NUR440 – Ch 9 Population-Based Public Health Nursing Practice: The Intervention Wheel – Flashcards

Public health nursing is defined as the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences (APHA, 1996). The title "public health nurse" designates a registered nurse with educational preparation in both public health and nursing. The primary focus of public health nursing is to promote health and prevent disease for entire population groups. This is done by working with individuals, families, communities, and/or systems.

The focus on populations as opposed to individuals is a key characteristic that differentiates public health nursing from other areas of nursing practice. A population is a collection of individuals who have one or more personal or environmental characteristics in common (Williams and Highriter, 1978). Populations may be understood as two categories. A population at risk is a population with a common identified risk factor or risk exposure that poses a threat to health. For example, all adults who are overweight and hypertensive constitute a population at risk for cardiovascular disease. All underimmunized or unimmunized children are a population at risk for contracting vaccine-preventable diseases. A population of interest is a population that is essentially healthy but that could improve factors that promote or protect health. For instance, healthy adolescents are a population of interest that could benefit from social competency training. All first-time parents of newborns are a population of interest that could benefit from a public health nursing home visit. Populations are not limited to only individuals who seek services or individuals who are poor or otherwise vulnerable.

Health inequities are defined as health status inequalities that society deems to be avoidable or unnecessary (Kawachi, Subramanian, and Alemeida-Filho, 2002). Significant health disparities related to race, gender, age, and socioeconomic status exist within the United States. The Health, United States, 2009 Chartbook (CDC, 2009) provides the following examples: • In 2006, the U.S. rate of infant deaths per 1000 live births was 6.7. At least 29 other developed countries had lower infant mortality rates; the lowest was Hong Kong with 1.8 (Table 22, p 184). • Between 2003 and 2005, the U.S. neonatal mortality rate per 1000 live births for all races was 4.6; across races and ethnicities the rates varied. For infants born to white women the rate was 3.7; for Black and African-American women, 9.2; for Hispanic or Latina women, 3.9; for American Indian or Alaskan Native, 4.3; for Asian or Pacific Islanders, 3.3 (Table 21, pp 182-183). • In 2005 life expectancy at birth for men in the United States was 74.9 years; Hong Kong had greatest life expectancy with 77.8 years. For U.S. women, the life expectancy at birth in 2005 was 79.9; Japan ranked first with 85.5 (Table 23, p 187). What are the factors driving these differences? Factors that influence health status across the life cycle are known as the determinants of health. They include: income, education, employment, social support, biology and genetics, physical environment, housing, transportation, and personal health practices. Resolving health inequities and addressing the determinants of health are key distinguishing characteristics of public health nursing. In a recent interpretive qualitative study of PHNs' practice in Nova Scotia, researchers found that PHNs routinely implemented "ecosocial surveillance functions" that focused on monitoring changes in social determinants of health. The researchers observed that PHNs "...monitored both bottom-up changes in individual, family, and community determinants of health, and top-down vertical changes or policy directives in the larger system" (Meagher-Stewart et al, 2009, p 557).

In the context of the Intervention Wheel, a community is defined as "a social network of interacting individuals, usually concentrated in a defined territory" (Johnston et al, 2000). Assessing the health status of the populations that comprise the community requires ongoing collection and analysis of relevant quantitative and qualitative data. Community assessment includes a comprehensive assessment of the determinants of health. Data analysis identifies deviations from expected or acceptable rates of disease, injury, death, or disability as well as risk and protective factors. Community assessment generally results in a lengthy list of community problems and issues. However, communities rarely possess sufficient resources to address the entire list. This gap between needs and resources necessitates a systematic priority-setting process. Although data analysis provides direction for priority setting, the community's beliefs, attitudes, and opinions as well as the community's readiness for change must be assessed (Keller et al, 2002). PHNs, with their extensive knowledge about the communities in which they work, provide important information and insights during the priority-setting process.

Prevention is "anticipatory action taken to prevent the occurrence of an event or to minimize its effect after it has occurred" (Turnock, 2009, p 516). Prevention is customarily described as a continuum moving from primary to tertiary prevention (Leavell and Clark, 1965; Novick and Mays, 2001; Turnock, 2009). The Levels of Prevention box provides definitions and examples of the levels of prevention. A hallmark of public health nursing practice is a focus on health promotion and disease prevention, emphasizing primary prevention whenever possible. Although not every event is preventable, every event has a preventable component.

To improve population health, the work of PHNs is often carried out sequentially and/or simultaneously at three levels of prevention (see Figure 9-2). Community-level practice changes community norms, community attitudes, community awareness, community practices, and community behaviors. It is directed toward entire populations within the community or occasionally toward populations at risk or populations of interest. An example of community-level practice is a social marketing campaign to promote a community norm that serving alcohol to under-aged youth at high school graduation parties is unacceptable. This is a community-level primary prevention strategy. Systems-level practice changes organizations, policies, laws, and power structures within communities. The focus is on the systems that impact health, not directly on individuals and communities. Conducting compliance checks to ensure that bars and liquor stores do not serve minors or sell to individuals who supply alcohol to minors is an example of a systems-level secondary prevention strategy practice. Individual-level practice changes knowledge, attitudes, beliefs, practices, and behaviors of individuals. This practice level is directed at individuals, alone or as part of a family, class, or group. Even though families, classes, and groups are comprised of more than one individual, the focus is still on individual change. Teaching effective refusal skills to groups of adolescents is an example of individual secondary prevention strategy level of practice.

Although the components of the nursing process (assessment, diagnosis, planning, implementation, and evaluation) are integral to all nursing practice, PHNs must customize the process to the three levels of practice. Table 9-1 outlines the nursing process at the community, systems, and individual/family levels of practice.

Interventions are "actions taken on behalf of communities, systems, individuals, and families to improve or protect health status" (ANA, 2010). The Intervention Wheel encompasses 17 interventions: surveillance, disease and other health investigation, outreach, screening, case finding, referral and follow-up, case management, delegated functions, health teaching, consultation, counseling, collaboration, coalition building, community organizing, advocacy, social marketing, and policy development and enforcement. The interventions are grouped with related interventions; these wedges are color coordinated to make them more recognizable (Figure 9-3, A). For instance, the five interventions in the red wedge are frequently implemented in conjunction with one another. Surveillance is often paired with disease and health event investigation, even though either can be implemented independently. Screening frequently follows either surveillance or disease and health event investigation and is often preceded by outreach activities in order to maximize the number of those at risk who actually get screened. Most often, screening leads to case finding, but this intervention can also be carried out independently. The green wedge consists of referral and follow-up, case management, and delegated functions—three interventions that, in practice, are often implemented together (Figure 9-3, B). Similarly, health teaching, counseling, and consultation—the blue wedge—are more similar than they are different; health teaching and counseling are especially often paired (Figure 9-3, C). The interventions in the orange wedge—collaboration, coalition building, and community organizing—although distinct, are grouped together because they are all types of collective action and are most often carried out at systems or community levels of practice (Figure 9-3, D). Similarly, advocacy, social marketing, and policy development and enforcement—the yellow wedge—are often interrelated when implemented (Figure 9-3, E). In fact, advocacy is often viewed as a precursor to policy development; social marketing is seen by some as a method of carrying out advocacy. The interventions on the right side of the Wheel (i.e., the red, green, and blue wedges) are most commonly used by PHNs who focus their work more on individuals, families, classes, and groups and to a lesser extent on work with systems and communities. The orange and yellow wedges, on the other hand, are more commonly used by PHNs who focus their work on effecting systems and communities. However, a PHN may use any or all of the interventions.

mplementing the interventions ultimately contributes to the achievement of the 10 essential public health services (see Chapter 1). The 10 essential public health services describe what the public health system does to protect and promote the health of the public. Interventions are the means through which public health practitioners implement the 10 essential services. Interventions are the how of public health practice (Public Health Functions Steering Committee, 1995).

The Cornerstones of Public Health Nursing (Box 9-1) were developed as a companion document to the Intervention Wheel. The Wheel defines the "what and how" of public health nursing practice; the Cornerstones define the "why." The Cornerstones synthesize foundational values and beliefs from both public health and nursing. They inspire, guide, direct, and challenge public health nursing practice (Keller, Strohschein, and Schaffer, 2010).

The upper portion of the Intervention Wheel clearly illustrates that all levels of practice (community, systems, and individual/family) are population based. Public health nursing practice is population focused. It identifies populations of interest or populations at risk through an assessment of community health status and an assignment of priorities.

Public health nursing practice intervenes with communities, the individuals and families that comprise communities, and the systems that impact the health of communities. Interventions at each level of practice contribute to the overall goal of improving population health. The work of PHNs is accomplished at all levels. No one level of practice is more important than another; in fact, many public health priorities are addressed simultaneously at all three levels. At the community level, PHNs work with health educators on public awareness campaigns. They perform outreach at schools, senior centers, county fairs, community festivals, and neighborhood laundromats.

The Intervention Wheel encompasses 17 interventions: surveillance, disease and other health investigation, outreach, screening, case finding, referral and follow-up, case management, delegated functions, health teaching, consultation, counseling, collaboration, coalition building, community organizing, advocacy, social marketing, and policy development and enforcement.

The goal of systems-level practice is to change the laws, policies, and practices that influence immunization rates, such as promoting population-based immunization registries and improving clinic and provider practices

Primary prevention promotes health and protects against threats to health. It keeps problems from occurring in the first place. It promotes resiliency and protective factors or reduces susceptibility and exposure to risk factors. Primary prevention is implemented before a problem develops. It targets essentially well populations. Immunizing against a vaccine-preventable disease is an example of reducing susceptibility; building developmental assets in young persons to promote health is an example of promoting resiliency and protective factors.

Secondary prevention detects and treats problems in their early stages. It keeps problems from causing serious or long-term effects or from affecting others. It identifies risk or hazards and modifies, removes, or treats them before a problem becomes more serious. Secondary prevention is implemented after a problem has begun, but before signs and symptoms appear. It targets populations that have risk factors in common. Programs that screen populations for hypertension, obesity, hyperglycemia, hypercholesterolemia, and other chronic disease risk factors are examples of secondary prevention.

Tertiary prevention limits further negative effects from a problem. It keeps existing problems from getting worse. It alleviates the effects of disease and injury and restores individuals to their optimal level of functioning. Tertiary prevention is implemented after a disease or injury has occurred. It targets populations who have experienced disease or injury. Provision of directly observed therapy (DOT) to clients with active tuberculosis to ensure compliance with a medication regimen is an example of tertiary prevention.