NURS 4102 Community Health Nursing Exam 1
Week 1: Population Health, Health Promotion, Disease Prevention, Epidemiology, &
Screening (Unit I)
What is Population Health
The health outcomes of a group of individuals, including the distribution of such
outcomes within the group.
 Often geographic populations such as nations or communities
 Can also be other groups such as employees, ethnic groups, disabled persons,
prisoners, or any other defined group.
Social Determinants of Health
Conditions in the environments where people are born, live, learn, work, play,
worship, and age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks.
Five Domains:
 Economic Stability
 Education Access & Quality
 Healthcare Access & Quality
 Neighborhood & Built Environment
 Social & Community Context
Public Health Nursing
 Population Focused
o Population of individuals who live in the community
 Community Oriented
o Connection between population’s health status and their environment
(e.g., physical, biological, sociocultural)
 Health and disease - prevention focused:
o Strategies for health promotion, health maintenance, and disease
prevention: 1st, 2nd & 3rd.
 Intervention at the community and population levels
o Using political process to affect policy
o Health of all members, especially vulnerable subpopulations
Health Promotion and Disease Prevention
Triad of Promotion
 Health Promotion
 Health Education
 Disease Prevention
Health Promotion
The process of enabling people to increase control over and improve their health.
 A commitment to dealing with challenges of reducing inequities, extending the
scope of prevention and helping people to cope with their circumstances.
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Creating environment conducive to health in which people are better able to
take care of themselves.
Health Education
The process by which individuals and groups learn to:
 Promote, maintain, and restore health
 Address risks and prevention of disease or injury.
 Note: Education for health begins w/people as they are with whatever interests
they may have in improving their living conditions.
Targets of Health Education
 Health Behavior: Activity taken to prevent illness/disease.
 Health Belief: statements held to be true by an individual or group. Ex: The
belief flu shots give you the flu.
 Attitudes: Position, disposition or manner w/regard to a person or thing. Forms
how others view you or a population.
Disease Prevention: Important
Interventions or actions to minimize the burden of disease and associated risk
factors.
 Primary: Disease has not occurred. Goal is to prevent it from happening. Ex:
Immunizations, encouraging exercise to prevent weight gain.
 Secondary: Screening for illness or disease. Ex: TB skin test or Check BMI at
provider visit to identify individual who are overweight or obese.
 Tertiary: Intervention that you implement AFTER the illness or injury has
occurred. Reason: to prevent. Ex: cardiac rehabilitation programs or disease
management programs (diabetes etc. )
Screening Programs
 Accurate, reliable results
 Inexpensive
 Quick administration
 Little to no adverse effects
 Access to large groups
 Available treatment (does not mean cure)
Screening Programs
Reliability
o Accurate measurement with consistent use
 Validity
o Identify a condition
 Recommendations
o Determined by the US Preventive Services Task Force (USPSTF)
o Grades
 A – Strongly recommends
 B – Recommends
 C – Neutral
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D – Against
I – Insufficient evidence
Page 349: Box 20.5
TRANSLATING DATA TO PREVENTION/SCREENING
Children – Health Concerns
 Perinatal problems
 Congenital conditions
 SIDS
 Motor Vehicle
 Unintentional Injuries
Prevention/Screening Priorities
 Height/weight
 Vision and hearing
 Lead
 Dental
 Immunizations
 Anticipatory guidance
 Home safety
 Car seat safety
 Nutrition & Exercise
Women’s – Health Concerns
 Menopause
 Osteoporosis
 Heart Disease
 DM
 Cancer – Breast, cervical, ovarian, colorectal
Women - Screening/Prevention
 Ht, Wt, BP
 Dental
 Cholesterol
 Colonoscopy, sigmoidoscopy
 Pap smear
 Mammography
 Immunizations
 Rubella serology
 DM
 HIV, STIs, Hep B, Hep C
 Skin screen
Men – Health Concerns
 Heart Disease
 Cancer – Prostate, Testicular, Skin, Colorectal
 Accidental Injuries
 Lung disease
 Liver disease
Men - Screening/Prevention
 Height/Weight
 Blood Pressure
 Cholesterol
 Lead
 Dental
 Colonoscopy/Sigmoidoscopy
 Immunizations
 DM
 HIV and STIs, Hep B and Hep C
 Skin screen
 Substance use
 Injury prevention
Additional Screening Information Slides
 Common Disease Screenings
 Pap smear screens for cervical cancer
 Fasting blood sugar screens for diabetes
 Fecal occult blood test screens for colorectal cancer
 Blood pressure screens for hypertension
 Bone densitometry screens for osteoporosis & osteopenia
 PSA test screens for prostate cancer
 PPD test screens for tuberculosis
 Mammography screens for breast cancer.
Nursing Process & Evidence Based Practice
 Assessment of health and health care needs of a population in collaboration of
other disciplines
 Develops and plans intervention to meet these needs, and the plan includes
resources available and activities for health and prevention
 Implement the plan effectively, efficiently, and equitable
 Evaluates progress if outcomes of the population impacted
 Use the results to influence and direct the delivery of care, the use of health
resources, and the development of local, regional, state, and national health
policy and research to promote health
Week 2: Epidemiology & the Community Health Nurse in a Nutshell
Definition of Epidemiology
 Epidemiology is the study of the distribution and determinants of healthrelated states or events in specified populations, and the application of this
study to the control of health problems.
We’re going to:
 Study the spread (distribution) of something
 Examine things that helped it spread (determinants)
 Apply this knowledge (from the study) to halt or slow down (control) health
issues.
5 W’s of Epidemiology
 What: Diagnosis or health event
 Who: Person/Population
 Where: Place/location
 When: Time (when)
 Why (and how): Causes, risk factors, and modes of transmission
Why Do We Use Epidemiology?
 Assessing the community’s health
 Completing the clinical picture
 Searching for causes
 Making individual decisions
Assessing the community’s health
 What are the actual and potential health problems in the community?
 Where are they occurring?
 Which populations are at increased risk?
 Which problems have declined over time?
 Which ones are increasing or have the potential to increase?
 How do these patterns relate to the level and distribution of public health
services available? (Can we handle it??)
Completing the clinical picture
 Epidemiologists contribute to physicians’ understanding of the clinical picture
and natural history of disease.
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A physician saw 3 patients with unexplained eosinophilia (an increase in
the number of a specific type of white blood cell called an eosinophil) and
myalgias (severe muscle pains).
o Couldn’t make a definitive diagnosis.
o Public health authorities were alerted. Epidemiologists hopped on the
case.
o In weeks, they identified enough cases and characteristics/course of
illness which became to be known as eosinophilia-myalgia syndrome.
Searching for causes
 A significant amount of epidemiologic research is devoted to searching for
causal factors that influence one’s risk of disease.
 The goal is to determine a cause of a disease or illness so that appropriate
public health action might be taken.
Making individual decisions
People often influenced, consciously or unconsciously by epidemiologists’ assessment
of risk. Examples:
 When a person decides to quit smoking
 Climb the stairs rather than wait for an elevator
 Eat a salad rather than a cheeseburger with fries for lunch
 Use a condom they may be influenced, consciously or unconsciously, by.
 We use epidemiologic information to make daily decisions affecting our health.
Descriptions of Frequency & Occurrence of Disease
 Incidence – number of new events in a specific population during a specific time
period. Eg. the incidence of tennis elbow is 4% per annum means that in any one
year four percent of the population develops a new case of tennis elbow
 Prevalence – number of existing cases in a given population at a given time. eg.
The prevalence of back pain in the community is 25% means that at any one
time 25% of the population reports they have back pain. Commonly used with
chronic disease.
 Ratios – a comparison between two groups that are not necessarily related to
one another.
Common Study Designs in Epidemiology
 Correlation study – studies relationships between variables. Used when little is
known about a situation and funds are limited;
 Case study – descriptions of a single case;
 Cross-sectional study – gathers information about a population at a specific
time (think section of time) and analyses the information.
 Case-control study – compares patients with a disease (case) to those without a
disease (control). A relatively quick, easy and cost effective way to study rare
diseases
 Cohort study – usually a large study that uses randomly selected subjects from
a group that share a defining characteristic. (Nursing cohort)
 Intervention study – an experiment where something is done (intervention) to a
group of subjects.
Causation: the relationship between cause and effect
Terms related to “causation”
 External Agent: originally referred to an infectious microorganism or pathogen:
a virus, bacterium, parasite, or other microbe. Usually, the agent must be
present for disease to occur. However, presence of that agent alone is not
always sufficient to cause disease.
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Susceptible Host: refers to the human who can get the disease. Some of the
factors of hosts contributing to the prevalence of asthma are genetics,
ethnicity and socioeconomic status, sex, and gender.
Environment: extrinsic factors that affect the agent and the opportunity for
exposure. Environmental factors include physical factors such as geology and
climate, biologic factors such as insects that transmit the agent, and
socioeconomic factors such as crowding, sanitation, and the availability of
health services.
Causation Model: Epidemiologic Triad
 Multiple models of disease causation have been proposed.
 One of the simplest (and widely used) epidemiologic triad or triangle, the
traditional model for infectious disease.
 Premise of Epi Triad Causation Model: disease results from the interaction
between the agent and the susceptible host in an environment that supports
transmission of the agent from a source to that host.
The “Epi” Triad
 What is the AGENT?
 Who is the HOST??
 What’s the ENVIRONMENT ??
A true association between risk factor (causal agent) and disease must possess three
features:
1. A link between causal agent and disease should be clearly seen;
2. The causal agent must come before the disease; and
3. The causal agent may lead to the disease, but not vice versa.
Example: Smoking causes cancer(s).
1. There is a clear link between the incidence of lung cancer and smoking.
2. The “smoking” comes before the disease (lung cancer, throat, tongue
etc.)
3. Smoking may lead to lung cancer; lung cancer doesn’t cause smoking
Level of disease
 Endemic refers to the constant presence and/or usual prevalence of a disease or
infectious agent in a population within a geographic area.
 Epidemic refers to an increase, often sudden, in the number of cases of a
disease above what is normally expected in that population in that area.
 Outbreak carries the same definition of epidemic, but is often used for a more
limited geographic area.
 Cluster refers to an aggregation of cases grouped in place and time that are
suspected to be greater than the number expected, even though the expected
number may not be known. (COVID clusters are usually 5 or more.)
 Pandemic refers to an epidemic that has spread over several countries or
continents, usually affecting a large number of people.
Epidemiological surveillance
 “Public health surveillance is the ongoing, systematic collection, analysis,
interpretation, and dissemination of health data to help guide public health
decision making and action” CDC, 2012).
 The purpose of surveillance is to work to detect where disease organisms, such
as bacteria and viruses, may be located with the goal of predicting and
preventing human illness (Texas Department of State Health Services).
Conceptual framework for public health surveillance
Global infectious disease surveillance frameworks
The Role of Community/Public Health Nursing during COVID-19
 Screen patients for symptoms over the phone
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Conduct appointments, such as behavioral health appointments, remotely
Take on extra duties including educating patients about self‐isolation and
quarantine via hotlines, and volunteer at vaccine clinic
Help interpret the changing and developing recommendations and information
from the CDC
Educating the community about social distancing, proper hand-washing, and
other sanitation practices.
Nurses in community or public health clinics often have regular and ongoing
connections to community members. They are uniquely positioned to recognize
symptoms of new or reemerging infectious diseases.
Take home message:
Epidemiology describes the risk of disease, injury or death. It predicts disease
based on risk factors or exposure. It is a tool used to assess populations and
improve the health of the general public.
Nursing leaders can work to develop early reporting networks that keep public
health officials and public health organizations, such as local and state health
departments, informed so they can take early preventive measures and
communicate with the public.
Week 3: Community Assessment and Family Health (Unit II)
Community
What Is a Community?
 Community: people and the relationships that emerge among them as they
develop and use in common some agencies and institutions and a physical
environment
o People: the community residents
o Place: both the geographical and time dimensions
o Function: the aims and activities of the community
Community as Client
 A community practice setting is insufficient reason for saying that the practice is
oriented toward the community client
o When the location of the practice is in the community but the focus of
practice is the individual or family, the nursing client remains the
individual or family, not the whole community
 Community as client requires that the improved health of the community
remains the overall goal of nursing intervention
o Change to benefit the community client often must occur at several levels
ranging from individual to society as a whole
Community-oriented vs. Community-Based
 Community-oriented nurses operate from a health care focus based on an
understanding of broad community needs. They focus on health promotion,
health education, disease prevention, and coordination of health care for
members of the community to the benefit of the entire community. They also
work to identify high-risk groups in the community.
 Community-based nurses are focused on managing acute or chronic conditions
and promoting self-care among individual clients and families. The nursing care
is family centered. Throughout care delivery, the nurse teaches and counsels
clients so that they can more fully develop their own ways of taking care of
themselves.
Goals & Means of Community-Oriented Practice
 Goal: nurse and community seek healthful change together
 Community health has three common characteristics: status, structure, and
process
o Status: involves physical (morbidity and mortality rates), emotional (client
satisfaction), and social (crime rates) components
o Structure: services and resources in a community
o Process: effective community functioning or problem solving
Goals and Means of Community-Oriented Practice (cont’d)
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Healthy People 2020 (and now 2030): offers a vision of the future for healthy
communities and goals to fulfill that vision
 Recognizes the need to work collectively, in community partnerships, to
bring about the changes necessary to fulfill this vision
Community partnerships: the active participation and involvement of the
community or its representatives in healthful change
 Most changes aimed at improving community health involve partnerships
among community residents and health workers from a variety of
disciplines
Community Health Assessment: What is it?
 A community health assessment (sometimes called a CHA), also known
as community health needs assessment (sometimes called a CHNA), refers to
a state, tribal, local, or territorial health assessment that identifies key
health needs and issues through systematic, comprehensive data collection and
analysis. (CDC.gov/2018)
Power of a Community Assessment
 Assessments provide evidence to:
o Improve a policy
o Change a system
o Enhance the environment
 Multiple assessments can better examine an issue and involve the community in:
o Helping to collect data
o Helping to generate meaning
o Helping to share findings and create action plans
 Assessments can be targeted to specific “problem areas.”
Community assessment
 Should integrate behavioral and environmental assessments as well as
assessments of public health organizations and community-based organizations
 Assessment of the community
o Diagnosis - community focused
o Planning - "with" the community
o Implementation - with the community, intervention addresses the health
of the community
o Evaluation - with the community, outcomes are measured at the level of
the community
 Indicators for Assessing Community Health Status: total 18, on Page 207 Box 12.3,
Stanhope & Lancaster
 Infant Mortality (per 1000 live birth)
 Death Rates (per 100,000 population)
 Reported Incidence (per 100,000 population)
 Indicators of Risk Factors : Low birth rate: less than 2500 g at birth,
Birth to adolescents , Prenatal care & Childhood poverty & exceeding
EPA air quality
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Assessment tool: page 583
Nursing Process with Communities
 Assessment and Analysis: Include community members in process
 Diagnosis: identify health issues and problems
 Planning: involve community leaders
 Implementation (Selected Intervention Examples: health education, screening,
direct health services
 Evaluation: includes both process and outcome evaluation, community
members contribute to evaluation process
Community-Focused Nursing Process: Assessment to Evaluation
 Using the nursing process to promote community health
 Assessing community health
 Data collection and interpretation
 Data gathering
 Data generation
 Composite database analysis
 Data collection methods
 Collection of direct data
Community Assessment: Components
 Geography
 Population
 Environment
 Industry
 Education
 Recreation
 Religion
 Communication
 Transportation
 Public services
 Political organization
 Community development or planning
 Disaster programs
 Health statistics
 Social problems
 Health manpower
 Health professional organizations
 Community services
 Primary Data
 Collected by you
-Windshield survey, observations, "the lived experience", needs assessment
Community Assessment: Sources of Data
 Windshield Survey
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Census Data
Vital Statistics
Other Sources of Health Data
Use Maps to Show Statistics
This image shows the percentage of people in each county who are physically
inactive. The CDC defines a person as physically inactive if during the past month,
other than a regular job, he or she did not participate in any physical activities or
exercise. We can use this map to compare our county to other surrounding counties
and state data on physical inactivity
Community Diagnosis: Example #1
 Genesee County, MI is urban county with a rapidly increasing number of older
adults. The assessment data indicate the presence of only one taxicab company
serving that area. No public bus system is available.
 Obviously, the problem is lack of transportation; but how might this be worded in
nursing diagnosis format?
 Nursing diagnosis: Altered health-seeking behaviors related to inadequate
transportation services for senior citizens.
Community Diagnosis Examples
 However, inadequate transportation probably also affects other areas of seniors’
lives, such as socialization and community participation. If this factor were
validated through further assessment, an additional diagnosis might be as
follows:
“Impaired social interactions related to inadequate transportation for senior
citizens”
Example #2
Students in a local high school test very low on an acquired immunodeficiency
syndrome (AIDS) awareness survey. Further investigation reveals that no information
is provided to the students, and the parents do not want information taught in the
school. Ninety-eight percent (98%) of the students stated that they do not believe
they are in any danger of getting human immunodeficiency virus (HIV).
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Nursing Diagnosis: knowledge Deficit about HIV/AIDS in high school students
related to:
 Inadequate information provided in school curriculum
 Parental attitudes about the disease
 Perception that they are not at risk for the disease
Community-Focused Nursing Process: Assessment to Evaluation (cont’d)
 Identifying community problems
 Community Diagnosis
 Planning the community health
 Analyzing problems
 Problem priorities
 Establishing goals and objectives
 Identifying intervention activities
 Implementing for community health
o Factors influencing implementation
o Nurse’s role
 Evaluating interventions for community health
o Role of outcomes in the evaluation phase
Personal Safety in Community Practice
 Personal safety is a prerequisite for effective community-oriented practice and
should be a consideration throughout the process
 An awareness of the community and common sense are the two best guidelines
for judgment
 Three sources of information about a community
o Other nurses, social workers, or health care providers who are familiar
with the dynamics of a given community
o Community members
o Your own observations
Putting it all together
Community assessments:
 Provide valuable population-level data on the health conditions and risk factors
present in a community.
 Data guides public health program planning.
 The assessment provides a profile of the community's assets and needs to achieve
a level of community competence. (Community competence is the ability of the
community to engage in effective problem solving to meet the community's
needs.)
Putting it all together: YOUR TURN
 Windshield survey (To be conducted Thursday 09/02)
o Stanhope & Lancaster: p213 Table 12.3 ( Project)
o ATI: p 29
 Components
People: demographic, biological, social & cultural factors
Place or environment : physical & environmental
Social systems
Community Assessment Group Project presentation (10/21, Thursday):
BB/Clinical folder
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Family Assessment
What is a “Family”?
 Multiple definitions of family
 Most basic definition is: “a group of individuals that share a bond”:
o Biological
o Legal
The definition is HOWEVER that family defines it!!
Characteristics of the Family
 Is its own social system
 Has a structure
 It is the first social group to which the individual is exposed
 Has it’s own cultural values and rules
 Every family have certain basic function
 Every family moves through stages in its life cycle
Function of the family
 Affection, love, care, an emotional support
 Security
 Identity
 Affiliation
 Socialization
 Control
 A sense of belonging and of history and place
 Family rituals for rejoicing and grieving
 Systems for earning money , supporting partners and children
 Sharing of labor, chores required to keep the family running
Family Health
What is Family Health:
 Possessing the abilities & resources to accomplish family developmental
tasks
Importance of Family Health:
 Family as a unit of services
 Effect of the family health on individual health
 Effect of family on community health
Characteristics of Healthy Family
 Facilitative interaction among members
 Enhancement of individual development
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Effective structuring of relationships
Active attempts made to cope with problems
Healthy environment and lifestyle
Regular link with the broader community
Healthy tasks of the family
 Recognizing interruptions of health or development.
 Seeking health care
 Managing Health and non- health crises
 Providing nursing care to the sick, disabled and dependent member of the
family.
 Maintaining a home environment conductive to good health and personal
development.
 Maintaining a reciprocal relationship with the community and health and
institutions
Family as a Client
 Working in a community setting generally involves working with families.
 Community health nurses must there for understand the interactions and
dynamics of families so that they can provide appropriate family assessment ,
planning, intervention and evaluation
 Thus, an understanding of family dynamics and the context of the community
assists the nurse in planning care.
 When family is the client, the nurse determines the health status of the family
and its individual members, the level of family functioning, family interaction
family strengths and weakness
Family Health Assessment
 The process of collecting data about the family structure, and the relationships
and interactions among individual members.
 It is a continuous process.
 It’s aim is to generate Nursing diagnoses with goals and interventions for care
created in collaboration with the family.
 Focus on the family as a total unit
 Ask goal-directed questions
 Collect data over time
 Combine qualitative and quantitative data
 Exercise professional judgment
 Assessing family health in a systematic fashion require three tools:
o Conceptual framework upon which to base the assessment
o A clearly defined set of assessment categories for data collection
o A method for measuring a family’s level of functioning
Family Health Assessment: Conceptual Frameworks
 A conceptual framework is a set of concepts integrated into meaningful
explanation that helps one interpret human behavior or situations.
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Three conceptual frameworks are particularly useful in community health
nursing:
o Interactional
o Structural-Functional
o Developmental
Interactional Framework Describes the family as:
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Unit of interacting
Personalities
emphasize communication
Role
Coping patterns and
Decision-making process (focus on internal relationships)
Structural-Functional Framework
Describes the family as a social system relating to other social systems in the external
environment, such as:
 School
 Work
 Religion places
 Health care system
Developmental Framework
 Studies family from lifecycle perspective by examining members’ changing
roles and tasks in each progressive life cycle
Developmental Framework: Family Developmental Tasks
 Beginning family
o Establishing a mutually satisfying marriage
o Planning to have or not have children
 Childbearing family
o Having and adjusting to infant
o Support needs of all three members
o Renegotiating marital relationship
 Family with pre- school children
o Adjusting to cost of family life
o Adapting to needs of pre-school children to stimulate growth and
development
o Coping and parental loss of energy and Privacy
 Family with school age children
o Adjusting to the activity of growing children
o Promoting joint decision making between children and parents.
o Encouraging and supporting children’s educational achievements
 Family with teenagers and young adults
o Maintaining open communication among members.
Supporting ethical and moral values within the family.
Balancing freedom with responsibility of teenagers.
Releasing rituals and assistance
Strengthening marital relationship.
Maintaining supportive home base young adults with appropriate
Post-parental family
o Preparing for retirement
o Maintaining ties with younger and older generations.
Aging family
o Adjusting to retirement
o Adjusting to loss of spouse
o Closing family house
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Family Assessment: Data collection categories
 Family demographic (composition, socioeconomic status)
 Physical environment
o Housing and the conditions inside, outside and surrounding it
o Any existing safety or environmental hazards
o The amount and quality of available services
o Geography and climate
 Psychological and spiritual environment such as:
o Mutual respect, support, promotion and members self-esteem
 Family structure and roles include:
o Family organization
o Division of labor and allocation
o Use of authority and power
 Family functions refers to a family’s ability to carry out appropriate
developmental tasks and provide for it’s members needs
 Family values and beliefs influence all aspects of family life, e.g. making and
spending money, education, work and religion
 Family communication pattern include the frequency and quality of
communication with a family and between the family and its environment
 Family decision-making pattern
 Family problem solving
 Family coping patterns, family support system, responses to stressors
 Family health behavior
 Family social and culture pattern
Family Assessment: Data Collection Methods and Tools
Assessment methods
 Ecomap: is diagram of the connection between a family and the other system in
its ecological environment or its A picture of the family’s patterns.
 Nurses can use an ecomap to identify:
o Family resources that are present
o Family needs
o Conflicts
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Connections that are present or absent
The balance or lack of balance between a family's needs and the resources
available to the family
Ecomap
Data Collection: Genogram
 A graphic picture of family history, usually used over three or more generation .
 The genogram maps such information as:
o Relationships among family members
o Important life events
o Place of residence
o Characteristics such as race, culture and religious affiliations
Data Collection: Genogram
Data Collection: Family Health Tree
 A record of diseases that occur in a family.
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It can be used to track:
o Diseases that have genetic bases
o Environmental diseases
o Mental health disorders
Family Nursing Diagnosis
The family nursing process is the same nursing process as applied to the family, the
unit of care in the community.
Family Nursing Diagnosis
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Family Processes, Dysfunctional: Alcoholism (substance abuse).
Family Processes, Interrupted.
Family Processes, Readiness for Enhanced.
Family coping, ineffective.
Family coping, potential for growth.
Examples for family nursing diagnosis:
Parental role conflict.
Parent/infant/child attachment, altered, risk for
Parenting, altered.
Parenting, altered, risk for.
Role performance, altered
Social interaction, impaired.
Social isolation.
Family Care Plan
 Family Assessment and Planning Instrument
 Instrument to help the nurse in organizing the data collected.
 Assists the nurse to implement strategies to improve the health of the family.
 Not to be taken into the home as an interviewing instrument.
Planning and Implementation
Remember:
 Planning and intervention for families must be in partnership with family
members.
 Planning and intervention for families by CHN must used the three level of
prevention
 Collectively work with the family
 Meet the family where they ARE (not where you want them to be)!
 Fit nursing intervention to the family stage of development
 Recognize the validity of family structural variation
 Emphasize family strength
Interventions
The three most common intervention in home health care include:
a) Helping families deal with stress created by health problems.
b) Making referrals for community services.
c) Teaching and educating clients, with the focus on strengths rather than
weakness.
Evaluation
 A systematic, continuous process of comparing the client’s response to the
written goal & objective.
 Determines process and evaluate the implemented intervention regarding:
o Effectiveness
o Efficiency
o Adequacy
o Acceptability
o
Appropriateness
Summary
 When family is the client, the nurse determines the health status of the family
and its individual members, the level of family functioning, family interaction
family strengths and weakness
 Family health assessment is the process of collecting data about the family
structure, and the relationships and interactions among individual members.
 Data from the family health assessment formulates the family care plan.
 The family care plan assists the nurse in implementing strategies to improve the
health of the family.
Week 5: Ethics, Global Health, Sociocultural Factors & Social Determinants of
Health
Ethics
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“Ethics is a branch of philosophy concerned with determining right and wrong
in relation to people’s decisions and actions” (Chaloner, 2007, p 42)
“How should I behave”, “What actions should I perform?” “What kind of person
should I be?” “What are my obligations to myself and others?”
Beneficence (doing good) & Nonmaleficence (do no harm)
o Non-maleficence: 5 rights for mediation checks
Bioethics: Nuremberg Code of 1947
Nightingale (1820-1910): first moral leader and nurse
o Principle is to do the most good for the most people by altering
environmental hygiene. Decrease the infection rate and saves lives
Public health nurse & genomics
P 52, box 4.1
“The greatest good for the greatest number” (Racher, 2007, p68)- social
distancing, and mask wearing
Ethical Principles
 Utilitarian Ethics Decision Making: action determined by overall benefits
(consequenctialism) - p53-54
 Denontology: individual rights and dignity, people treated as ends, not means
to the ends of others - p 54
 Distribution of justice or social justice: allocation of benefits and burdens to
members of society (p 52, box 4.1)
 Principlism: relies on ethical principles to guide decision making
 How to apply Principlism to ethics decision making? P56

Other principles: virtue, care, feminist P 56
Public Health Code of Ethics: page 60, box 4.3
 Aim to prevent adverse health outcomes
 Respects rights of individuals in the community
 Engaging community members for policy development, programs
 Basic resources accessible to all members
 Seek information for programs to promote health
 Share information and obtain consent for policy /program implementation
 Act in a timely with given information
 Programs/policies meeting the needs of diverse values, beliefs, and cultures
 Enhancing physical and social environment
 Protect confidentiality & professional competencies
 Collaboration to build trust and being effective
Cultural Influences
1. Immigrant Health
 Populations: hispanic, India, China
 Limited English speaking LEP
 Refugees
 Family conflicts
2. Cultural Diversity
1. Communication
2. Space & time
3. Food preferences
4. Environmental control: harmony
5. Social organization
Social Determinant of Health- Culture
 Cultural competency:
o Definition: behavior, attitudes, and policies allowing nurses to work in
cross-cultural situations
o awareness, knowledge, skill, encounter, and desire
 10 standards by American Academy of Nursing p 74
 Maintain a broad, objective, and open attitudes toward individuals & cultures
 Avoid seeing all individuals alike
 Stages of competency development: incompetent, sensitive, competent (page
75, table 5.3)
 Cultural awareness: identify in Asian children - mental health
 Developing competency: p 77 box 5.3
 Inhibitors: stereotyping, prejudice, racism, ethnocentrism, cultural imposition,
culture conflict, & culture shock
Social Determinant of Health-Environment
 Lead poisoning education project
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I PREPARE
o I: investigate
o P: Present work
o R: Residence
o E: Environmental concerns
o P: Past work
o A: Activities
o R: Referrals and resources
o E: Educate
National Health Care goals & Levels of Prevention: ATI P 18
Social determinants of health- Access to care
 Barriers: ATI p 19
 Financing
o Affordable Care Act
o Medicare & Medicaid
o Private funding & self pay
 Organizations
o Federal
o State
o County/local
Social Determinants of Mental Health
Exam practice questions: group work
1. A nurse is preparing an educational program on cultural perspectives in nursing.
The nurse should include that which of the following factors are influenced by
an individual’s culture? (Select all that apply.)
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A. Nutritional practices
B. Family structure
C. Health care interactions
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D. Biological variations
E. Views about illness
Exam practice questions: group work (con’t)
2. A nurse is caring for a client who is from a different culture than the nurse.
When beginning the cultural assessment, which of the following actions should
the nurse take first?
Determine the client’s perception of their current health status
Gather data about the client’s cultural beliefs.
Determine how the client’s culture can affect the effectiveness of nursing
actions.
D. Gather information about previous client interactions with the health care
system.
A.
B.
C.
Exam question: group work (con’t)
3. A nurse is reviewing information about the local health department to prepare
for an interview. Which of the following services should the nurse expect the
local health department to provide? (Select all that apply.)
A.
B.
C.
D.
Managing the Women, Infants, and Children program
Providing education to achieve community health goals
Coordinating directives from state personnel
Reporting communicable diseases to the CDC E. Licensing of registered nurses
Exam practice question: group work (con’t)
4. A nurse is conducting health screenings at a statewide health fair and identifies
several clients who require referral to a provider. Which of the following
statements by a client indicates a barrier to accessing health care?
1. “I don’t drive, and my son is only available to take me places in the
mornings.”
2. “I can’t take off during the day, and the local after-hours clinic is no longer in
operation.”
3. “Only one doctor in my town is a designated provider by my health
maintenance organization.”
4. “I would like to schedule an appointment with the local doctor in my town who
speaks Spanish and English.”
Healthy People 2030: https://health.gov/healthypeople
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Mental health https://health.gov/healthypeople/objectives-and-data/browseobjectives/mental-health-and-mental-disorders/increase-proportionadolescents-depression-who-get-treatment-mhmd-06
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Lead level ( identify 3 goals and post on BB discussion board )
https://health.gov/healthypeople/objectives-and-data/browseobjectives/housing-and-homes/reduce-blood-lead-levels-children-aged-1-5years-eh-04
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Childhood immunization recommendation ( type of immunizations for children
under 2, identify 3 goals and post on BB discussion board)
https://health.gov/healthypeople/objectives-and-data/data-sources-andmethods/data-sources/national-immunization-survey-child-nis-child
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Adult immunization recommendation (review only)
Global Health
 Human Development Indicators: what did you learn?
 Influences of global health : wars, disasters, limited resources, international
travel (COVID), sanitation, climate changes, maternal health, nutrition
 Goals of global health
o Eradicating hunger
o Primary education worldwide
o Empowerment of women and gender equality
o Reducing child mortality
o Fostering maternal health
o Reducing malaria, HIV/AIDs, and other communicable diseases
o Promoting sustainable environment
o Developing global partnerships
Human Development Indicator in
Global Community (resources)
http://hdr.undp.org/en/countries
What can you do?
 Food bank , health fair, senior centers, cultural events
 Food of Love: https://www.youtube.com/watch?v=-m0wojavBYk#action=share
o 50 states, 124 organizations sending food to communities in need May,
2020
Three Research Articles From “Nursing Education Perspectives”
September/October 2020 Evidenced Based
1. “Are Nursing Students Learning About Social Determinants of Health?” (Lee
& Wilson, 2020)
 Significance:
Institute of Health: paradigm shift for innovative curriculum(2011);
RWJF “culture of health” (Denham, 2017);
American Association of College of Nursing: SDH cross curriculum (2008)
National League of Nursing (2019): necessary for health profession, Little
research found
 Longitudinal, qualitative: pre & post over 21 months with the following
questions
o How do you identify poor health contributing to SDH?
o How do you perceive the nurse’s role/responsibilities to identify and
address changes in SDH clients?
o What types of actions have you taken to address SDH (baseline)
o How have your perceptions of the nurse’s role/responsibilities changed
(at completion)
1. (Continued) “Are Nursing Students Learning About Social Determinants of
Health?” (Lee & Wilson, 2020)
 Results (at the end of 21 months
o SDH to poor health:
 Communities (35%): sedentary lifestyles, unhealthy food, changed
to geographical barrier, transportation, absity, unclean water and
food et
 Family income (81%, unchanged): poverty and low socioeconomic
status , unchanged
 Access to health (39%): fear/mistrust/rumor, lack of insurance,
resident status, and prenatal care, changed to illness, disabilities
& mental health
o Nurses’ role
 Patient education: 72%, prevention, resources
 Community assessment and intervention 8%
 Volunteer at health fairs, clinics and events: 5%
 Advocacy: 4%
o Application of SEM: individual, relationship, and community levels
 Implications: Replicate the study, integrate SDH across the curriculum, turning
questions into scholarly inquiries
2. Redesigning Nursing Education to Build Healthier Communities: An
Innovative Cross- Sector Collaboration (Swan et al, 2020)
o Produced a white paper: Nursing Education Plan White Paper and
Recommendation for California” (Berg & Orlowski, 2016) with five
recommendation, and the 5th is “design curricula with the capacity to
fluidly accommodate evolving healthcare environment and emerging
nursing roles encompassing the continuum of care
o Cross section team to support 4 schools with the funded project for 15
months
o Meetings, discussion, webinars, traninings
o 2 of 4 schools received approval from the state licensing board for
completing a major curriculum redesign, 3 of 4 school moved to
concept-based curriculum
o
o
o
o
o Positive relationship built with nursing schools and consultants.
3. Population Health Beyond the Classroom: An Innovative Approach to
Educating Baccalaureate Nursing Students (Ruiz, 2020)
o Redesigning a multicultural population health course in Texas
o Community health needs assessment indicating mortality high and only
50% kindergarteners on track in all five developmental domains - need
for change
o Institute of Medicine IOM: “expand opportunities for nurses to lead and
diffuse collaborative improvement efforts”
o Students working with city government, child abuse advocacy,
Department of State and Human services, local community hospitals,
and many other nonprofits
o Students assessing, analyzing, and utilizing various data sets to
determine community needs
o Students work with local literacy program and get child abuse training,
and participate in faculty-led leadership activities such as conferences
and grant-funded event
o Future of Nursing Report 2020-2030 will focus more on the role of the
nurse addressing SDH and health inequities (National Academy of
Medicine, 2019)
“Wake Up” Movie Screening Thinking Points/Study Guide for Quiz
1. What are some of the myths about suicide?
Asking for help makes you weak, suicide is selfish, students do not struggle
with mental health, suicide will go away if we ignore it,
2. What are factors preventing people seeking help /social determinants of
mental health for mental illness?
a. Reason: sigma of being weak, scared of being judged, do not feel like no
one is listening/isolation,
b. Solution:
c. Implication for nursing: refer join a support group,
3. List several examples of each three levels of Suicide prevention identified in
the movie
Primary level: the Risk for Suicide Assessment at LSU
Secondary level: Crisis counseling at multiple colleges
Tertiary level: Rehab for veterans.
4. In what ways policy can affect suicide prevention?
The policy/laws can be so strict that it prevents people from getting the help
they need. Example, veterans who do not receive an honorable discharged are
2x as likely to commit suicide then the veterans who do receive it.
5. Does suicide data for each group surprise you? Why or why not?
No because the rate of suicide has always been high, people have never gotten
the help that they needed.
6. In your opinion, what is the most compelling message from this movie you want
the public to know? And what methods are most impactful (designing Public
Service Announcement)
Not only is suicide the 10th leading cause of death but in every 11
minutes there is one suicidal death. In healthcare, suicidal people are
often overlooked and turned away especially If it is not a major
emergency. If you can take 11 minutes out of your day to talk to
someone, you can save their life in 11 minutes. Instead of being too late
we want to be on time!
Always pay attention to someone Commercials Because a lot of people
watch tv. TED or public speech because you tend to reach people and it
starts a movement.
7. In what ways does this movie affect you personally?
Chapter 5: Cultural Influences in Nursing in Community Health
Introduction
 United States population becoming increasingly diverse
 Nurse and client often come from different cultural background and may
not recognize or understand their differences
 Nurses must be able to provide culturally competent care
Immigrant Health Issues
 Recent changes in immigration laws have increased migration to the United
States
 1965 amendment of the Immigration and Nationality Act
 Refugee Act of 1980
 1986 Immigration Reform and Control
1. Come to the United State for religious and political freedom and for economic
opportunities
Immigrant Categories

Legal immigrant: not a citizen but allowed to both live and work in the United
States also known as lawful permanent resident
o Trend toward more immigrants being “low skill” workers, and they
compete with native low skill workers for jobs
 Refugees: admitted outside the usual quota restrictions based on fear of
persecution due to their race, religion, nationality, social group, or political
views
 Nonimmigrants: admitted to the United States for a limited duration and
specific purpose (i.e., students, tourists)
 Unauthorized immigrant: may have crossed the border illegally or legal
permission expired ; eligible only for emergency medical services
Factors to Consider for Providing Health Care for Immigrants
 Financial constraints (uninsured)
 Language barriers
 Differences in social, religious, and cultural backgrounds between the
immigrant and the health care provider
 Providers’ lack of knowledge about high-risk diseases in the specific immigrant
groups for whom they care
 Traditional healing or folk health care practices that may be unfamiliar to their
US health care providers
 When working with immigrant populations, consider how your own background,
beliefs, and knowledge may be significantly different from those of the people
receiving care.
Culture, Race, and Ethnicity
 Culture: a set of beliefs, values, and assumptions about life that are widely
held among a group of people and that are transmitted across generations
 Race: a biological designation whereby group members share features (e.g.,
skin color, bone structure, genetic traits such as blood groupings)
 Ethnicity: shared feeling of peoplehood among a group of individuals
Cultural Diversity
 Refers to the degree of variation that is represented among populations based
on lifestyle, ethnicity, race, interest, across place, and place of origin across
time
 Also includes the awareness of the presence of differences among the members
of a social group or unit
Cultural Competence
 A combination of culturally congruent behaviors, practice attitudes, and
polices that allow nurses to work effectively in cross-cultural situations
 Four principles
 Care is designed for the specific clients
Care is based on the uniqueness of the person’s culture and includes
cultural norms and values
 Care includes self-employment strategies to facilitate client decision
making in regard to health behavior
 Care is provided with sensitivity and is based on the cultural uniqueness
of clients
Key Reasons Nurses Must Be Culturally Competent
 The nurse’s culture often differs from that of the client, leading to different
understandings of communication
 Nonculturally competent care may increase the cost of health care and
decrease the opportunity for
 To meet some of the objectives for persons of different cultures as outlined in
Healthy People 2020
Developing Cultural Competence
 Two principles
 Maintain a broad, objective, and open attitude toward individuals and
their cultures
 Avoid seeing all individuals as alike
 Three Stages
 Culturally incompetent
 Culturally sensitive
 Culturally competent
 Three dimensions of each stage:
 Cognitive (thinking)
 Cognitive (feeling)
 Psychomotor (doing)
Inhibitors to Developing Cultural Competence
 Stereotyping
 Prejudice
 Racism
 Ethnocentrism
 Cultural blindness
 Cultural imposition
 Cultural conflict
Cultural Nursing Assessment
 During initial contact with client, nurse asks about the following issues:
o Ethnic background
o Religious preference
o Family patterns
o Cultural values

o Language
o Education
o Politics
o Health practices
Two Phases of an In-Depth Cultural Assessment
 Data-collecting phase
 Organizing phase
In Conducting Cultural Assessment
 Be aware of the environment.
 Know about community social organizations.
 Know the specific areas that the nurse wants to focus on.
 Select a strategy to help gather cultural data.
 Identify a confidante.
 Know the appropriate questions to ask.
 Interview other nurses or health care professionals.
 Talk with formal and informal cultural leaders.
 Be aware that all information has both subjective and objective data
 Avoid pitfalls.
 Be sincere, open, and honest.
Cultural Groups’ Differences
 Although all cultures are not the same, all cultures have the same basic
organizing factors:
o Communication (verbal and nonverbal)
o Space
o Social organization
o Time perception
o Environmental control
o Biological variations
o Culture and nutrition
Five Principles of a Culturally Competent Organizational Model
 Valuing diversity
 Conducting cultural assessment
 Understanding the dynamics of difference
 Institutionalizing cultural knowledge
 Adapting to diversity
Nursing Process:
Goals: SMART goals. What you want to see the change in the person/group you are
caring for. Goals is for the client vital sign to remain the normal
Intervention: what you do a achieve the goals. Ex. Taking vitals signs q4h.