Safe practice of population-focused nursing care: Development of a public health nursing concept

Patient safety, a cornerstone of quality nursing care in most healthcare organizations, has not received attention in the specialty of public health nursing, owing to the conceptual challenges of applying this individual level concept to populations. Public health nurses (PHNs), by definition, provide population-focused care. Safe practice of population-focused nursing care involves preventing errors that would affect the health of entire populations and communities. The purpose of this article is to conceptually develop the public health nursing concept of safe practice of population-focused care and calls for related research. Key literature on patient safety is reviewed. Concepts applying to population-focused care are organized based on Donabedian's Framework. Structural, operational and system failures and process errors of omission and commission can occur at the population level of practice and potentially influence outcomes for population-patients. Practice, research and policy implications are discussed. Safe PHN population-focused practice deserves attention.     

Setting a new course for advanced practice community/public health nursing.

In recent years the changes in the organization and delivery of health care have created an environment that places great demands on nursing education at all levels. Determining a sound, responsive course of study in advanced practice community/public health nursing (C/PHN) is dependent on clear educational outcomes and competencies. Outcomes and competencies for C/PHN practice need to continue to be derived from the rich knowledge, experience, and research tradition with populations living in the community. However, in today's health care environment, these outcomes and competencies also must be integrated within the context of a very different health care system perspective. This article describes the outcomes and competency indicators developed to guide a curriculum designed to integrate traditional C/PHN and a health systems perspective for students seeking advanced practice education in C/PHN at the College of Nursing, University of Nebraska Medical Center.     

Public health nursing practice change and recommendations for improvement

OBJECTIVES: This paper reports the characteristics of recent public health nursing (PHN) practice change experienced by staff-level public health nurses. Recommendations for improving PHN practice offered by study participants are reported and discussed. DESIGN: A cross-sectional written survey was used to collect data from 424 public health nurses in 76 local health departments (LHDs) in Wisconsin (68% response rate) in 2003. Characteristics of practice change were identified using a 15-item-scaled response set. Recommendations on improving practice were made through responses to an open-ended survey question. Content analysis was conducted to identify major themes among the responses. RESULTS: PHN practice has become more population focused. Major themes emerging from the recommendations for practice improvement included increasing system and organizational resources, expanding visibility of public health, and strengthening collaboration. CONCLUSIONS: Implications for practice include the need for continuing education in concepts and skills required for population-focused PHN practice, advocacy for more public health resources, and collaboration with academic partners for education and research.     

Community/public health nursing: Is there a future for the specialty?

Graduate nursing education in the United States has undergone significant changes over the last decade with institution of the doctorate in nursing practice (2006) and the revised Essentials of Master's Education in Nursing (2011). An overview of the status of community/public health nursing (C/PHN) education and practice during the past 100 years provides a historic context for understanding the current situation of the specialty. An analysis of U.S. graduate nursing programs in C/PHN is used to foreground a discussion of the factors that may significantly affect community/public health nurses' interest in graduate education and the ability to sustain a master's-prepared C/PHN workforce. Questions are raised about how the potential loss of this particular specialty may influence the practice of C/PHN and the role of nursing in general in ensuring the public's health. Recommendations are offered for strengthening the specialty long-term, with a particular focus on C/PHN education and practice.     

Improving public health nursing education: recommendations of local public health nurses

OBJECTIVES: This paper reports recommendations for improving public health nursing (PHN) undergraduate, graduate, and continuing education (CE) made by staff-level public health nurses working in local health departments (LHDs). Implications for academia and practice are discussed. DESIGN: A cross-sectional written survey was used to collect data from 424 public health nurses in 76 LHDs in Wisconsin (68% response rate) in 2003. Recommendations for improving undergraduate, graduate, and CE were made through responses to open-ended survey questions. Content analysis was conducted to identify major themes among responses. RESULTS: Major themes emerging from the recommendations for undergraduate education included the need for more clinical public health experiences and population-focused practice content. Graduate education improvement recommendations included addressing access barriers and increasing organizational incentives. Improved access and more public health content were the major recommendations for improving CE. CONCLUSIONS: Implications for academia focus on increasing opportunities for students to experience population-focused PHN and to learn organizational and collaborative practice skills, supporting PHN preceptors and building evidence for PHN intervention through research. Implications for practice include the need to expand opportunities for students with LHDs and to collaborate with academic partners for education and research.     

PSYCHIATRIC-MENTAL HEALTH NURSING AT THE INTERFACE: REVISIONING EDUCATION FOR THE SPECIALTY

In the emerging health care environment, families and communities are facing a broad range of conditions that require more integrated views of wellness and illness, mind and body, and the biomedical and the behavioral. This also calls for an enhanced care delivery system. Three interfacing areas of practice have particular significance for the psychiatric-mental health nursing workforce: enhanced primary care, public health or population-focused health interventions, and managed care. This paper addresses the broad range of knowledge, skills, and competencies that are required for the future of advanced practice psychiatric-mental health nursing and describes interactive learning experiences and new pedagogies to deliver them.     

Psychiatric-mental health nursing at the interface: revisioning education for the specialty

In the emerging health care environment, families and communities are facing a broad range of conditions that require more integrated views of wellness and illness, mind and body, and the biomedical and the behavioral. This also calls for an enhanced care delivery system. Three interfacing areas of practice have particular significance for the psychiatric-mental health nursing workforce: enhanced primary care, public health or population-focused health interventions, and managed care. This paper addresses the broad range of knowledge, skills, and competencies that are required for the future of advanced practice psychiatric-mental health nursing and describes interactive learning experiences and new pedagogies to deliver them.     

Conceptual models for population-focused public health nursing interventions and outcomes: the state of the art

The conceptual basis of public health nursing (PHN) has evolved particularly over the past three decades. In October 2010, a national research agenda setting conference was held with grant support from the Agency for Healthcare Research and Quality. From the conference, public health nursing intervention models emerged as one of four top priorities. The need for a stronger theoretic base that can guide population-focused nursing practice and research was strongly emphasized. The purpose of this review, in concert with this priority, is to analyze the current status of PHN conceptual models. Based on the review, a set of recommendations is presented related to future conceptual development and testing, with an emphasis on PHN interventions and outcomes. A key recommendation is the refinement of the existing conceptual models with perhaps some consolidation of models, thereby establishing strong grand, middle-range and practice theories that include explicit PHN intervention and outcome components. Another recommendation calls for rigorous comparative analysis and testing. Professional support from the PHN community along with funding agencies will be needed to implement the recommendations related to PHN theory development and testing.     

Using Nursing Perspectives to Inform Public Health Nursing Workforce Development

ABSTRACT Recent national and regional public health workforce development efforts have been conducted through a framework of public health services research. Public health nurses (PHNs) are the single largest professional group in the formal public health system, and thus have the greatest potential for positively impacting our community health systems. Effective public health workforce development is contingent on examination of how PHNs themselves make meaning of their practice. This paper suggests that a nursing perspective should be used from which to conduct research surrounding PHN practice. Literature describing PHN practice and recent workforce assessment efforts are reviewed. Assumptions are identified regarding the nature of nursing knowledge, and a theoretical perspective for inquiry about PHN praxis is developed. Finally, a model is offered to illustrate the reciprocal influence of nursing science and public health nursing practice.     

Articulating the Culture and Tradition of Community Health Nursing

While community health nursing (CHN) leaders speculate about the future, nurses on the front lines care for vulnerable families and populations in the midst of diminishing resources, radical changes in health care delivery systems, and unwieldy bureaucracies. Narrative data from a recent interpretive study provided an unexpected opportunity to explore how CHN practice in diverse settings is evolving in response to such changes. Data consisted of interviews and observations of 25 nurses in their practice setting. Several clinical stories or exemplars are selected to highlight how the "culture" of agency settings shapes public health nursing (PHN) practice in ways that need to be recognized and strengthened or affirmed. Clinical storytelling can play a crucial role in preserving the PHN tradition and restoring and transforming local cultures when PHNs, administrators, educators, and researchers commit to PHN excellence.     

Essentials of Baccalaureate Nursing Education for Entry‐Level Community/Public Health Nursing

ABSTRACT Community/public health nursing (C/PHN) educators and practitioners need a framework from which to plan, implement, and evaluate curriculum and community‐based practice. The Association of Community Health Nursing Educators (ACHNE) periodically updates the Essentials of Baccalaureate Nursing Education for Entry Level Community/Public Health Nursing to reflect changes in core knowledge, basic competencies, and practice. This update reflects relevance to 21st‐century health care and to national trends influencing nursing education. The 2009 revision is based on critical analysis of key C/PHN literature and input from public health nursing educators and practitioners. A key assumption is that a baccalaureate nursing degree is the minimum requirement for professional C/PHN. Fifteen essential concepts for baccalaureate nursing education are delineated along with related competencies. Newly defined essentials include communication, social justice, and emergency preparedness, response, and recovery. Issues related to didactic and clinical experiences are addressed. The ACHNE Essentials is an important guide for baccalaureate education curriculum planning and evaluation. The Essentials may be useful as a baseline from which to develop competencies of graduate nursing programs. The document is also useful for guiding practice setting orientation and professional development.     

A public health nursing research agenda

Public health nurses (PHNs) use many interventions to prevent illness and promote the health of populations. Unfortunately, generating evidence regarding PHN practice is not explicitly identified as a research priority area of the major national funding agencies. Nor has PHN, as a profession, had a strong enough research agenda to drive practice improvement on a population-level and to drive funding to support such areas of research. To further advance the science needed to guide PHN practice, a national conference to set the research agenda was held in October 2010 with grant support from the Agency for Healthcare Research and Quality. The conference was part of a multimethod, participatory, multistage approach taken to generate the final research priority themes and corresponding priority research questions. The process yielded four high priority PHN research themes: PHN intervention models, Quality of population-focused PHN practice, Metrics of/for PHN, and comparative effectiveness and PHN outcomes. As the agenda is adopted by funding agencies, researchers, and practice-based partners, a more focused program of research will produce evidence that can guide population-focused PHN practice.     

A competency-based approach to public health nursing performance appraisal

OBJECTIVES: To integrate public health nursing (PHN) competencies into a comprehensive performance review instrument for nurses at multiple practice levels in an urban public health department. DESIGN: Based on thorough review of PHN competency literature, the tool evaluates performance for 5 nursing practice classifications (Staff RN, Public Health Nurse, Nurse Practitioner, Clinical Nurse Specialist, Nursing Supervisor) in eight PHN domains (assessment, policy development/program planning, evaluation, communication, cultural competency, partnership/collaboration, disease prevention/health promotion, leadership/systems thinking). SAMPLE: Tool was piloted with over 50 nurses from PHN workforce (n>400) of Public Health-Seattle & King County (Washington). METHOD: Pilot testing includes all components of the performance appraisal system: Public Health Competency Grid, statement of general workplace expectations, Nursing Performance Appraisal Tool, and supporting documents defining performance elements by job classification. RESULTS: Supervisors find the tool easy to use and report that it provides opportunity for real communication between employee and supervisor. Nurses at all practice levels report that it effectively describes/evaluates their practice. CONCLUSIONS: This tool is an efficient performance appraisal instrument providing meaningful feedback to nursing employees within a framework of PHN competencies. Adopting such tools in PHN practice can help nurses to better understand their role in population-based public health efforts.     

Evolution of a Public Health Nursing Program, Yukon Kuskokwim Delta, Alaska, 1893-1993

Abstract The role of public health in a reformed health care system is currently a matter of great debate at the national and state levels. Many public health nursing leaders have expressed concern about changes in public health policy and funding sources that have led to the near demise of the generalist public health nurse. Generalist public health nurses may be an endangered species; however, the role is still in existence in rural Alaska. Will they be one more example of how “what we learn from history is that we don't learn from history?” Taking the discrete area of the Yukon Kuskokwim Delta of Alaska and studying the forces of geography, politics, economics, social factors and health issues, this article provides an historic account of the development of a unique health care delivery system and the role of the public health nursing structure within it, from earliest known records to present day. The long-standing efforts to document these data were spurred by the National Centennial of Public Health Nursing activities, celebrated in 1993.     

Three population-patient care outcome indicators for public health nursing: results of a consensus project

ABSTRACT Objectives: Difficulties in recruiting nurses into public health settings threaten the public's health. Gaps in existing data make determining the health impact of workforce changes numbers difficult to perform. Public health practice leaders are left to make difficult staffing and program decisions without knowing how the health of their vulnerable populations will be affected. The objective of this study was to identify indicators that could be used to document the effect of the shortage of public health nurses (PHNs) on the health of a population. Design and Sample: A consensus‐building process was used. Nursing directors from 6 local health departments (LHDs) in 2 states participated along with 3 public health system researchers. Results: The findings from this collaborative process suggest that it is possible to identify outcome indicators across states and multiple LHDs that may be sensitive to PHN staffing levels and interventions. Possible connections between PHN staffing and each population‐patient care indicator (rates of Chlamydia, first trimester prenatal care, early childhood immunization) are presented. Conclusions: The process used here in identifying these indicators and the proposed nursing‐sensitive population outcome indicators themselves provide a template for the development and analysis of additional outcome indicators sensitive to the quality of nursing and other health care.     

Nursing in Cuba: Population-focused Practice

Cuba, faced with an inadequate health care system at the time of its 1959 revolution, has brought about major health care reforms. Marked change in health status has occurred through the evolution of broader social change and the geographic distribution of health care to the entire population. The country was recently recognized as already having met the World Health Organization's mandate of “health for all by the year 2000,” and community health nursing has played a major role in achieving this goal. Cuba has implemented population-focused community health nursing practice, an approach to improve the health of the entire community.