Influences on Health Care Delivery and Community Health Nursing By N. Haliyash MD, BSN
Public Health & Community Health “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.”— C. Everett Koop
Public Health • Definition : Public Health ~ The science and practice of protecting and improving the health of a community, as by preventative medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards.
Community Health • Definition: Community Health - a subset of the health and human services system; it is an area of human services directed towards developing and enhancing the health capacities of people - either singularly as individuals, or collectively as groups or communities.
What is Public Health? • Public Health System = Government + Private Sector • Several Unique Factors • Public Health’s Primary Responsibilities (IOM)
Public Health System • The public health system is a united effort that incorporates the resources of both the government and the private sector. • Several Unique Factors: • A focus on prevention as a primary strategy for improving health and quality of life (from cure to prevention) • A collective policy decision-making process that includes collaboration • Interventions and policies that are grounded in epidemiology, biostatistics, environmental science, management sciences, and behavioral and social sciences
The role of government • The role of government in public health protection was well articulated by the 1988 Institute of Medicine (IOM) report that cited three primary responsibilities. • Called the three core functions, they are: • Assessment: To identify trends in illness and death and the factors which may cause these events, as well as available health resources and their application, unmet needs, and citizens’ perceptions about their health. • Policy Development: The information taken from the assessment data is used to develop state and local health policies. Policies are incorporated into community priorities and plans, public agency budgets, and local ordinances and statutes. • Assurance: This function translates the policies into services and monitoring of the quality of all health services provided in both the private and the public sectors.
What is Community Health? • Relationship between community health and public health Public Health • State of Nevada ~ Community Health Nurses • Like Epidemiology, Community Health is a subsection of the larger public health umbrella.
Levels of Public Health Institute of Medicine Environmental Protection Agency National Institute on Health Federal Human Resources & Services Administration Center for Disease Control and Prevention United States Department of Health and Human Resources (Region 9) Regional State State of Nevada Department of Health and Human Services Local Clark County Health District Washoe County Health District County Health Officer
The Department of Health and Human Services • At the State level, the Department of Health an Human Services houses the public health authority. • This department includes • the Health Division, • the Division of Mental Health and Developmental Services, • and the Division for Aging Services, among others. • The Department is responsible for all public health related services in the rural and frontier areas of the state. Each county has a health officer that works in conjunction with the State to coordinate services and address needs.
Prevention • Levels of Prevention: • Primary Prevention refers to those measures that focus on prevention of health problems before they occur (education, immunization, family planning) • Secondary Prevention begins when pathology is involved and is aimed at early detection through diagnosis and prompt treatment (Inactive TB) • Tertiary Prevention is the treatment of an established disease (Active TB) • Nurse’s Role in Prevention Essentials of Community-Based Nursing: http://communitynursing.jbpub.com
Nurse’s Role in Prevention • The community health nurse is an essential part of the public health system. The nurse uses prevention at all levels. • Primary prevention is utilized through education in homes, schools, health fairs, and clinics. • Secondary prevention is used when completing screenings and counseling. • Tertiary care is highly important and can effect both the individual with the active disease or infection as well as the community as a whole. While treating a patient at a tertiary level, you could be utilizing primary prevention for the population. The nurse’s main role in prevention is through direct patient care services such as immunization, STD screening, and family planning .
10 Greatest Public Health Achievements in the United States • Vaccination • Motor-vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning (Title X) • Fluoridation of drinking water • Recognition of tobacco use as a health hazard Center for Disease Control ~ MMRW
National Statistics Source: CDC
Community Health Nursing • Services Include: • Family Planning, Education, Counseling and Treatment; • Health Education; • Cancer Screening; • Immunizations; • Well-Child Examinations and Healthy Kid Screenings; • Sexually Transmitted Disease Education, Counseling, and Treatment; • HIV/AIDS Counseling, Education and Testing; • Assist Office of Epidemiology with Communicable Disease Investigation; • Tuberculosis Screening and Education; • School Health Promotion and Education; and • Children's Special Health Care Needs referrals
Community Health Nursing • Scope of Practice • the scope of practice for a community health nurse is described in the standard protocols. • Impact of Nurses
Impact of Nurses • The influence a nurse has on a rural area can vastly affect the health of the community. The greatest impact the nurse has on the community is through direct services and prevention activities directed at individuals and groups. • The health of a population is measured based on health statistics such as • birth rate, • death rate, • infant mortality rate, • and incidence and prevalence of a number of factors.
Community Health NursingLevels of Priority Communicable Diseases ~ Casual Transmission Least Frequency of Services Communicable Diseases ~ Non-Casual (Intimate) Transmission Communicable Infection & Disease Prevention Greatest Other Prevention Activities and Primary Care
Reporting Refer to the Standard of Care Guidelines and Protocols Majority of Patients If Standard of Care Guidelines do not apply to a particular case or you need clinical advice, contact a supervisor or the State Health Officer Unique Cases
Public Health Process Patient Disease Investigation Office of Epidemiology Disease Investigator Treatment Diagnosis Community Health Nurse Community Health Nurse Follow-up Private Provider Private Provider Office of Epidemiology Disease Investigator Emergency Room or Other
What Is Ethics? • Ethics is a philosophical pursuit originating in an ancient discourse on the definition of the human good. • To maintain a clear focus on ethics, it is helpful to contrast its domain to that of law.
Ethics versus law • The essential points of comparison are the following: • Whereas ethics considers people as inherently good, law presumes them to be basically bad; • Therefore, ethics proposes what a person should do, whereas law specifies what one must do; • In fact, although one may be chastised if found in violation of ethical principles, there are no definite sanctions for violations of its precepts, whereas law imposes penalties in terms of fines and imprisonment.
Finally, ethics includes many levels of discourse, but the division of ethics most useful to health care decision making is that of applied ethics. The function of applied ethics is to provide a systematic, logical framework for analysis, discourse, and decision making that helps ensure that decisions are grounded in the philosophy of вЂњgoodвЂќ actions.
Seven Principles Essential in Health Care Ethics • Autonomy • Respect for persons • Beneficence • Nonmaleficence • Justice (distributive and retributive) • Veracity • Advocacy
Autonomy • The right of individuals to self-determination (autonomy) is the core value of western European and American law and ethics. In application to health care, it means that decisions should be made by those most affected, be they individuals, families, groups, or communities. Clearly, autonomy is the umbrella concept of the community-as-partner model. Particularly in community health, it is important to understand that many health care professionals will come and go, and any outside program, no matter how worthy, will endure only as long as those professionals remain, unless the community makes an autonomous investment to endorse and adopt the idea behind the program.
Respect for People • The second essential ethical principle, respect for people, recognizes that every person and community has intrinsic value. Applying this principle to community health directs health care professionals to evaluate the effect of proposed initiatives in light of their implications for all who might be affected. • One example of applying the principle of respect for people might be to encourage a community to reevaluate its proposal to resolve its solid waste or toxic waste problem by transporting this waste to another community. The benefit to people in one community creates potential harm for those in another. Another example would be to give careful consideration before introducing western medical practices and ideals that might conflict with a community's cultural norms and folk-healing practices. Other examples will be discussed in more detail in the next sections in relation to justice issues and programs that are restricted to serve only a portion of the community in need.
Beneficence • The desire to act in the best interest of others, beneficence, is perhaps the strongest guiding ethical principle of health care professionals. Most people who enter the helping professions do so because of an altruistic desire to help others. Because of the desire to help people, to take care of them, and to alleviate their suffering, health care professionals often find themselves faced with conflicts between their desire to help (beneficence) and their respect for the other person's right to choose (autonomy). In fact, the principles of beneficence and autonomy are so often at odds that it is all but impossible to imagine an uncomplicated example of beneficence as applied to community health nursing. Even a community health initiative as apparently benign as an immunization campaign to protect community members from a communicable disease may conflict with the autonomy of people whose religious beliefs do not support the practice. The complexity of communities makes it unlikely that any community-wide activity will be uniformly beneficial to all sectors.
Nonmaleficence • Nonmaleficence, the avoidance of harm, is the silent partner of beneficence. Often, health care decisions may offer no really good option that will provide positive results, but at least there may be a choice that does not cause any outright harm. When proposals are considered for community health initiatives, it is important to evaluate not only what positive good (beneficence) may come from the activity, but also what harm might result, particularly if, as in the example above of solid waste and respect for people, the same initiative may well be beneficial for some community members and harmful to others. If a community attracts more industry to the area, the results may include increased job opportunities and better economic conditions for its residents, but there may be counterbalancing health risk factors such as environmental harm and decreased water and air quality.
Justice • The principle of justice has two aspects, both of them applicable to health care decision making. • Most often, discussions of health-related justice center on distributive justice, the fair distribution of rights and resources. These discussions often center on allocation of scarce resources in ways that are fair and of greatest benefit to the most people. In this context, community health care providers and advocates argue for increased governmental support for preventive health programs that lead to better quality of life (beneficence) for the greatest number of people in the community (respect for people).
Veracity • Veracity is the commitment to tell the truth. In application to community health nursing, it centers on honesty about who you are and what you bring to the community. In some communities, many programs and researchers have come and gone and a cynical materialism has arisen in the community. Community health nurses may find themselves entering communities that have become accustomed to outsiders bringing in programs, goods, or services. It is difficult but necessary to be clear from the beginning that, in the spirit of community as partner, the only gift brought by the nurse is the gift of self, offering advocacy and energy in support of the community. • Community health research raises issues of veracity. Many communities, particularly those with underrepresented population groups, are frequently visited by teams of researchers who screen residents for any number of health conditions or risk factors, including chronic illness and toxic exposure. Community health nurses, as community advocates, should help ensure that these researchers are honest with the community about exactly what is to be provided. All too often, residents do not understand that the only benefit from participation in a research study is the screening itself. Access to the results of health screening raises a separate issue of veracity, as well as issues of beneficence and nonmaleficence. It does not benefit anyone to know they have a serious health condition if they have no access to treatment for it.
Fidelity • The last of the seven essential principles is fidelity, or faithfulness. To work with communities or individuals, the health care professional must be careful in making promises and steadfast in keeping them. This obligation may be embodied as simply as making and keeping appointments. It also may extend to a pledge to report back to community leaders on the outcome of a • To be effective on a long-term basis in a community, a community health nurse needs to network with health care providers in the community to obtain treatment for people made aware of serious health conditions by community health screenings. Much of the work of the community health nurse, then, involves building relationships to advocate effectively for treatment for community members diagnosed with serious health conditions.
It is important to be aware of the reciprocal nature of this relationship and how it relates to issues of retributive justice and political involvement. Thus, if the community health nurse expects another health care professional to respond to a community and its needs, the time will come that the health care professional is entitled to ask for a favor in return. An effective approach is to consider what one's community, one's associates, or oneself might have to offer in advance of asking the favor. It is also good to know about tax incentives, public relations, referrals, and other nonaltruistic motives as well.
Advocacy in community health nursing. • New roles of the health care professional within the framework of community as partner reflect an increasingly balanced participation between providers and recipients of health care. One role, developed and elaborated by nurse ethicist Sally Gadow, is that of advocacy. In her philosophical discourse, advocacy involves understanding the world view, life circumstances, and priorities of those requesting or receiving care and exploring the possible options with them in light of their preferences. In contrast to a strict contractualist or consumerist approach, however, the health care professional tries to imagine experiencing the situation of the person seeking care and offers an opinion of the best choice in full consideration of the other party's individuality (Gadow, 1990).
Outline • General Trends impacting the Health Care Workforce • The Public Health Workforce • National Data • State Studies • Profession Specific Examples • Pew Recommendations • Future Directions
Present Outlook • General workforce issues affecting all sectors of the economy • Aging workforce • Technical skill gap • Diversity disparity • Displacement of traditional pathways of employment • Values of next generation • Inadequate education/work integration
Winds that are blowing... • A national crisis is looming for health workforce but it has as much to do with lack of innovation, as it does with shortages of workers • Three key trends • Changing Demographics • Technological Innovation • Change to market driven health • system
The workforce is changing… Are you ready for the next generation? • Age: Great depression/ WW II era workers, Baby Boomers, and Generation X all see the world from a different vantage point • Race: Moving from a majority culture (1995), to diversity (2005), to multicultural (2025) • Gender: Dramatic expansion of career opportunities for women over past 30 years, not restricted to nursing and teaching
Technology Driven Changes Biomedical • US Investment in basic and applied biomedical sciences leads the world • The next generation of technology promises to reduce cost, move care to ambulatory settings, and improve outcomes
Health care is a knowledge based service enterprise Consumers are increasingly technology savvy Technology Driven Changes Information • Technological changes in • health care are likely to • increase the demand for • skilled labor
How to balance the tradition of individualism with the needs of: Population health System outcomes Broader social needs Balance of equity and choice Changes needed: Public understanding and expectation Legal framework Financing system Provider expectations Funded and deployed public system Market Pressures
Workforce implications • Workforce expenditures represent the major costs to systems • Increasing pressure to reduce/streamline personnel costs • Competence of providers, whether technical, cultural, clinical, is key to system success • Mal-distribution of services • Forecasting future needs is difficult but necessary, for the pipeline is long
Medicine: Nursing: Dentistry: Allied Health: General state of workforce shortages across health professions Public Health??
Public Health Workforce Data • US employment census information • Local / State Surveys or Reporting • National Association of City and County Health Organizations (NACCHO) • US Office of Personnel Management • Equal Opportunity Employment Commission (EEO-4) • Professional Associations • Information from: • BHPr (2001) “The Public Health Workforce: Enumeration 2000” HRSA. • Turnock and Hutchison (2000) “The Local Public Health Workforce” Illinois Center for Health Workforce Studies. • Mertz and Finocchio (1999) “A Snapshot of California’s Local Public Health Department” California Center for Health Workforce Studies.
Practicalities* Range of workers? Level of specificity? Data source? Time period? Data Issues* Quality and specificity Classification schemes Counting Unclassified Workers The Public Health Workforce: Enumeration 2000 *BHPr (2001) “The Public Health Workforce: Enumeration 2000” HRSA.
Findings • Physicians are small part of PH workforce • Epidemiologists are less than 1% of workforce • PHNs are largest professional group • Have most accurate numbers on lab professionals and nutritionists • Professional and leadership of PH is influenced by the number and quality of technical and administrative support
Western States Study Rural PH has higher per capita spending, but relies mostly on PHNs Similar per capita supply of PH workers Low turnover, but difficult to fill vacant positions Recruitment of Professional staff with previous experience or format training is a challenge Varying amount of support staff Nursing core of staff, more diversity in urban regions Rural Public Health Workforce *Data from two reports done by WWAMI Center for Health Workforce Studies And a third from the Illinois Center for Health Workforce Studies
Urban and Rural Composition of the PH Workforce *Data from two reports done by WWAMI Center for Health Workforce Studies And a third from the Illinois Center for Health Workforce Studies
Augmenting a limited PH workforce Lessons from recent studies show: • Collaborations with local hospitals and other services to ensure population coverage are successful • Volunteers play a key role in provision of PH • Leadership in creating and maintaining partnerships is key • Focus on strengths as a way to build relationships and attract new talent • Composition of staff and aspects of organizational structure may be more important influences on core functions than pure quantity of workers