Law The issues related to disabilities have far-reaching social and
101-336) defines disability as a physical or mental impairment public health consequences in the United States. The cost of
that substantially limits one or more of the major life activities supporting employable Americans with disabilities who cannot
of an individual. According to the World Health Organization work is approximately $232 billion annually (U.S. Department
(WHO): of Health and Human Services [USDHHS], 2011a). The
national cost of disabilities totals more than $452 billion each
Disabilities (disability) is an umbrella term, Â�covering impair-
year, including an estimated $350 billion in medical costs
ments, activity limitations, and participation Â�restrictions. An
(AHRQ, 2007).
impairment is a problem in body function or structure; an
Disabilities have a variety of causes and are not evenly
activity limitation is a difficulty Â�encountered by an individ-
Â�distributed among the population. Causes of disability include
ual in executing a task or action; while a Â�participation restric-
congenital defects, mental retardation, traumatic injuries, and
tion is a problem experienced by an individual in involvement
consequences of diseases (e.g., amputation in those with dia-
in life situations. (WHO, 2011)
betes, altered mobility related to pain from arthritis, altered
According to the Agency for Healthcare Research and Quality cognition in those with schizophrenia). Although disability
(AHRQ, 2011), there is no one definition of disability that will occurs in people of all ages, disability rates increase with age.
fit all circumstances. Considerations regarding disabilities vary As life expectancy and the number of aged persons in Â�society
according to the person's age and place within the lifespan, and increase, more people with disabilities will require care. We
the definition used will influence both the approaches and the are now able to control chronic illnesses and injuries more
objectives utilized with regard to persons with disabilities. Not Â�effectively, and as a result, people with disabilities live longer. The
everyone who has impairment is disabled, nor is every person number of older adults (65â•›years and older) with disabilities has
with a disability handicapped, i.e., limited in some fashion by increased from approximately 55% (USDHHS, 2011a) in 1997
a disability. For example, someone may be missing a fifth finger to approximately 61% in 2009 (CDC, 2011). The prevalence of
but may be able perform all desired tasks without it. This person disability in the United States for all age groups has remained
would have a disability but not be handicapped by it. consistent at 18% to 19% (USDHHS, 2011a). The majority of
An estimated 71.4 million Americans (32% of the population)
Â� adults with disabilities report incomes below the federal poverty
live with disabilities (Centers for Disease Control and Prevention threshold, influenced, in part, by the inability to work and by
[CDC], 2011). Of those 15.9 million have great difficulty or are the need to purchase medical equipment (Altman & Bernstein,
unable to walk a quarter of a mile (TableÂ€26-1). Approximately 2008). Other reasons for this disparity include inadequate pre-
natal nutrition and care, higher accident rates, less preventive
care, a higher prevalence of chronic Â�disease, and less access
TABLEÂ€26-1â•…â•‡DISABILITIES AMONG to treatment for health problems among poor Â�populations.
NONINSTITUTIONALIZED According to the Community health and Â�rehabilitation nurses
ADULTS AGED >18 YEARS seek to Â� prevent and reduce sources of handicaps, such as
Â�stereotyping, architectural barriers, and Â�failure to accommo-
NUMBERS
DISABLED (IN
date those with disabilities. Such Â�interventions are a part of the
PERCENT OF
DISABILITY TYPE THOUSANDS) POPULATION
rehabilitation process.
Difficulty with specific 37,669 17.3%
functional activities CONCEPT OF REHABILITATION
Example: Climbing stairs Historical Overview
Walking three city blocks
Rehabilitation includes a wide range of activities in Â�addition
Difficulty with activities of â•‡8,451 3.9%
daily living to medical care, including physical, psychosocial, and occu-
Example: Bathing/toileting pational therapies. It is a process aimed at enabling Â�people
Difficulty with instrumental 13,485 6.2% with Â�disabilities to reach and maintain their optimal Â�levels
activities of daily living of Â�physical, sensory, intellectual, psychological, and/or social
Example: Preparing meals functioning. Rehabilitation provides people with disabili-
Taking care of money/bills ties the tools they need to attain independence and self-Â�
Reported selective 13,923 6.4% determination, including means to provide and/or restore
impairments functions or compensate for the loss or absence of a function
Example: Mental retardation or for a functional limitation (WHO, 2007). The mission of
Alzheimer's disease rehabilitation is complex. Its objectives reach beyond the reha-
Learning disability bilitation of individual clients to include educating all health
Use of assistive aid 11,226 5.2% care professionals, as well as the general public, to create a
Example: Use of wheelchair society in which people with disabilities have a fair chance to
or cane work, enjoy life, and live as independently as possible. Thus, a
Limitations in ability to work 13,104 6.3% central focus of rehabilitation is the quality of life.
Data from Centers for Disease Control and Prevention. (2009). Prevalence Historically, the problems of people with disabilities were
and most common causes of disability among adults—United States, often treated in an indifferent fashion or ignored. People had
2005. TableÂ€1. Morbidity and Mortality Weekly Report, 58(16), 421-426. little understanding of the degree of adaptation required to
CHAPTER 26â•… Rehabilitation Clients in the Community 661
Â�
successfully carry out the activities of daily living (ADL). interventions. Expertise in the areas of Â�psychiatric, medical,
Indignities and isolation have long surrounded people with dis- and surgical nursing is essential. Clients with mental health
abilities. Historical examples include the following (Rosen & needs may benefit from rehabilitation services as well
Fox, 1972): (see ChapterÂ€33).
• Blind persons forced to beg The Association of Rehabilitation Nurses (ARN) was recog-
• Lepers shunned and ridiculed by society nized as a specialty nursing organization by the American Nurses
• Infants with disabilities isolated and left to die in some Association (ANA) in 1976. The ARN's stated purpose is “to
cultures Â�promote and advance professional rehabilitation nursing prac-
• People who were crippled, malformed, and visibly ill were tice through education, advocacy, collaboration, and research
considered either cursed or possessed by the devil to enhance the quality of life for those affected by disability and
Over time, attitudes moderated as the belief in the essential chronic illness” (ARN, 2007). The ARN publishes a journal,
worth of all individuals evolved in Western thinking. People Rehabilitation Nursing, which serves as a vehicle for sharing infor-
with physical and mental disabilities were better tolerated. In mation and rehabilitation nursing research. The organization ini-
the nineteenth century, international legislation was passed that tiated certification for specialty practice as a means of recognizing
made workplaces responsible for injuries to employees. World a level of rehabilitation nursing expertise. Certified nurses use the
War II produced an interest in functional rehabilitation as well title certified rehabilitation registered nurse (CRRN).
as care of the actual injury or injuries. Currently, there are almost 6000 members and 10,000 CRRNs
Dr. Howard Rusk, director of the Army Air Corps ConvalÂ� (ARN, 2011a). The organization continues to grow, facilitating
escent and Rehabilitation Services during World War II, devel- educational, research, and professional Â�advancement opportuni-
oped the philosophy and concept of rehabilitation medicine. ties for rehabilitation nurses. Members are active in promoting
He continued his work after the war at Bellevue Hospital in the civil rights of people with disabilities and their families and in
New York City. Other health care professionals slowly came to lobbying for legislation that provides an Â�accessible Â�environment
embrace the concept of rehabilitation (Rusk, 1972). for all citizens.
The World Rehabilitation Fund, founded in 1955, was an The rehabilitation nurse functions as a teacher, caregiver, case
early advocate for those with disabilities. The fund sponsors manager, counselor, consultant, client advocate, and researcher
international projects to assist such people and lobbies to Â�create (Hoeman, 2008). Rehabilitation nurses help individuals affected
a better understanding of their problems, provide training by chronic illness or physical disability to adapt to their disabili-
for health care professionals in the field of rehabilitation, and ties, achieve their greatest potential, and work toward produc-
increase employment opportunities for rehabilitation clients tive, independent lives. They take a holistic approach to meeting
(Rusk, 1972). patients’ medical, vocational, educational, environmental, and
Access to public spaces and transportation has been spiritual needs (ARN, 2011b).
addressed by legislation and regulatory efforts. For example, in The goal of the rehabilitation process is to support a holis-
1973 the Rehabilitation Act established the Architectural and tic approach to nursing care that, with the collaboration of the
Transportation Barriers Compliance Board. This board can hold team, will maximize client independence (Hoeman, 2008). In
public hearings, conduct investigations, and order the recruit- the professional practice of rehabilitation nursing, the nurse
ment and hiring of applicants with disabilities. The Act also issues must be sensitive, flexible, creative, and assertive as she or he
regulations concerning barrier-free public facilities and edu- assists clients to successfully enter or reenter a society primarily
cational institutions (Russel, 1973). With effect from 1983, the designed for able-bodied persons. Nurses must examine their
American National Standards Institute established standards to beliefs and feelings about disabilities and handicaps. Not all
make buildings and facilities accessible to and usable by individu- nurses can cope with a client's lifelong consequences of devas-
als with physical disabilities. tating illnesses or injuries such as spinal cord injury, stroke, or
Modern rehabilitation nursing emerged during World War II. muscular dystrophy. A belief in the promotion of quality of life
The contributions of rehabilitation nurses were recognized as dis- is essential. Negative attitudes toward disability create Â�serious
tinct and important. Rehabilitation nursing evolved into a nurs- obstacles to the formation of a therapeutic relationship and
ing specialty. To some extent, all nurses working with clients with Â�client adaptation.
impairments, chronic diseases, and acute injuries include aspects Rehabilitation nursing plays a role in, and should be a com-
of rehabilitation in their practice. ponent of, all phases of recovery. For those with injuries and
severe illnesses, recovery often begins with admission to the
Rehabilitation Nursing: A Specialty acute care facility and continues throughout community rein-
“Rehabilitation nursing is the diagnosis and treatment of tegration. The rehabilitation nurse is a consistent, objective
human responses of individuals and groups to actual or resource for the client and family as they adapt to an altered
potential health problems stemming from altered functional self-concept, changes in roles, and different means of accom-
ability and [related] altered lifestyle” (American Nurses plishing ADLs. The rehabilitation nurse must work together
Association [ANA] & Association of Rehabilitation Nurses with the client, family, and rehabilitation team, as well as the
[ARN], 2000, p. 4). Community health nurses who provide community and the environment, to achieve realistic and
Â�
rehabilitation must be skilled in giving comfort and perform- Â�favorable outcomes.
ing therapy, promoting adjustment and coping, supporting For those whose impairment is discovered at birth or in
adaptive capabilities, and promoting achievable indepen- childhood, the habilitative process begins with acknowledg-
dence and meaning in life (Neal-Boylan & Buchanan, 2008). ment of the problem. Rehabilitation is the recovery of an ability
The community health Â�rehabilitation nurse must possess that once existed, whereas habilitation is the development of
specific knowledge and skills to provide effective nursing abilities that never existed before in the child.
The Environment and the Rehabilitation Client as steps, curbs, features of public transportation vehicles, and
The environment is the critical factor in determining the doorways can significantly hamper independent functioning.
extent of an individual's handicap. Disabilities can be hand- In one study, the majority of persons with disabilities (84.7%)
icapping in one situation but not in another, depending on reported that they had trouble with environmental barriers
the environment. For example, consider the person with because of their disability. In that same study, one Â�quarter of
chronic obstructive pulmonary disease (COPD) whose symp- those with disabilities indicated that they were in need of home
toms are aggravated by walking to an office on the fifth floor modifications but were unable to get them, and about the same
in a building without elevators. When he arrives at work, his number reported that they had difficulty accessing
Â� their health
altered Â�oxygenation affects his ability to concentrate. Such a provider's office (CDC, 2006a).
person would be disabled in the major life activity of work.
Furthermore, if the employer insisted that the employee Psychosocial Aspects of the Environment
must perform his job at that site, the individual would be The environment also has a psychosocial component. Attitudes
Â�handicapped. (Although the Americans with Disabilities Act, of “able-bodied people” have a profound effect on successful
Â�discussed later in the Â�chapter, could make this employer's community reintegration. Incorrect beliefs about individuals
action illegal, such Â�practices Â�continue to occur.) with disabilities such as the belief that they cannot maintain jobs,
Community health nurses assist people with disabilities and attend school, or function as sexual human beings may severely
their families in schools, workplaces, clinics, and homes. Nurses inhibit or even halt the rehabilitation process. However, excessive
need to be alert to the environmental conditions encountered by sympathy such as providing extra privileges, failing to hold the
people with disabilities in various settings. Atmospheric condi- person responsible for his or her actions, or Â�attributing “good”
tions, for example, temperature, humidity, rain, wind, and snow, qualities to someone because he or she has a disability, can be just
can affect the signs and symptoms of medical conditions such as inhibiting. Both the physical and psychosocial components of
as multiple sclerosis, arthritis, and chronic pain. Nurses can help the environment may require restructuring so that peopleÂ� with
clients learn to cope with such influences as they begin to rein- disabilities have a fair chance to work, attend school, play, and
tegrate into the community. In addition, physical barriers such live satisfying lives (see the Ethics in Practice box).
ETHICS IN PRACTICE
Fear in the Community Gail Ann DeLuca Havens, PhD, RN
Rose, a community health nurse, was delighted to learn that Mr. Wilfred at home at night and benefit from social connections. They come
had bequeathed his house to be used as a community-based mental to day treatment for counseling and supervision of their medication
health center. It is a lovely property, but more importantly, it is situ- administration.
ated in an attractive residential neighborhood that more closely approxi- “Their care providers are committed to helping them remain in the
mates the kind of environment in which most clients of the Waveview community, provided they can clothe, feed, and shelter themselves and
Village Community Mental Health Center are accustomed to living. The that there is no evident risk of harm to themselves or to others by their
Waveview Village clients are currently receiving day treatment in a doing so. It is the opportunity to avoid potential harm to our clients that
ramshackle house on the perimeter of the commercial district. It is a makes Mr. Wilfred's house such an attractive setting for the Waveview
noisy and dirty area where the prevalence of drug and alcohol abusers Village Day Treatment Program. For those of you who are not familiar
makes it unsafe to walk the streets. Clients of Waveview Village have with it, the present site for the day treatment program is located in
been teased, ridiculed, and spat on over the years by people living in the an area that is not well maintained, and clients are harassed Â�coming
neighborhood who do not comprehend the implications of mental illness and going from Waveview. Relocating the day treatment program to
and consequently are fearful of those with mental illness. Mr. Wilfred's house will eliminate this potential for harm to Waveview
Now, a week before the ownership of Mr. Wilfred's house is to pass to Â�clients and will place them in an environment that is more comfortable
the Waveview Village Corporation, Rose is attending a special Â�session and familiar to them. I hope that the board's decision is a favorable one
of the zoning board called in response to a petition by people Â�living for Waveview's clients.”
in the neighborhood of Mr. Wilfred's house. The petition requests Several days later, Rose receives a letter from the zoning board
that the board modify the existing property-use statutes to explicitly stating that the board is postponing its decision to allow its mem-
exclude community-based mental health centers from residential areas. bers time to become personally acquainted with some of the clients
Neighborhood residents are very agitated and fearful of having “unsta- of Waveview Village. The letter asks her to arrange whatever kind
ble” people roaming their neighborhood. They voice concerns about per- of individual or group meetings she thinks would be most comfort-
sonal safety, the security of personal property, and the introduction of able for the clients, while still affording the members of the zon-
an “undesirable element who often associate with the mentally ill” into ing board the opportunity to get to know them. Usually, this type of
the neighborhood. request would be rejected because it breaches client confidentiality
Rose is a member of Waveview Village's board of directors. She has and discriminates on the basis of their medical diagnoses. However, a
been asked to provide information to the zoning board about how “dan- number of Waveview clients, knowing that Rose had been advocating
gerous” clients of Waveview Village are and whether the concerns for the program to relocate to Mr. Wilfred's house, have approached
expressed by neighborhood residents are justified. Rose explains, “The her, Â�volunteering to Â�provide Â�statements to the board in person. What
clients of Waveview Village are ill. As with all illnesses, whether physi- should Rose do in this Â�situation? Should she follow up on the clients’
cal or mental, a range of diagnoses will be present in the ill Â�population. offers and ask them to meet with members of the zoning board, know-
So, too, will illnesses exacerbate, or flare up. The clients who receive ing that such a request will breach their confidentiality? Or should she
care at Waveview are no exception. They are well enough to stay refuse to comply with the board's request?
Fear in the Community Gail Ann DeLuca Havens, PhD, RN
Community health nurses develop direct contacts with clients and that relevant data be shared with those members of the health care
their social networks, as well as relationships with mental health pro- team who have a need to know … only those directly involved with the
viders. These interfaces allow nurses to serve as natural intermediar- patient's care” (ANA, 2001, p. 12).
ies between the client and the larger systems of social and mental On the other hand, if Rose refuses to arrange the meetings between
health services. Evidence of this intermediary relationship is observed the client volunteers and the members of the zoning board, she will
in the fact that Waveview clients have approached Rose to volunteer be doing so to protect the confidentiality of the client volunteers. In
to talk with members of the zoning board, as well as that fact that this regard, Rose will be acting from a deontological perspective,
the zoning board has asked Rose to arrange opportunities for them to the essence of which is that some actions are right (or wrong) for
come to know some of Waveview's clients. If Rose accepts the offers Â�reasons other than their consequences (Beauchamp & Childress, 2009).
of the clients who have volunteered to meet with members of the However, Rose's refusal of the board's request does not actively encour-
zoning board, she will do so only after first ensuring that the clients age the board to rule in favor of the day treatment program. In fact, it
understand that their actions will breach the confidentiality regard- most likely Â�compromises any opportunity to use Mr. Wilfred's house for
ing their illness. She is also aware that she is contributing to that the Waveview Village Day Treatment Program.
infringement. However, from a utilitarian perspective, she perceives An alternative that Rose might consider is to suggest to Waveview's
her action to be doing the greatest possible good (Beauchamp & management staff that she work with them in arranging an open house
Childress, 2009). Furthermore, the Code of Ethics for Nurses explicitly event, inviting the residents of the neighborhood in which Mr. Wilfred's
indicates, “Nurses should actively promote the collaborative multi-dis- house is located to visit the present day treatment facility to see firsthand
ciplinary planning required to ensure the availability and accessibility what it contains, how it is organized, and where it is located. Waveview
of quality health services to all persons who have needs for health staff, management personnel, and members of the board of directors
care” (American Nurses Association [ANA], 2001, p. 11). Given that would be available to discuss the philosophy, mission, and treatment
context, presuming that the zoning board decides in favor of the day goals of the Waveview Village Day Treatment Program with visitors and
treatment center, sacrificing the confidentiality of a few clients to gain to answer their questions. As people become informed about a topic,
access to a treatment environment that is safe and therapeutic for all they often change their opinions related to it. This strategy has the poten-
may be justified. tial to diffuse the objections and resistance to relocating Waveview to
The ANA Code also clearly states, however, that “the nurse safeguards Mr. Wilfred's house and to preserve the privacy of its clients.
the patient's right to privacy” and “advocates for an environment that Which course of action would you choose?
provides for sufficient physical privacyâ•›.â•›.â•›.â•›and policies and practices that
protect the confidentiality of information.â•›.â•›.â•›. The rights, well-being, and References
safety of the individual patient should be the primary factors in arriving American Nurses Association. (2001). Code of ethics for nurses with
at any professional judgment concerning the disposition of confidential interpretive statements. Washington, DC: Author.
information received from or about the patient.â•›.â•›.â•›. The standard of nurs- Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical
ing practice and the nurse's responsibility to Â�provide quality care require Â�ethics (6th ed.). New York: Oxford University Press.
Cost and Access Issues The change to managed care and case management arrange-
Clients and families frequently have concerns about the avail- ments has been anxiety provoking for some individuals with
ability and cost of health care. These concerns bring additional disabilities, particularly in light of publicity about poor qual-
stress to an already stressful environment. Medicare pays for ity in some managed care arrangements (see ChaptersÂ€3 and 4).
inpatient rehabilitation and selected home health care Â�services Although there has been widespread public concern about the
for older persons and for individuals with disabilities who quality of care provided in managed care, there are no Â�substantial
receive Social Security disability payments regardless of age. data at this time to indicate that managed care Â�provides less or
Medicare requires a 2-year wait for eligibility for young Â�persons lower-quality care. Some studies of clients who are chronically ill
with Â�disabilities who do not already qualify for Medicare show that managed care clients receive worse care for physical con-
because of age (Center for Medicare and Medicaid Services ditions, whereas others show the opposite (Sultz & Young, 2010).
[CMS], 2011a). Rehabilitation services under Medicaid vary
by state. Private health insurance Â�programs vary widely in MAGNITUDE OF DISABILITY IN
the type of coverage provided to people who are disabled and THE UNITED STATES
chronically ill.
In an effort to curb the cost of care, government health Disability is a result of impairments that often occur because of
plans (Medicare and Medicaid) and private insurers have injury or chronic disease. The National Health Interview Survey
turned to health maintenance organizations (HMOs) and (NHIS), a continuous, nationwide household survey conducted
other forms of managed care. One strategy, initiated in man- by the U.S. Census Bureau, includes questions about disability
aged care programs and expanded into private insurers, has and health. The six most prevalent chronic conditions
Â� causing
been the institution of strict case management programs for disability are arthritis, back or spinal pain, heart Â�disease, lung
people with chronic Â�illnesses and other types of high-cost and other respiratory problems, mental or emotional problems,
conditions (McCollum, 2008). Rehabilitation nurse special- and diabetes (CDC, 2009). However, more people report hav-
ists and community health nurses are often the case managers ing these chronic impairments and diseases than report being
for these individuals. disabled by them. Consequently, community health Â�nursing
efforts to prevent disability must address prevention and ade- living in community placements as a result of the push toward
quate treatment of these chronic conditions. Many of the deinstitutionalization (see ChapterÂ€33).
Healthy People 2020 objectives (USDHHS, 2010) Â�specify targets
for identifying people with disabilities and reducing Â�barriers Chronic Illnesses and Disabilities
that they typically confront. (See the Healthy People 2020 box Some impairments and chronic diseases are associated with
on this page.) greater disability than are others. TableÂ€26-2 identifies com-
mon chronic conditions that cause limitations in a major activ-
Mental Illness and Disabilities ity. Stroke is a leading cause of serious long-term disability in
According to the National Interview Health Survey, in 2010, the United States along with cancer and heart disease (Kung
approximately 3.2% of adults age 18â•›years and older reported etÂ€al., 2008). Half of all stroke clients will have residual physical
experiencing serious psychological distress in the previous and/or social disabilities (American Heart Association [AHA],
30â•›days. This is largely unchanged from 2008 (CDC, 2011; 2007). The most common cause of disability is arthritis (CDC,
USDHHS, 2011b). Services provided to those with Â�mental Â�illness 2009). Arthritis can seriously inhibit a person's ability to work
have moved toward general practitioners rather than Â�psychiatric and function independently.
specialists (Wang etÂ€al., 2006). Consequently, Â�persons with men- Mental illness is a source of functional disability. In 2005,
tal illness are more likely to be integrated into the commu- approximately 16 million reported having cognitive, emotional,
nity than previously. Persons with mental illness are not often or mental functional difficulties (Brault, 2008). Traumatic
thought of as candidates for rehabilitation services (Neal-Boylan Â�injuries also account for a substantial number of persons with
& Buchanan, 2008). There are many people with mental illness long-term disabilities.
HEALTHY PEOPLE 2020

Objectives for Persons with Disabilities
1. Include in the core of all Healthy People 2020 surveillance instru- 12. Reduce the proportion of people with disabilities reporting barri-
ments a standardized set of questions that identify “people with ers to participation in home, school, work, or community activities
disabilities” (baseline: 2 of 26 Healthy People data systems in (developmental: no baseline).
2010). 13. Increase the number of Tribes, States, and the District of Columbia
2. Increase to 46.3% the proportion of newly constructed and retrofit- that have public health surveillance and health-promotion programs
ted U.S. homes and residential buildings that have visitable fea- for people with disabilities and caregivers (baseline: 16 states and
tures (baseline: 42.1% of homes and buildings in 2007). the District of Columbia, no Tribes in 2010).
3. Increase to 95% the proportion of children with disabilities, birth
through age two years who receive early intervention services in SPECIFIC CHRONIC DISEASE OBJECTIVES RELATED
home or community-based settings (baseline: 91% of children in TOÂ€REHABILITATION
2007). Arthritis
4. Increase the proportion of people with disabilities who participate 1. Reduce to 35.5% the proportion of adults aged 18â•›years and older
in social, spiritual, recreational, community, and civic activities to with doctor-diagnosed arthritis who experience a limitation in activity
the degree that they wish (developmental: no baseline). due to arthritis or joint pain (baseline: 39.4% of adults in 2008).
5. Increase to 76.5% the proportion of adults with disabilities report-
ing sufficient social and emotional support (baseline: 69.5% of Diabetes
adults in 2008). 1. Reduce the rate of lower-extremity amputations in persons with diag-
6. Reduce the proportion of people with disabilities who report Â�serious nosed diabetes (baseline: 3.5 per 1000 lower extremity amputations
psychological distress (developmental: no baseline). 2005 to 2007).
7a. Reduce to 31,604 the number of adults (22â•›years and older) living
Hypertension (for stroke control)
in congregate care residences that serve 16 or more persons (base-
1. Increase to 57% the proportion of the population diagnosed with
line: 57,462 persons in 2008).
diabetes whose blood pressure is under control (baseline: 51.8% of
7b. Reduce to 26,001 the number of children and youth (aged 21â•›years
adults in 2005 to 2008).
and under) with disabilities living in congregate care facilities
(baseline: 28,890 children and youth in 2009). Injury Prevention
8. Reduce to 13.1% unemployment among people with disabilities 1. Reduce the rate of nonfatal injuries caused by motor vehicle crashes
(baseline: 14.5% of disabled unemployed in 2009). to 694.4 per 100,000 population (baseline: 771.5 per 100,000 popula-
9. Increase to 73.8% the proportion of children and youth with Â�disabilities tion in 2008).
who spend at least 80% of their time in regular educational programs
(baseline: 56.8% of children and youth in 2007 to 2008). Mental Health
10. Reduce the proportion of people with disabilities who report physi- 1. Increase to 64.4% the proportion of persons with serious mental ill-
cal or program barriers to local health and wellness (developmen- ness who are employed (baseline: 58.5% in 2008).
tal: no baseline).
11. Reduce the proportion of people with disabilities who report barri- Respiratory Disease
ers to obtaining the assistive devices, service animals, technology 1. Reduce to 18.7% the proportion of adults whose activity is limited
services, and accessible technologies that are needed (develop- due to chronic lung and breathing problems (baseline: 23.2% of
mental: no baseline). adults in 2008).
From U.S. Department of Health and Human Services. (2010). Healthy People 2020: Washington, DC: Author.
speech, vision, educational performance, memory, concentra-

TABLEÂ€26-2â•…â•‡SELECTED CONDITIONS AS
tion, attention, and behavior.
MAIN CAUSE OF DISABILITY
Those with SCIs are another significant group requiring
IN ADULTS 18 YEARS AND extensive rehabilitation. SCIs are most common in young men
OLDER, UNITED STATES, 2005 between 16 and 30â•›years of age. Approximately 85% of Â�people with
PERCENTAGE SCI who live through the first 24 hours survive at least 10â•›years
NUMBER OF OF DISABLED Â�(SCI-Info-Pages, 2011). The number of people in the United
PERSONS (IN WITH SPECIFIC States who live with an SCI is estimated to be between 250,000
CHRONIC CONDITION THOUSANDS) CONDITION and 400,000 (National Spinal Cord Injury Association, 2011).
Arthritis 8,552 19.0 Because of significant advances in health care technology
Back or spine problem 7,589 16.8 and practice, more persons are surviving severe traumatic inju-
Heart trouble 2,988 6.6 ries. For example, approximately 87% of patients Â�hospitalized
Lung or respiratory problem 2,224 4.9 for TBI recover sufficiently to be discharged from the Â�hospital
Deafness or hearing problem 1,908 4.2 (CDC, 2006c). Client needs in this population are exten-
Limb/extremity stiffness or 1,627 3.6 sive and vary with the level and type of injury (i.e., Â�complete
deformity or Â�incomplete nerve damage). Both SCIs and TBIs require
Mental or emotional problem 2,203 4.9 extensive long-term health care. An estimated 5.7 million
Â�
Diabetes 2,012 4.5 Â�persons require long-term care or lifelong help in performing
Blindness or vision problem 1,460 3.2 ADLs as a result of either injury (CDC, 2008; National Spinal
Stroke 1,076 2.4 Cord Injury Association, 2007).
Broken bone/fracture 969 2.1
Mental retardation 671 1.5 Veterans with Disabilities
Cancer 1,007 2.2 Veterans are returning from the wars in Afghanistan and Iraq
High blood pressure 857 1.9 with disabilities. Over 5.32 million have served during the Gulf
Head or spinal cord injury 516 1.1
wars. In addition, there are living veterans with disabilities from
Learning disability 492 1.1
injuries sustained during early conflicts. The number of Â�veterans
Senility/dementia/Alzheimer's 546 1.2
with disabilities (physical or mental) is over 5.5 million (U.S.
disease
Kidney problems 411 0.9 Census Bureau, 2010). These veterans seek services through the
Paralysis 257 0.6 Veterans Administration (VA) and community organizations.
Missing limbs/extremities 209 0.9 Due to improvements in protective equipment such as body
Other 7,496 16.8 and vehicle armor, the mortality rate for Gulf War veterans is
lower compared with rates from previous conflicts. More of
Data from Centers for Disease Control and Prevention. (2009). Main these veterans have survived with multiple and severe injuries.
cause of disability among civilian noninstitutionalized U.S. adults
These include:
aged > 18 years with self-reported disabilities—United States, 2005.
Morbidity and Mortality Weekly Report, 58(16), 421-426.
• Traumatic brain injuries and spinal cord injuries
• Amputations
• Burns
• Mental health issues such as posttraumatic stress disorder
Spinal Cord Injury and Traumatic Brain Injury (PTSD)
and Disability Rehabilitation nurses, both within inpatient facilities and in
Approximately 1.7 million people experience traumatic brain the community, are working to help restore function in veterans
injury (TBI), and 11,000 persons sustain a spinal cord injury and reintegrate them into the community.
(SCI) each year in the United States (Brainline, 2011; SCI- Congress authorized the Vocational Rehabilitation and
Info-Pages, 2011). TBI is the most common condition requir- Employment (VR&E) VetSuccess Program under Title 38,
ing extensive rehabilitation efforts. An estimated 5.3 million Code of Federal Regulations. The VetSuccess program helps
Americans live with disabilities resulting from TBI. Annually, veterans with disabilities acquired during their military service
more than 1.4 million people sustain a brain injury (CDC, to Â�“prepare for, find, and keep suitable jobs.” If a veteran is so
2006b). TBI most often occurs between the time of birth and Â�disabled that he or she cannot work, the program offers Â�services
4â•›years and between15 and 19â•›years (Faul etÂ€al., 2010). to help that person live at the maximum level of Â�independence
Approximately 80,000 persons each year are left with Â�lifelong (U.S. Department of Veterans Affairs, 2011). The federal
disabilities as a result of TBI (Pangilinan & Campagnolo, 2011). Â�government spent approximately $38 million for medical ser-
Their lifelong disabilities have an impact on their lives and vices, vocational rehabilitation, and educational services in 2008
the lives of their family members. The average survivor of TBI (U.S. Census Bureau, 2010).
requires 5 to 10â•›years of rehabilitation. TBI costs the country an
estimated $60 billion per year in medical costs and lost wages Children with Congenital and Traumatic Injuries
(Brainline, 2011). The severity of the injury influences the degree or Illnesses
of residual deficit and the person's subsequent need for Â�medical Although the numbers are difficult to estimate, it is apparent that
and social support services in the community. People who many children are surviving congenital and traumatic illnesses
Â�sustain head injuries might have permanent functional
Â� deficits or injuries. Many of these children have physical and develop-
in one or more of the following areas: cognition, Â�performance mental disabilities. As of 2005 (the most recent data), 1.9% of
of ADLs, manipulation, bowel and bladder functions, mobility, children under age 3â•›years and 3.8% between the ages of 3 and
5â•›years were reported to have a disability. In the age group of Rehabilitation facilities and additional community Â�follow-up
birth to 5â•›years, disability typically refers to developmental delay. involving various therapy modalities are often recommended
A broader definition that includes interactions with others, abil- for people with cognitive decline caused by dementia or stroke.
ity to perform schoolwork, emotional and mental conditions Home health care, clinic services, or nursing home care might
in addition to physical difficulties is used for older children. In be required. Respite care might be helpful for family members
2005, 4.7 million children between the ages of 6 and 14â•›years who are caregivers.
were reported to have a disability (Brault, 2008). Children are These critical illnesses influence nearly all aspects of clients’
more likely to have mental or developmental impairments and their families’ ADLs. Role changes, fear, anxiety, and the
Â�compared with adults. ability to provide adequate care must be assessed in the com-
munity environment. Safety issues such as the ability to sum-
Increasing Life Span and Disabilities mon help if left alone at home, crime prevention, and cognitive
Disability rates increase with age (FigureÂ€26-1). However, higher abilities (e.g., judging whether water is too hot to bathe in or
percentages of children, adolescents, and those older than remembering how to transfer from a wheelchair to a toilet with-
85â•›years of age receive assistance because of limitations in out falling) are of critical importance. If there are steps in the
carrying out basic life activities. Approximately 36.3 million home, is the client with a cardiac problem able to climb them
Americans, or 12.4% of the population, are 65â•›years of age or without compromising his or her cardiorespiratory status?
older. As the “baby boomers” (those born between 1945 and Is there an adequate family or social support system for these
1964) get older, the population of people age 65â•›years or older Â�clients? These issues indicate that the integration of these clients
is expected to increase to 70 million. While improved public into the community environment is an ongoing process.
health and medical care have increased longevity, this increase Following through with medical treatment regimens is of
has been accompanied by an increase in dementia and other critical importance to those with chronic diseases. People who
chronic diseases. Approximately 5 million Americans have experience a sudden onset of illness might have to learn a regular
Alzheimer's disease, and that number is expected to grow to regimen of medications. Compliance with diets and medication
approximately 16 million by 2050. People with Alzheimer's dis- schedules and the reestablishment of sexual and social relation-
ease comprise less than 13% of people who receive Medicare, ships take time. The community health nurse may be notified
but in 2005, the cost of their care accounted for approximately of problems only after complications develop from a chronic
$91 billion. Cognitive decline can profoundly affect a person's Â�condition. Difficulties may result from a failure to understand
ability for self-care (Gerberding, 2007). Older adults make up the treatment regimen (e.g., medication administration or nutri-
the largest population of community-based rehabilitation tional needs). Cost factors can also influence a person's ability to
clients (Gender, 2008). adhere to recommended health care practices.
Age
3.6 Severe disability
Under 15 years
8.8 Any disability
5.0
15 to 24
10.4
7.5
25 to 44
11.4
12.8
45 to 54
19.4
20.8
55 to 64
30.1
26.1
65 to 69
37.4
27.6
70 to 74
43.8
37.8
75 to 79
55.9
56.2
80 years and older
71.0
FIGUREÂ€26-1â•‡ Disability prevalence and the need for assistance by age, 2005 (in percent). (From
U.S. Bureau of the Census. [2008]. Americans with disabilities: 2005 [Current Population Reports, P70-117].
Washington, DC: U.S. Department of Commerce.)
Disability by Employment Status and Gender Vocational Rehabilitation Acts

In 2010, less than 25% of adult Americans under age 65 with The Social Security Act of 1935 authorized vocational reha-
disabilities reported being employed (FigureÂ€26-2). A Â�little bilitation, old-age insurance, aid to the visually impaired, and
less than half of that group who had nonsevere disabilities services for children who were crippled. Amendments to the
and almost 16% who had severe disabilities reported being Vocational Rehabilitation Act have been enacted periodically.
employed full time. In addition, people with hearing dis- The law has been broadened to include emotionally disturbed
abilities were more likely to be employed than people with persons and those with intellectual disability and to provide
visual difficulties (Brault, 2008). For persons with disabili- maintenance money for living expenses and occupational tools,
ties, however, acquiring and keeping a job is more difficult training grants for the preparation of professional rehabilita-
than it is for those without disabilities. Gender differences tion personnel, and federal support for research.
exist with regard to disability and work. There is discrimina- During the 1960s, the Council of State Governments published
tion and less access to essential services for women with dis- the Workmen's Compensation and Rehabilitation Law, which
abilities compared with men with disabilities (Hefner, 2006). contained detailed provisions governing vocational rehabilita-
There are gender and racial differences with regard to stroke tion services for injured employees. Other amendments passed
incidence and poststroke disability (Petrea etÂ€al., 2009). during that decade provided federal assistance to plan, equip, and
Non-Hispanic black women are more likely than white or initially staff rehabilitation facilities and workshops, authorized
Hispanic women or black men to have difficulty with physi- funds for evaluation to determine rehabilitation potential, and
cal activities after a stroke. mandated follow-up services to clients and families.
Injury and chronic disease patterns also vary by gender. Among Starting in 1975, mandatory vocational rehabilitation laws
adolescents and young adults who sustain traumatic injuries, males were enacted in most states. Currently, all states have workers’
are twice as likely as females to sustain severe injuries (Pangilinan & compensation laws that require employers to assume the cost
Campagnolo, 2011). Such injuries most often result from vehicular of occupational disabilities without regard to any fault involved.
accidents, unintentional falls, and assaults. Employers, therefore, are spared civil lawsuits involving negli-
gence (Workers Compensation Law, 2011).
LEGISLATION Rehabilitation Act of 1973
Legislation to protect and promote the rights of people with dis- One of the most critical reforms affecting the rehabilitation
abilities is a critical component of rehabilitation. Nurses should movement was the Rehabilitation Act of 1973, which requires
have basic knowledge about legislation affecting the civil rights state rehabilitation agencies to develop an individualized, writ-
of people with disabilities. The following sections discuss major ten care plan for each client. The plan must state long-term
legislative initiatives that have helped expand the employability and short-term goals and spell out the terms under which ser-
and integration of people with disabilities in the community. vices are offered (Hoeman, 2008). The Rehabilitation Services
Administration under the U.S. Department of Education
Employers’ Liability Laws administers rehabilitation programs authorized by the act.
In 1911, the first workmen's compensation laws were enacted The provisions of the Rehabilitation Act include the following
in the United States to provide financial support for workers (Rehabilitation Act of 1973, 2010.) (2011):
unemployed because of work-related injuries. In 1920, the first • Development of affirmative action programs for employ-
civilian rehabilitation program was established by means of the ment of disabled people in the executive branch of the
Smith-Fess Act (Civilian Rehabilitation Act). This program pro- Â�federal government
vided vocational rehabilitation services through state boards of • Development of standards for compliance with regulations
vocational rehabilitation to people disabled in industry (Social to overcome architectural, transportation, and communica-
Security Administration, 2011). tion barriers in public facilities
Percentage Employed
0 10 20 30 40 50 60 70 80
No Disability (64.7%)
Disability Status
With a Cognitive Disability (6.2%)
With a Mobility Disability (8.3%)
With a Sensory Disability (11.1%)

(Vision/hearing)
With any Disability (21.8%)
FIGUREÂ€26-2â•‡ Employment percentages by disability status. Note: Employment rates for Â�persons
with or without disabilities were both down in 2010 compared with previous years. (Data from U.S.
Bureau of the Census. [2011]. Employment status of the civilian noninstitutionalized population by Â�disability
status. TableÂ€ 1. Retrieved June 24, 2011 from http://www.bls.gov/news.release/disabl.to1.htm; and U.S.
Census Bureau. [2010]. Employment of people with disabilities by type TableÂ€3. Monthly Labor Review Online,
133[10].)
• Forbids discrimination of qualified persons with disabilities amended and updated in 2008 (ADA, 2011) to include updated
in any federally assisted program or activity definitions of disability.
• Ensures children with disabilities have a free, appropriate The ADA deals with access to employment, government
public education in the least restrictive setting Â�services, public accommodations, public transportation, and
• Forbids denial to postsecondary and vocational programs to telecommunications. Five key provisions are as follows:
qualified people with disabilities 1. All state and local government agencies and businesses open
• Prohibits employers from refusing to hire people with dis- to the public must make their services available to people
abilities if they meet the job requirements with disabilities unless the cost to do so is excessive.
• Prohibits preemployment inquiries about disabilities 2. Interstate and commuter rail systems and local and intercity
• Requires all federally assisted programs to provide facilities bus lines must accommodate passengers in wheelchairs.
that are accessible and usable 3. All businesses with 15 or more employees are required to
• Requires all new facilities built with federal funds be barrier free Â�disregard handicaps in hiring decisions.
4. All telephone companies are required to provide special
Catastrophic Care Act Â�services for people with speech or hearing impairments.
The Medicare Catastrophic Coverage Act of 1988 is a historic 5. Food industry employers can reassign workers with diseases
health care legislation that required a large expansion of the that are transmitted through contact with food (e.g., salmo-
Medicare program. Most of the act was repealed because of nellosis, hepatitis A).
opposition to the funding mechanism. As part of the repeal, The ADA intended to integrate persons with disabilities,
unlimited coverage of hospital and physician costs once out- whenever possible, into the community. In 1999, the Supreme
of-pocket expenses reached preset limits, outpatient prescrip- Court upheld the right of such integration when it ruled in
tion drug coverage, and extended nursing home coverage were Olmstead v. L.C. and E.W. that the states could not require insti-
eliminated; the law also never addressed insurance needs for the tutional care for patients with mental illness when their care
cost of long-term nursing home care. providers determined that the patients were able to be placed
A few parts of the act, including a mandate for states to in community settings (Center for an Accessible Society, 2007).
expand Medicaid coverage to include not only low-income Community care, rather than institutional care, is the goal for
older adults but also low-income pregnant women and children, many persons with disabilities.
still remain. States also were required to increase the amount of
income and assets that may be kept by a person whose spouse's Air Carrier Access Act
nursing home costs are being paid by Medicaid (see ChapterÂ€4). This 1990 act prohibits any discrimination of persons with
Â�disabilities in air travel. Air carriers must accommodate such
Technology-Related Assistance Act travelers and are limited in the types of restrictions they
The Technology-Related Assistance for Individuals with DisabiÂ� may place on them, for example, requiring a travel attendant
lities Act (Tech Act) of 1988 (Public Law 100-407) offers grant (Accessible Journeys, 2011).
money to states interested in establishing programs for informing
the public about the benefits of assistive technologies for people Family and Medical Leave Act
with disabilities. These programs are required to be statewide, and The Family and Medical Leave Act of 1993 provides Â�employees
the activities initiated with the federal funding are to be eventu- with up to 12â•›weeks of unpaid leave per year to care for a Â�newborn
ally funded by state and local resources. The following six require- or recently adopted child; a foster child; a spouse, parent,
Â� or
ments are to be addressed in each program: child with a serious health condition; or the employee's
Â� own
1. Conduct a needs assessment for assistive devices. serious health condition. The law applies to all public and
2. Identify resources. Resources must be coordinated between Â�private employers with 50 or more employees and is enforced
public and private agencies. by the Department of Labor.
3. Provide assistive technology devices and services. Assistive Although not everyone can afford unpaid leave, the act
devices include wheelchairs, computers, and modified eating allows family members to care for each other during times of
utensils. Services are provided directly or through funding to serious health problems, for example, during recuperation from
companies who provide such devices. surgery for correction of congenital defects or recovery from
4. Disseminate information. The public must be informed an SCI. Health care insurance continues during the worker's
of the benefits and availability of assistive technologies. absence, and the worker is guaranteed his or her job or an equiv-
Information should be provided via computer databases and alent job on return to work.
print and electronic media.
5. Provide training and technical assistance. States must teach Balanced Budget Act of 1997
consumers and professionals how to use assistive technologies. The Balanced Budget Act of 1997 imposed stricter limits
6. Support public and private partnerships. The public and on Medicare reimbursement for home care services. The act
Â�private sectors are encouraged to work closely together to narrowed the definition of home-bound. To be eligible to
meet the assistive technology needs of the community. receive home health care, one must require services only on
an intermittent basis and be unable to leave home without
Americans with Disabilities Act considerable difficulty (in need of the assistance of equip-
The ADA, which was enacted in 1990, provides protection from ment or another person). Currently, a physician must order
discrimination for the 49 million Americans with disabilities. services. However, legislation is under consideration to
This act extends the protection of civil rights to people with allow APRNs to certify patients to receive home health care.
physical and mental handicaps and chronic illnesses and was Home health patients may leave home for medical visits and
to attend Â�religious Â�services or adult day care (CMS, 2011b). require many lifestyle adaptations. For example, a client who
Consequently, patients who do not meet the criteria for home has experienced multiple fractures, contusions, and lacerations
health care may often need rehabilitation
Â� services that they might have to deal with chronic pain for the rest of his or her
are ineligible to receive. life. Some of the issues to assess are as follows:
• To what extent is the client capable of performing ADLs such
Community Living Legislation as bathing, dressing, and toileting?
Most individuals with disabilities who qualify for long- • Does the client have use of his or her hands and/or legs?
term care support services must use the Medicaid program. • Does the client have fine motor control, and is he or she
This program is heavily weighted toward institutional mobile?
care. Home-based and community-based support services • Does the client have a healthy self-concept or is the person
represent just 14.4% of Medicaid's annual expenses (Kaiser depressed?
Family Foundation, 2011). • Does the client have a support network of friends and family?
Two new federal legislative efforts are an attempt to help those Family roles may have to be altered to accommodate the
with disabilities stay in the community and access support ser- individual's disability. Spouses or other family members may
vices, as needed. The Community Living Assistance Services and have to assume caregiving, financial, or nurturing roles previ-
Support (CLASS) Act would provide for an insurance program ously assumed by the individual with disability. Spouses may
administered by the U.S. Department of Health and Human have to explore new ways of expressing sexuality (Duchene,
Services, much like the optional Medicare part B and D pro- 2008). The issue of substance abuse should be assessed
grams. It would be a voluntary program in which premiums because alcohol or other drug abuse is often a contributing
would be pooled. If a person used the program and became dis- factor in accidents resulting in traumatic injury. Wound heal-
abled, he or she would receive cash benefits to pay for assistance ing and the threat of infection may be present if the person
services (White House, 2011). This legislation has been consid- has sustained a severe injury or is prone to skin breakdown
ered by Congress in the past several years but has not been passed. because of circulation problems (patients with diabetes or
The second bill is entitled the Community Choice Act of 2007, who have suffered a stroke).
House Resolution 1621, U.S. Congress, House of Representatives. BoxÂ€26-1 presents a guide for assessing health problems and
It would require Medicaid to pay for community-based atten- barriers for persons with disabilities in the community. Access to
dants and support services and increase federal funding for the health care, availability of physical and interpersonal resources,
Medicaid program. This bill has not yet been passed. safety, attention to psychosocial concerns, and promotion of a
barrier-free environment are essential for well-being.
NEEDS OF PERSONS WITH DISABILITIES Employment
Persons with disabilities can require little assistance or substan- Myths abound regarding the interest, motivation, and capa-
tial help to function and live as independently as possible. Some bility of people with disabilities with regard to work. For
individuals will have a static set of assistance needs through- example, some people believe that those with disabilities need
out their lives. Others, with deteriorating conditions, may have someone to take care of them because they do not fit into
escalating assistance needs as their physical or mental condition the workplace and that making the workplace fit them would
becomes more severe. be too costly. Others believe that persons with disabilities do
not want to work because they receive enough support from
Personal Care Needs the government. Still others believe that people with disabil-
Approximately 11 million people have difficulty carrying out one ities do not make good employees because they are unreli-
or more ADLs or instrumental ADLs (IADLs) (Brault, 2008). able, dependent, frequently absent from their jobs because of
Most rely on a child or spouse to assist with care. Almost 25% of illness, and too expensive to employ because of their health
those with limitations in performing basic life activities such as care costs. All of these myths and stereotypical notions are
dressing and food preparation do not receive help from others. inaccurate.
The percentage of persons who are in need but do not have assis- Nurses must remember that those with disabilities are Â�people
tance increases with age (Brault, 2008). Approximately 23% to first. Abrasive personalities and behavioral characteristics can
27.8% of people with disabilities live alone (U.S. Census Bureau, be found in any individuals. There are competent employees,
2006), which means that they often cannot rely on friends or and there are those who demonstrate poor work habits and
family members to assist them with personal care needs. attitudes, regardless of the presence or absence of Â�disability.
Because persons with disabilities are at greater risk of Employment provides special as well as economic benefits
poverty and lack of health insurance, they are often unable (Loprest, 2007). Financial hardship may result or intensify if the
to pay for personal care. Many insurance programs do not client is unable to work. The older people are when they acquire
pay for care or pay for only a limited amount of care. The their disabilities, the less likely they are to receive accommoda-
federal government has been considering changes to insur- tion in the workplace.
ance programs that would help persons with disabilities with Some of the barriers people with disabilities encounter
personal care expenses. These efforts were discussed earlier when securing and maintaining employment are listed in
in the chapter. BoxÂ€26-2. Potential employers have expressed concern about
hiring people with disabilities. Their fears have been based, in
Assessment of Needs part, on the anticipation that providing work site accommoda-
Client care needs vary with the level and severity of disability. tions for these employees might be costly. Job accommodation
The residual effects of traumatic injuries or chronic illness often is usually not expensive (FigureÂ€26-3). Most employers report
BOXÂ€26-1â•…â•‡GUIDELINES FOR ASSESSING COMMUNITY REINTEGRATION NEEDS

OF PERSONS WITH DISABILITIES
ACCESS TO â•› HEALTH CARE • Does the client have a plan in the event that he or she must summon
• Are health care facilities (inpatient and outpatient) and practitioners’ help? (For example, how will a person with a communication disorder
offices architecturally accessible? report an emergency situation over the telephone?)
• Does the client have access to either private or public transportation • Has crime prevention been addressed? An individual using a wheel-
that may be used by a person with his or her specific disability? chair may be especially vulnerable to street crime.
• Is telemedicine available?
• Are needed health care programs available? (Substance abuse treat- PSYCHOSOCIAL ISSUES
ment programs may not be accessible or available.) • What role changes have taken place as a result of the client's disability?
• Are needed health care programs financially accessible? • What are the financial resources and what effects do they have on
• Are negative attitudes on the part of the client, family, or health care wellness?
professionals prohibiting adequate health care? (Feelings regard- • If the person with a disability requires assistance with activities of
ing sexuality counseling or employment capability may have a major daily living, are other members of the family unit feeling neglected by
impact on community reintegration.) the caregiver?
• Does the client want to promote his or her own wellness? • Is the caregiver given a chance to grieve? Is he or she devoting all
energy to the person with the disability and in danger of compromis-
COMMUNITY RESOURCES ing his or her own wellness?
• Are community resources financially, attitudinally, and architecturally • Has the family been assessed for adequate coping skills?
accessible? • Does the client have emotional as well as physical support systems?
• Are the sources used credible? • Are the developmental tasks of the client and family being addressed?
• Does the client or family know how to locate and access resources?
This may be a particular problem in a rural area in which resources PROMOTION OF A BARRIER-FREE ENVIRONMENT
and transportation may be limited. • What attitudinal barriers exist in the client's environment? Are there
• The telephone book may be a valuable tool for locating community feelings that individuals with disabilities cannot adequately work,
resources. Does the client or family have the necessary reading and attend school, or enjoy leisure activities?
verbal skills to use this method? • How is the client's sexuality viewed by himself or herself and others?
• The Internet is a valuable resource for locating community and • Does the client have a negative outlook? Does he or she avoid inter-
national resources. Does the client have access to the Internet? Does personal relationships or refuse to maintain wellness, look for a job,
the client have the computer skills necessary to use the Internet? The attend school, or interact with the health care system?
public library often offers free Internet access and training. • Is there adequate housing for individuals with disabilities?
• Is there a mayor's or governor's office on disability in the client's city • Is there barrier-free public and/or private transportation?
or state? • If the client requires 24-hour care, how are these caregivers located,
• Has the rehabilitation team investigated community resources avail- evaluated, and trained?
able in the client's environment and have they notified both the client • Are the client's place of worship, school, work setting, and shopping
and the resource agencies? facilities accessible?
• Does the health care professional make it a point to network with key • What advocacy groups exist in the community? What barriers exist to
community resource personnel? these groups?
• Do health care providers have feelings that negatively influence their
SAFETY ability to provide adequate care for those with disabilities?
• Has the home been assessed for potential safety problems? The • Has the client or family been taught to plan ahead when going to a
local fire department will often provide a free checklist and/or new setting for the first time? Are schools, restaurants, and stores
walkthrough. assessed before using?
• Do the client and family know how to assess workplaces, schools, • What provisions are available for travel and vacations? Resources for
and recreational areas for potential problems? traveling with a disability can be located on the Internet.
accommodations have no cost and are often as simple as a opportunities for persons with functional limitations. The
rearrangement of equipment. On average, for those employers Â�following are examples of job accommodations:
who accommodate a person with disability, the one-time cost • A mail carrier with a back injury could no longer carry his
is $600 (Job Accommodations Network [JAN], 2011). mailbag. A cart was purchased for $150, which allowed him
The Job Accommodations Network (JAN), a consulta- to keep his route.
tive service of the President's Committee on Employment • A woman who used a wheelchair could not sit at her desk
of People with Disabilities, is an international information because her knees would not fit under it. The center desk
network and consulting resource for accommodating per- drawer was removed, which allowed the employee to sit and
sons with disabilities in the workplace (JAN, 2011). This is work comfortably at the desk. This simple modification cost
a free service with a data bank of more than 20,000 possible the company and the worker nothing.
accommodations. • A medical technician who was hearing impaired could
Employing persons with disabilities does, in fact, have some not hear the buzz of a timer, which was necessary for
benefits. It can reduce workers’ compensation and other insur- Â�specific laboratory tests. A $26.95 indicator light solved the
ance costs, increase the pool of qualified employees, and Â�create problem.
BOXÂ€26-2â•…â•‡BARRIERS ENCOUNTERED BY PEOPLE WITH DISABILITIES SEEKING EMPLOYMENT

• Lack of educational preparation. Students with disabilities or work site accommodations. The passage of the Americans with
who do not attend college might have little vocational prepara- Disabilities Act (ADA) in 1990 and other legislation has facilitated
tion. These students will face unemployment, social isolation, and discussions of workers’ and employers’ fears and attitudes regarding
greater Â�difficulties achieving integration into their communities. The persons with disabilities and workplace accommodation.
U.S. Department of Education's National Institute of Disability and • A belief that provision of income supplements discourage
Rehabilitation Research provides leadership in researching and advis- employment. When employers and others believe that people
ing regarding educational preparation of people with disabilities (The with disabilities who receive welfare benefits or Social Security
U.S. Department of Education's National Institute of Disability and disability subsidies have sufficient income and are satisfied, they
Rehabilitation Research, 2011). are not inclined to consider employment for them. Although mini-
• Inadequate preparation in independent living skills. Limited mum-wage jobs still leave people near poverty, some people with
social, self-care, economic, or job skills may make it difficult for per- Â�disabilities may be reluctant to give up a government subsidy for a
sons with disabilities to live independently in the community. Social paycheck, Â�particularly if health benefits are not included with the job.
and vocational supports and assistive technologies can reduce the Supplements to the ADA have reduced this problem, but it still exists.
Â�dependence on caregivers. • A belief that people with disabilities are more unreliable in
• Feelings of the person with a disability and an employer that job attendance because of frequent illness. Some people with
the person does not fit into the work environment. Discrimination disabilities may be more susceptible to disability-related illnesses
in the workplace continues. Individuals who sustain work-related (e.g., urinary tract infections and skin breakdown in persons with
injuries continue to quit and/or be fired from their jobs. Neither the paraplegia), but this possibility does not permit discrimination in
employer nor the employee has information about job restructuring hiring.
2% Require a combination of A variety of living arrangements are available for people

one-time and annual costs with disabilities, on the basis of their income, functional Â�status,
4% Ongoing annual cost and existing support systems. Some of these are described in
BoxÂ€26-3. Additional information about housing resources
can be obtained by contacting a state's Office on Aging,
Department of Housing and Community Development, Health
37% One-time cost 56% No cost Department, or Developmental Disability Administration.
Mental Health Associations, independent living centers, the
federal Division of Vocational Rehabilitation (Rehabilitation
Service Administration), and head injury foundations may also
have information about the location of specialized housing and
community programs for people with specific disabilities.
FIGUREÂ€26-3â•‡ Employers report on cost of workplace accommo-
dation. (Data from Job Accommodations Network. [2010]. Workplace
accommodations: Low cost, high impact. Retrieved June 24, 2011 from RESPONSIBILITIES OF THE REHABILITATION
http://www.AskJAN.org/media/LowCostHigImpact.doc).
NURSE
The responsibilities of the community-based rehabilitation
Individuals with disabilities should be well informed nurse are varied and challenging. BoxÂ€26-4 lists several prac-
regarding their rights under the ADA. Excellent information tice environments and describes the focus of nursing care for
is Â�available at the JAN website (see Community Resources for the person with disability in each environment. As in any nurs-
Practice at the end of the chapter). ing specialty, the role of caregiver is important. The nurse must
develop flexible and creative interventions and an acceptance
Community Living Arrangements of the clients’ rights to determine their care when dealing with
Many people feel that individuals with disabilities must be clients who must adapt the ways in which they carry out every
taken care of and cannot live independently. Much of that pub- aspect of their lives.
lic Â�perception has focused on those with developmental dis-
abilities or mental illnesses living in group homes and on older Team Member and Case Manager
adults in nursing homes. Efforts are needed to assess the needs The first step in assisting a client in adjusting to physical limita-
of people with disabilities and to project the future housing tions is an assessment of the client's physical, mental, and emo-
needs of all citizens. tional status. The nurse case manager needs to assess a Â�client's
The 1988 Fair Housing Amendments were designed to health status, functional skills, psychosocial status, environ-
increase the access to housing opportunities for people with ment, and financial status (McCollum, 2008). BoxÂ€26-5 Â�provides
Â�disabilities (U.S. Department of Education, 2011). Although examples of assessment measures helpful in determining the
these amendments do not cover all dwellings, multifamily hous- needs and issues of concern for each person.
ing units built after May 1991 are required to consider the needs Primarily, the nurse and other members of the health care
of people with disabilities in accessing common building areas, team need to remember that the client is the captain of his
kitchens, bathrooms, and environmental controls (e.g., light or her care team. The nurse or another team member might
switches and thermostats). Â�disapprove of a treatment option chosen by the client, but the
BOXÂ€26-3â•…â•‡ALTERNATIVE LIVING ARRANGEMENTS AVAILABLE FOR PEOPLE

WITHÂ€DISABILITIES
• Nursing homes—Most nursing homes are privately run facilities program (work, prevocational, or therapeutic activity) during the day
for clients with chronic illnesses. Available services range from and organize their meals and leisure activities in the evenings and on
fully accredited rehabilitation programs to total nursing care. For weekends. Staff are available to assist in problem solving, facilita-
Medicaid to pay for nursing home care, a person's assets must be tion, socialization, and conflict negotiation.
almost depleted (see ChaptersÂ€3 and 4). Older adults are typically • Senior and disabled citizen housing—Senior and disabled citizen
the long-term residents in these facilities. Young people in their housing offers living units designed to accommodate the needs of
twenties or thirties who have spinal cord injuries (SCIs), severe mul- older adults and those with disabilities, regardless of age. These
tiple sclerosis (MS), acquired immunodeficiency syndrome (AIDS), housing programs offer security, social activities, and transportation
or amyotrophic lateral sclerosis (ALS) become residents of nursing to community activities and shopping.
homes because there are no other alternatives available to them in • Independent living apartments—Those with financial assets can
the community. purchase lifetime residence and care in independent living apart-
• Group homes—Group homes and supervised living quarters provide ments. Medical, rehabilitation, and other support services are offered
people with disabilities the structure and support to live outside of to address specific needs. Those who ultimately require 24-hour nurs-
institutions. These living situations typically provide housing for two ing care will find it accessible in life care communities.
to four adults who may have developmental disability or have a head • In-home residences with support services—Individuals with disabil-
injury or a chronic mental illness. ities and their caregivers may take advantage of a variety of Â�community
• Transitional living—In transitional living, people recovering from support services. The following programs are usually available for children
a head injury or other conditions may try out their independent living and adults (eligibility requirements may vary): home health, Â�in-home aid
skills in a supportive environment. These are short-term, posthospital and personal care, respite care, Meals on Wheels, daycare, information
facilities. Clients are generally expected to participate in a structured and referral, and support groups (see ChaptersÂ€30 and 31).
BOXÂ€26-4â•…â•‡PRACTICE ENVIRONMENTS BOXÂ€26-5â•…â•‡SELECTED ASSESSMENT

FOR COMMUNITY-BASED MEASURES FOR USE WITH
REHABILITATION NURSES AND PERSONS WITH DISABILITIES
FOCUS OF NURSING CARE • Activities of daily living (ADLs) tools—Measure ability to feed,
• Outpatient rehabilitation clinics—The focus is on reintegration bathe, groom, dress self. Assess mobility, such as chair to bed trans-
of client into his or her community. fer, stair climbing, and ability to handle a wheelchair. Measure bowel
• Assisted living facilities—The focus is on maintaining optimal and bladder control and ability to toilet alone or with assistance.
level of health for the client within the constraints of the client's • Sample tool: Barthel Index
Â�disabilities and health. • Instrumental ADLs scales—Assess areas of social and eco-
• Home health care—The focus is on providing nursing care in the nomic capabilities. Look at mental health, physical health, and
client's home. ADLs. For example, can a person pay bills by themselves, handle
• Schools—The focus is on providing hands-on nursing care to bank accounts, make and keep doctors appointments?
Â�children with disabilities and education, counseling, and referral • Sample tool: OARS (Older American Resources and Service): 1-ADL
services for parents, teachers, and children. • Cognitive status tools—Assess ability to reason; orientation to
• Case management—The focus is on acting as a liaison and plan- time, person, and place; and mood level.
ning for the ongoing health care needs of a person with Â�disability. • Sample tools: Mini-Mental State Examination, Depression Scale
The nurse may provide health education, health Â�promotion, and • Quality-of-life tools—Assess a person's feelings and emotions
referral services as well. as well as physical and social activities.
• Sample questions: Does the person have a social life outside
Adapted from Parker, B. J. (2002). Community and family-centered the home? How is the person adjusting to physical or mental
rehabilitation nursing. In P. A. Edwards (Ed.), The specialty practice of Â�limitations? Does the person have an active support system?
rehabilitation nursing: A core curriculum (4th ed.; pp. 17-41). Glenview, • Sample tool: MOS (Medical Outcome Survey) three-item survey
IL: Association of Rehabilitation Nurses.
team must respect the client's wish. For instance, a client might physical, speech, and recreational therapists and vocational
elect to use a wheelchair for mobility rather than an artificial counselors are some of the specialists working to enhance the
limb. Every team member should strive to incorporate the cli- rehabilitation process. If a community health nurse is assess-
ent's cultural and spiritual beliefs into all aspects of care and ing a client's ability to self-administer medications in the
must avoid imposing her or his own attitudes and values on home and notices that the client is not using the dressing tech-
the client. niques taught by the occupational therapist, the nurse should
An important characteristic of a community-based rehabili- reinforce the proper method. The occupational therapist may
tation nurse is the ability to work collaboratively with other need to be notified, and additional home visits may be neces-
health care professionals (FigureÂ€26-4). This becomes essential sary. Thus, the nurse needs to be aware of all treatment inter-
as more persons with disabilities are covered by Â�managed care ventions advocated by the team and support continuity of
arrangements (Neal-Boylan & Buchanan, 2008). Occupational, Â�interdisciplinary care.
Educator
The primary role of the rehabilitation nurse, whether in
the inpatient, outpatient, or home setting, is that of client-Â�
family educator. The rehabilitation nurse helps the client and
Â�family learn new skills that must be applied continuously in
all Â�components of daily living. Common nursing diagno-
ses used by rehabilitation nurses in the care of clients appear
in BoxÂ€26-6. Functions such as walking or speaking might
be taken for granted, but when a person is forced by illness
or injury to relearn these skills, the emotional stress can be
significant.
Education should include how to prevent complications or
further disability and how to promote healthy lifestyles and
behaviors to minimize further problems. For example, those
with paraplegia are prone to lower limb atrophy. The benefits of
regular passive exercise in reducing or minimizing limb atrophy
should be part of any education program for persons with new
paraplegia and their families.
Cindy Barson is a community-based rehabilitation nurse and

a volunteer with the Multiple Sclerosis (MS) Society. She is
asked by the director of the society to present an educational
Â�
program to women with MS. Cindy knows that Â�clients with
MS experience physical limitations. She also knows that
women with MS are at greater risk for osteoporosis and
FIGUREÂ€26-4â•‡Many people are involved in the rehabilitation Â�fracture than are women in the general population (Zhang
of this young child. Members of the interdisciplinary team, & Wu, 2010). On the basis of this knowledge, she develops
Â�including the parent or caregiver, collaborate to assess, plan, an educational program for a group of women with MS that
implement, and evaluate the child's care. includes the following goals:
• Increasing their knowledge about osteoporosis
• Increasing their knowledge about the increased risk of
The nurse case manager's efforts are geared toward osteoporosis associated with MS
Â�
helping clients reintegrate into community living and inde- • Helping them identify preventive measures to reduce the
pendent Â�living. It is crucial that community-based rehabili- risk of osteoporosis
tation nurses have a very good knowledge base about what • Assisting them with a plan to consult their physicians to
Â�community resources are available and how they fit the cli- assess their own individual risk and develop appropriate
ent and family. A list of potential resources is provided in preventive measures.
Community Resources for Practice at the end of the chap-
ter. As case managers and client advocates, community health
and rehabilitation nurses can ensure that clients smoothly
BOXÂ€26-6â•…â•‡FREQUENT NURSING
transition between inpatient, custodial, and home care as
their Â�physical and financial needs change. For example, a cli-
DIAGNOSES FOR
ent who no Â�longer requires acute care will need to find an REHABILITATION
appropriate rehabilitation placement; a client whose private • Impaired physical mobility
health insurance benefits are depleted needs to find alternate • Self-care deficit
funding to continue the rehabilitation process. • Alteration in urinary elimination pattern
After returning to the community, rehabilitation clients • Impaired skin integrity
might be in danger of being “lost” by the health care system. • Alteration in bowel elimination pattern
Follow-up health care appointments may be infrequent, and • Potential for injury
problems may develop between visits and/or worsen. Clients • Knowledge deficit
may choose not to seek or maintain health care contacts • Impaired verbal communication
because of depression or anger, or they might fail to recognize • Decreased activity tolerance
(or refuse to acknowledge) a problem's existence. To be effec- • Alteration in nutrition
tive the rehabilitation community health nurse must be avail- • Alteration in thought process, memory
able over a period to reassess the client's readiness to accept • Altered family process
• Social isolation
rehabilitative care. There are many stumbling blocks to suc-
• Sleep pattern disturbance
cessful community interventions. As the number of persons
• Independence–dependence conflict
who survive traumatic illnesses and injuries grows, community
• Diversional activity deficit
health practitioners will become more and more critical to suc- • Powerlessness/hopelessness
cessful community reintegration.
Counselor Client Advocate

Often, the diagnoses used with people with recently acquired Often, client frustration and difficulties stem from inadequate
disabilities focus on their physical limitations and difficulties. community resources, for example, financially unattainable
Community-based rehabilitation nurses use additional diagnoses health care, lack of public transportation, or discriminatory
to focus on issues of community reintegration, including ineffec- attitudes. The nurse can advocate for accessible health care for
tive individual and/or family coping, Â�noncompliance, health man- all citizens.
agement deficit, and impaired thought processes. One of the most
important areas to address is the emotional concerns of the indi- Jay Albert is a community-based rehabilitation nurse work-
vidual with disability and family members who are the caregivers. ing as a case manager for a private social service agency. One
Pryor (2008) advised nurses to understand that people with newly of his clients, Alice Sumers, has muscular dystrophy. She
acquired disabilities usually experience a period of grieving as wanted to visit her family in California but was told that
they learn to deal with their physical limitations. One way to assist the airlines were reluctant to transport her because of her
clients in that process is to emphasize the clients’ positive areas of physical limitations and need for assistive devices (Levinson,
strength rather than merely their limitations. BoxÂ€26-7 provides a 2010). Ms. Sumers voiced her disappointment to Jay on
list of areas helpful to nurses who employ this strategy. one of his visits. He contacted three airlines on behalf of
For those family members who must adjust to caring for a Ms. Sumers and was able to convince one to allow her to
person with a disability, emotional support and education are travel. At the end of her 2-week trip, Ms. Sumers reported
crucial. Hertzberg (2008) reported that family members per- back to Jay that she had an enjoyable time.
ceive their task as daunting, and both physically and emotion-
ally draining. A broad range of concerns has been expressed There are no common denominators for the population with
by relatives of persons with new disabilities (Schempp, 2010). disabilities as a whole. Problems range from obvious physical
Their concerns include educational needs related to physical limitations (loss of a limb or use of a wheelchair for mobility)
care assistance, disease or condition progression, availability of to no visible sign of disability (such as cognitive deficits follow-
community resources, and future needs of the family member. ing a head injury). The nurse as advocate must have knowledge
Family members also express a need for information related to of current laws, especially those regarding financial entitlement,
financial reimbursement and limitations imposed by insurance and existing support services. Nurses must also know what ser-
providers. They also desire emotional support and understand- vices are needed but unavailable. For example, a community
ing in adjusting to their new responsibilities. All these areas health nurse may assist several persons with disabilities to form
should be part of counseling efforts for clients with chronic their own support groups.
Â�illnesses or disabilities and their families. Formal mechanisms for advocacy, such as legislative lobby-
ing and work through professional health care organizations,
Case Finder are excellent means for advocating for the rights of people with
The role of the case finder is useful in locating clients who need disabilities. Other sources of help for advocacy activities are
help but are outside the health care system. Financial concerns government, voluntary, and professional organizations such
may keep clients from receiving health care services and adher- as the Association of Rehabilitation Nurses (see Community
ing to good health practices. Holding free health screening Resources for Practice at the end of the chapter).
Â�clinics is often helpful in locating persons with disabilities who Day-to-day experiences also have the potential to suggest
are not receiving health care services. For example, a blood pres- civil rights issues. For example, during a routine shopping trip,
sure screening clinic gives the nurse an opportunity to assess a nurse may notice many barriers that restrict or prohibit the
blood pressure and case-find clients with other physical, finan- activities of persons with disabilities. Are there adequate pÂ� arking
cial, and educational needs. Community health nurses can speak at local shopping malls, grocery stores, churches, and schools
about topics of rehabilitation and community reintegration to for them? If so, are these parking spaces occupied by cars that do
senior Â�citizen centers, parent–teacher organizations, and support not have the “handicapped” license tags? Such vehicles should
groups for survivors of devastating illnesses and injuries. The be reported to the facility's management immediately. Do pub-
nurse should make a point of asking those present if they know lic buildings advertise themselves as being accessible to people
of potential clients or families who are in need of Â�rehabilitation with disabilities but have heavy doors that are difficult to open,
services and should come prepared to follow up on any concerns. even by able-bodied persons? A wheelchair ramp to a door-
way is useless if the doors cannot be opened by someone with
BOXÂ€26-7â•…â•‡STRATEGIES TO ASSIST Â�limited upper body strength or coordination.
COPING WITH DISABILITY In their daily lives, health care professionals should make it a
practice to review the environment for barriers to persons with
• Allow the client to talk about his or her disability. disabilities. A letter to management identifying such barriers
• Maximize the wellness aspect. will carry more influence if it contains not only a complaint but
• Build on the client's assets. also a reference to applicable legislation and a statement that the
• Help the client compensate for limitations. writer is a health care professional.
• Help the client cope with or modify negative environmental factors.
• Mobilize resources.
• Help identify social supports. COMMUNITY REINTEGRATION ISSUES
• Maximize the client's available energy.
• Promote healthy ego integrity.
Wellness can be defined as being sound in body, mind, and
• Encourage hope. spirit. It is an ongoing, dynamic process. Ultimate respon-
sibility for wellness rests with the client. Many areas must be
assessed as the rehabiÂ�litation client adapts in and modifies the

case manager was assigned to assist him. His case manager
environment. TheÂ€nurse must be aware of factors in the com-
made a referral to the local vocational rehabilitation agency.
munity that facilitate
Â� or inhibit successful community reinte-
Bill participated in vocational assessment and counseling
gration (BoxÂ€26-7).
and explored Â�possible career choices. Bill wished to remain
Promotion of health among those with disabilities fosters
in the construction business. He received vocational train-
optimal use of personal strengths and resources, and prevents
ing in drafting and attended the local community college for
further disability. New or existing resources must be evaluated
business classes. His vocational training included adaptive
for availability, accessibility, and acceptability. Family, friends,
driving with hand controls so that he could drive himself to
and paid caregivers are potential sources of supervision and
school and work. He received regular psychological counsel-
care. Community-based rehabilitation nurses are often respon-
ing to assist him with the transitions related to returning to
sible for teaching and initial supervising of caregivers in pro-
work and school.
viding appropriate, safe physical care. Community health
Over the next few years, Bill completed his business
nurses in rehabilitation can propose new services and modi-
degree and training in computer-aided drafting. He
fications to existing ones and are a primary source of refer-
returned to work full time for his previous employer. The
rals to community-based assistance services such as caregivers,
company provided him with the reasonable accommoda-
home maintenance services, and companion, transportation,
tions he required to function independently in his wheel-
and financial resources.
chair, for example, an extra handrail in the handicapped
toilet stall and a lower-pile carpet in common traffic areas
Bill, a 30-year-old construction worker, fell and sus-
of the office. With the Â�support of his family, community
tained an injury resulting in an L4-L5 complete spinal
resources, Â�rehabilitation team, and a cooperative employer,
cord injury. Following the acute care phase of hospitaliza-
Bill was successfully Â�reintegrated and adjusted well to his
tion, Bill was transferred to the rehabilitation hospital in
new disability.
his Â�community, where he worked with nursing, physical
therapy, occupational therapy, and recreation therapy per-
sonnel. He and his family attended classes on spinal cord Rehabilitation clients experience the loss of a variety of
injury, learned to care for his physical needs, and partici- skills. Adults with disabilities, as well as the parents of an infant
pated in Â�discharge planning to help with the transition to or child recently diagnosed with an impairment or disability,
his home environment. mourn the loss of full functioning. It is important that both the
As part of Bill's discharge plan (1) an assessment client and the family be given the opportunity to grieve. The
of his home was conducted by physical and occupa- nurse assists the client in acknowledging the loss, allows expres-
tional Â�therapists to identify accessibility issues and plan sion of grief, and provides information about the disabling con-
Â�renovations Â�necessary for him to be independent at home, dition. This support will foster realistic expectations and hope
(2) a home health agency was contracted to provide nurs- for the future. Throughout this chapter, barriers to community
ing care as needed, and (3) an outpatient therapy center reintegration of the rehabilitation client have been identified.
was scheduled to Â�continue his physical rehabilitation. An The community health nurse and the entire rehabilitation team
employment Â�assessment Â�indicated that he would no longer should make every effort to accurately identify and reduce or
be able to work at the same job. A workmen's compensation eliminate barriers to the successful community reintegration of
their clients with disabilities.
KEY IDEAS
1. Rehabilitation is a dynamic process that aids a person with 6. The nurse must be a client advocate, aware of Â�legislation
disabilities in successfully achieving well-being and the high- and community factors that affect the ability of the
est level of function possible. This process must also involve Â�person with disability to integrate successfully into the
successful community integration. community.
2. Society in general and health care professionals in particu- 7. A component of this advocacy role includes being able to
lar have a long history of treating citizens with disabilities as assess barriers to wellness that affect both clients and their
second-class people. A key characteristic of any rehabilita- families.
tion specialist is the belief in quality of life and the right of 8. Managed care affects the financial accessibility of services
all persons to live satisfying, productive lives. and the choice of providers for persons with disabilities.
3. As the U.S. population continues to age, the demand for 9. One of the biggest barriers to successful rehabilitation is
Â�rehabilitation services in the community will continue to grow. the possibility of a client's getting “lost” in the health care
4. Veterans returning from Iraq, Afghanistan, and other areas system. The rehabilitation client must be able to access the
of conflict are an increasing population among those with health care system, especially after returning home from
disabilities. an inpatient setting. The rehabilitation community/Â�public
5. As a member of an interdisciplinary team, the community/ health nurse must be aware of ways to keep the door to
public health nurse must have the ability to collaborate with Â�wellness open.
a variety of health care professionals.
CASE STUDY
Advocating for Rehabilitation Clients
A community health nurse is attending a small state university on a part- the wheelchair pushups and the importance of wheelchair-accessible
time basis. She is working on a master's degree and has a particular Â�bathrooms. The nurse may also share this information with her class-
interest in people with disabilities. On the first evening of class, she mates. She should probably examine her own feelings in this situation
is surprised to find that the class has been moved from one building because she did not intervene until after the student with disability left
to another. The first location was close to the parking lot, next to the the class in tears. For example, the nurse may also be feeling resentful
library, and a popular classroom setting for students and professors. at being inconvenienced.
The new location is a considerable distance from the parking lot and is The nurse has several options for action. He or she could contact
referred to in a negative manner by most students and faculty. It is “too the campus office responsible for implementing the Americans with
far from everything,” parts of the building are still under construction, Disabilities Act (ADA) to report her observations and make suggestions.
and the heating system is not working properly. She might also involve some of her classmates in touring the Â�campus
The nurse listens to her classmates grumble as they walk to the new and classroom building to identify barriers to wheelchair mobility. It
building. It seems that one of the students uses a wheelchair, and the is likely that some of them will continue to hold negative
Â� attitudes,
class had to be relocated to the newer, wheelchair-accessible building. but a practical, concrete illustration of barriers may be more effective
She tries to point out that communities have an obligation to provide than verbal arguments. She could also find out about the existence of
barrier-free academic settings, but no one really wants to listen. Most Â�advocacy groups for persons with disabilities on campus.
of the students in this business class are not health care professionals The nurse may help the student with disability gain access to appropri-
and are not happy about being inconvenienced. This class is an elective ate assistance for community reintegration. This is a particularly difficult
for the nurse, who hopes to enhance her budgetary skills. The nurse issue. The student has already refused assistance. If she does not return
believes she will also have an opportunity to be a client advocate. to class, the nurse may contact student health services and request that
The student with disability is approximately half an hour late for class. they attempt to contact the student. The student with Â�disability may
She seems nervous and uncomfortable when she arrives. The professor benefit from help in planning her ADLs. She may need help in Â�assessing
comments that the class has undergone considerable inconvenience on new situations for potential barriers. If the student is not found, or if
her behalf, and she should plan to arrive on time in the future. The student she continues to refuse assistance, the nurse cannot ethically pursue
has paraplegia and must do wheelchair pushups several times an hour to the matter. However, she can continue to work to promote a barrier-free
relieve pressure on her sacrum. This causes several giggles from watching environment in her academic setting.
classmates and another comment from the professor about distracting the The success of the plan does not depend totally on the ability of
class. At break time, the student wheels herself from the room in tears. Â�students and professors to acknowledge the barriers that are present
The nurse attempts to follow the student, but finds that there is and eliminate them. Realistically, the nurse must evaluate her impact
no wheelchair-accessible bathroom on this floor. It is still being con- on the academic setting by both long-term and short-term changes. If,
structed. The only accessible bathroom is two floors down. The nurse as a result of this nurse's efforts on campus, awareness of the rights of
finds the student, introduces herself as a nurse, and offers to assist her. Â�persons with disabilities has been increased and acknowledged, then
She is surprised when the student angrily refuses her help with the com- the nurse has been an effective client advocate. An important factor is
ment, “You nurses don't understand what it's like to be this way!” The the realization that nursing takes place in all settings and at all times
student does not return to class after the break. with a variety of roles, not merely within the professional work setting.
The nurse approaches the professor privately and discusses the need See Critical Thinking Questions for this Case Study on the book's
for successful community reintegration. She points out the need for website.
1. As you go about your day, take time to imagine what life 3. Explore a supply store or catalogue that sells equipment for
would be like if you used a wheelchair for mobility. Attend environmental adaptation and assistive devices for persons
class, go shopping, and see a movie, all from the viewpoint of with disabilities. Note what equipment and devices are avail-
a person with a disability. What barriers did you encounter? able, and their cost.
How would you attempt to eliminate these barriers? How do 4. Participate with a rehabilitation nurse, physical thera-
you feel about living with a disability? pist, occupational therapist, or vocational rehabilitation
2. Visit a supervised living arrangement such as senior hous- Â�counselor as he or she makes an assessment and plans care.
ing or a group home. Identify the criteria for residency, the 5. Recall a time you felt uncomfortable in the presence of some-
Â�services available, and the home's ambiance. What nursing one with a disability. Role-play alternative ways of relating to
care is available, and from whom? the person that emerge from different attitudes.

Access Abroad: http://umabroad.umn.edu/professionals/Â� American Association for Health and Disability (AAHD): http://
accessabroad.php www.aahd.us/page.php
Americans with Disabilities Act (ADA) Information Line: http:// American Heart Association: http://www.heart.org/HEARTORG/
www.ada.gov/infoline.htm American Stroke Association: http://www.strokeassociation.org/
Alliance for Technology Access: http://www.ataccess.org/ STROKEORG/
Association of Rehabilitation Nurses: http://www.rehabnurse.org/ National Clearinghouse of Rehabilitation Training Materials:

Brain Injury Association of America: http://www.biausa.org/ https://ncrtm.org/moodle/
Christopher and Dana Reeve Resource Center: http://www.Â� National Institute of Arthritis and Musculoskeletal and Skin
christopherreeve.org/site/pp.aspx?c=mtKZKgMWKwG&b= Diseases Information Clearinghouse: http://www.niams.nih.gov/
4451921 National Multiple Sclerosis Society: http://www.nationalmssoci-
Commission on Accreditation of Rehabilitation Facilities: http:// ety.org/index.aspx
www.carf.org/home/ National Rehabilitation Information Center: http://www.naric.com/
Consortium for Citizens with Disabilities: http://www.c-c-d.org/ National Stroke Association: http://www.stroke.org/site/Page
Developmental Disabilities Nurses Association: http://ddna.org/ Navigator/HOME
Disability Information and Resources: https://www.disability.gov/ Paralyzed Veterans of America: http://www.pva.org/site/c.
Disability Travel: http://www.disabilitytravel.com/ ajIRK9NJLcJ2E/b.6305401/k.BCBB/Home.htm
Disabled Sports USA: http://www.dsusa.org/ Spina Bifida Association of America: http://www.spinabifidaas-
Job Accommodation Network: http://askjan.org/ sociation.org/site/c.liKWL7PLLrF/b.2642297/k.5F7C/Spina_
Library of Congress National Library Service for the Blind and Bifida_Association.htm
Physically Handicapped: http://www.loc.gov/nls/ Special Olympics: http://www.specialolympics.org/
Mobility International USA (MIUSA): http://miusa.org/
National Clearinghouse on Disability and Exchange (NCDE):
http://www.miusa.org/ncde
WEBSITE
STUDY AIDS
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Loprest, P. (2007). Strategic

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• NCLEX Review Questions

• Critical Thinking Questions and Answers for Case Studies

CLAUDIA M. SMITH, PhD, MPH, RN-BC

COMMUNITY/PUBLIC HEALTH NURSING PRACTICE:

Unit opener photograph credits:

Library of Congress Cataloging-in-Publication Data

Content Strategist: Nancy O'Brien

Last digit is the print number: â•›

FRANCES A. MAURER MS, RN-BC CLAUDIA M. SMITH, PhD, MPH, RN-BC

UNIT 1 ROLE AND CONTEXT OF UNIT 5 TOOLS FOR PRACTICE

UNIT 3 FAMILY AS CLIENT UNIT 8 SETTINGS FOR COMMUNITY/

UNIT 1 ROLE AND CONTEXT OF Public and Private Sectors, 63

UNIT 2 CORE CONCEPTS FOR THE Ethnicity, 271

UNIT 4 COMMUNITY AS CLIENT 20 Health Teaching, 505

Responsibilities of the Home Health 33 Community Mental Health, 822

BOXÂ€1-2â•…â•‡WHERE ARE COMMUNITY For those currently enrolled in a baccalaureate nursing

DISTINGUISHING FEATURES OF COMMUNITY/ Community/public health nurses seek to empower Â�individuals,

to be “present” with a client when the nurse is both physically COMMUNITY

ences must be considered when developing and adapting nurs-

THEORY AND COMMUNITY/PUBLIC Person

Nursing practice is based on the concepts of human beings,

SUPRASYSTEM: City Department of Aging

health care provided INTERNAL FEEDBACK: Quality of life

Satisfaction with residence

Extended family support

TABLEÂ€1-1â•…â•‡PERSPECTIVES community/public health nurses apply the problem-solving

TABLEÂ€1-2â•…â•‡EXAMPLES OF HEALTH OUTCOMES RELATED TO GOALS OF COMMUNITY/

TABLEÂ€1-3â•…â•‡ BASIC ETHICAL PRINCIPLES IN HEALTH PROFESSIONS

FIGUREÂ€1-4â•‡Minnesota Public Health Interventions Wheel (March, 2001). (From Minnesota

TABLEÂ€1-4â•…â•‡ PUBLIC HEALTH INTERVENTIONS WITH DEFINITIONS

TABLEÂ€1-5â•…â•‡WAYS OF DEVELOPING PATTERNS OF KNOWING

COMMUNITY RESOURCES FOR PRACTICE

TABLEÂ€2-1â•…â•‡NURSING EFFORTS IN EUROPE BEFORE 1850

district nursing (Monteiro, 1985). With Rathbone's financial

District Visitors and Visiting Nurses in the United States

TABLEÂ€2-2â•…â•‡DATES IN U.S. COMMUNITY/PUBLIC HEALTH NURSING HISTORY

there were 15 nurses; by 1909, there were 47 nurses on call;

Public health nursing, as a composite of nursing and public Â�

TABLEÂ€2-3â•…â•‡DATES IN U.S. PUBLIC HEALTH HISTORY

Maternity services encompassed prenatal care, labor and Industrial Nursing

and gave immunizations (Hamilton, 1988). To stimulate the

prevent disease and provide health education to families of

DICHOTOMY IN PUBLIC HEALTH NURSING

This definition included government-sponsored services as Â�

HEALTHY PEOPLE 2020

Access to Health Services Human Immunodeficiency Virus

HEALTHY PEOPLE 2020 Goals

Data from U.S. Census Bureau. (2008). U.S. National Population

research by the Â� independent Task Force on Preventive

HEALTHY PEOPLE 2020

COMMUNITY RESOURCES FOR PRACTICE

STUDY AIDS WEBSITE RESOURCES

United Kingdom United Kingdom

United States United States

Oversight and Management

Health Care Services

HEALTH CARE DELIVERY SYSTEM

TABLEÂ€3-1â•…â•‡ COMPARISONS OF SELECTED HEALTH CARE PROFESSIONS

Other**** (3.9%) Academic Education (3.8%)

Ambulatory care*** (10.5%)

Home health (6.4%)

* Percents may not add to 100 due to rounding

BOXÂ€1-2â•…â•‡WHERE ARE COMMUNITY For those currently enrolled in a baccalaureate nursing

TABLEÂ€1-1â•…â•‡PERSPECTIVES community/public health nurses apply the problem-solving

TABLEÂ€1-2â•…â•‡EXAMPLES OF HEALTH OUTCOMES RELATED TO GOALS OF COMMUNITY/

TABLEÂ€2-1â•…â•‡NURSING EFFORTS IN EUROPE BEFORE 1850

TABLEÂ€2-3â•…â•‡DATES IN U.S. PUBLIC HEALTH HISTORY

BOXÂ€3-3â•…â•‡SCOPE OF SERVICES PROVIDED BY THE CENTERS FOR DISEASE CONTROL

BOXÂ€3-5â•…â•‡SAMPLE LISTING OF OTHER FEDERAL AGENCIES INVOLVED IN HEALTH MATTERS

TABLEÂ€3-3â•…â•‡CAMPAIGN CONTRIBUTIONS BY HEALTH CARE ORGANIZATION AND INDUSTRY

*Medicare and Medicaid programs begin Projected costs

BOXÂ€4-2â•…â•‡MEDICAID BENEFICIARIES AND SERVICES*

TABLEÂ€5-1â•…â•‡INTERNATIONAL COMPARISON OF HEALTH INDICATORS FOR SELECTED

BOXÂ€5-2â•…â•‡SAMPLE SERVICE ORGANIZATIONS

poverty, lack of knowledge about the importance of personal TABLEÂ€5-2â•…â•‡HUMAN IMMUNODEFICIENCY

TABLEÂ€5-4â•…â•‡NATIONAL HEALTH CARE SYSTEMS

TABLEÂ€6-1â•…â•‡EXAMPLES OF LAW AFFECTING CLIENTS AND NURSING PRACTICE

TABLEÂ€6-2â•…â•‡FEDERAL LEGISLATION THAT INFLUENCES PUBLIC HEALTH