NURS 455 Public health Exam 1

The Quad Council Now called: Council of Public Health Nursing Organizations

• Created the Core Competencies for Public Health Nurses (CCPHN). 

• In 2018, the QCC reviewed and updated public health nursing competencies to ensure they remained evidence-based and reflected the current knowledge, skills, attitudes, and values needed for safe, equitable, high-quality practice and collaboration.

• Public health nursing practice is population health focused at its core, emphasizes prevention and health promotion, addresses multiple determinants of health, and works across sectors to establish and maintain effective partnerships

• Public health nurses may work with: 

  • Centers for Disease Control and Prevention

  • National Institutes of Health

  • Department of Health and Human Services

    • These agencies do not determine the public health nurse’s competencies.

Major Challenges in Health Care in the 21st Century

• Escalating costs (top expensive in the one of high income countries) 

• Increasing morbidity and mortality from preventable chronic diseases

  • Ppl are waiting too long to get treatment

• Emphasis on episodic treatment of diseases rather than prevention and health promotion

• Ranks lowest in performance among key health indicators, including access to care, administrative efficiency, health care outcomes, and health equity   

Institute for Health Improvement’s Triple Aim—2008 What did it do or aim to do? 

• Sought to optimize the U.S. health system performance, by simultaneously addressing three dimensions

  • Enhancing the patient experience (quality and satisfaction)

  • Lowering health care costs

  • Improving population health 

• Enhance patient experience by embracing need to move from a provider-centric healthcare system to person/family-centered care 

Patient Protection and Affordable Care Act (ACA)—2010

• Provide affordable health insurance coverage to most Americans

• Lower costs

• Improve access to primary care

• Preventive care and prescription benefits

• Cover pre-existing conditions

• Extend young adults’ coverage

• Rooted in the triple aim- Obama care

-Criticized for more volume than quality care 

Evolved into the Quintuple Aim

• This added a 4th goal

  • Improve the work life of health care clinicians and staff

  • Lack of essential resources for health, such as quality education, employment, and income, is compounded by increased exposure to poor neighborhood conditions such as environmental hazards (air and noise pollution and unsafe water), violence, food insecurity, unsafe streets and playgrounds limiting physical activity, and unreliable transportation (impacting access to jobs and school) contributing to unfair and avoidable poor health

  • The framework has further evolved to include a focus on advancing health equity and addressing social determinants of health

Population Health

• Population health management is a process of improving clinical health outcomes of a defined group of individuals within an integrated clinical health system.

• describes population health as the “health outcomes of a group of individuals, including the distribution of such outcomes within the group…population health outcomes are products of many determinants of health, including healthcare, public health, genetics, behavior, social factors and environmental factors” (p. 380)

• Population health has been viewed as a continuum beginning with population health management (PHM), a process of improving clinical health outcomes of a defined group of individuals within an integrated clinical health system -> form an interactive multidisciplinary team that manages the overall health of an individual as opposed to reacting to the episodic disease-related needs of a patient

• Population health practice moves beyond individual disease and treatment to include the social determinants of health. 

Public Health

• Public health is what society does collectively to ensure the conditions exist in which people can be healthy. 

-founded on the principle of social justice, where health is viewed as a basic right for all, not a privilege

-Fair distribution of resources 

• Health in this context is defined as “the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization [WHO], 1946). 

• Simply, public health seeks “to promote and protect the health of all people in all the communities where they live, learn, work, and play” (APHA, 2021, para. 1).

Public Health core functions

• Structured around three core functions that are systematic: 

1. Assessment

• involves investigative and surveillance strategies to continually monitor the health of populations while identifying and responding to the causative factors of health hazards

• Communication experts guide us on thinking about how to keep community informed  and safety

  • Problem: they could come, do research, then leave without solving or helping the community

    • The community would feel they are being used or seen as lesser or identify a problem but do not provide any aid or give any advice on how to improve. 

  • Could also use researchers from the community

2. Policy development (Big p and little p) 

• seeks to maximize intersectoral collaboration through the shared development, implementation, and evaluation of laws, policies, and plans, using legal and regulatory processes as needed

3. Assurance

• relates to the adequacy of the organizational infrastructure, of diverse and effective personnel, of quality improvement efforts through ongoing research and innovation, and of the identification and removal of barriers that block equitable access for all populations

• Within these three core functional areas, 10 essential public health services, which were revised in 2020, further delineate public health (see Figure- next slide).

Public health approach for nurses

The four steps of the public health approach are 

• defining and monitoring the problem

• identifying risk and protective factors

• testing interventions

  • tested first before it can be implemented to a community.

• and assuring their widespread implementation

Outreach

• Action of a nurse going to locate a population at risk and connect them to appliances of resources 

  • Focus on population rather than individual health

    • (ex: smokers connect to cessation program) 

Social Determinants of Health (SDOH)

• nonmedical factors such as education, employment, income, and the conditions in which people live and work that impact health status

• “conditions in the environments in which 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” (Healthy People 2030 [HP 2030]). 

• The vision of HP 2030 is “a society in which all people can achieve their full potential for health and well-being across the lifespan,” and its mission, “To promote, strengthen, and evaluate the nation’s efforts to improve the health and well-being of all people,” supports the achievement of their vision (HP 2030, n.d.-b)

• HP 2030’s framework for conceptualizing SDOH includes five domains: education access and quality, economic stability, social and community cohesion, neighborhood and built environment, and healthcare access and quality

Public Health Initiatives in Early and Modern America

• American social values strongly influenced by British traditions

  • TB, small pox, typhus- common diseases back during the days of tenants

• Need for organized public health system

• William Rathbone devoted the rest of his life to expanding services for the sick poor, with assistance from his friend Florence Nightingale

• Mary Robinson: first district nurse 

• Lemuel Shattuck prepared a report for the Massachusetts Sanitary Commission that pointed out that much of the ill health and disability in American cities in 1850 could be traced to unsanitary conditions

• recommendations became the foundation of the sanitation movement in the United States

• Dorothea Dix

• aware of the dreadful conditions in prisons and mental hospitals, and she vigorously lobbied state and federal officials to remedy the situation

• Clara Barton convinced Congress to ratify the Treaty of Geneva, and the American Red Cross was established with an extended mission—to provide aid to communities devastated by natural disasters 

• Neutral relief society, help founded the American Red Cross 

• Lillian Wald with Mary Brewster founded Henry Settlement (1893), provided care/education, and helped put nurses in schools and businesses

  • Founder of public health 

  • Provided acute and long term care- taught society how to keep families safe

Public Health Initiatives in the 20th Century

• role of PHNs became more focused on teaching and counseling, showing others how to care for the sick, instructing them on how to prevent illness, and promoting maternal and child health

• Mary Breckinridge

  • Frontier Nursing Services: provide family-oriented healthcare to rural and underserved populations today

• Early 20th-century federal health care initiatives

• Recognize public health as a necessity 

• The Maternal and Infancy Act (Sheppard–Towner Act), passed in 1921, provided matching funds to states that developed maternal and child divisions in their health departments

• Public health in the second half of the century

Eight Principles of Public Health Nursing #1

Ask- who is the client? 

The primary focus of public health nursing practice is on systematic and comprehensive population-focused assessment, policy development, and assurance. 

• The client (or unit of care) is the population.

• The primary obligation is to achieve the greatest good for the greatest number of people.

• Public health nurses work with clients as equal partners.

• Primary prevention is the priority.

Eight Principles of Public Health Nursing #2

• Public health nursing focuses on creating conditions in which populations can thrive.

• There is an obligation to actively identify and reach out to those who may benefit from services.

• Resources should be used optimally to improve population health.

  • Evidence based

• Collaboration is the most effective way to promote and protect health.

Characteristics of Public Health Nursing

• Population Focus with addressing the population needs 

• Comprehensive Community Assessment

• Attention to Determinants of Health (culture and political) 

• Multi-Level Interventions

Surveillance

• An intervention the nurse with ongoing monitoring (systemic), analyze, and interpret to help plan and care for the community 

Screening

• Nurse identify individuals with unidentifiable risk factors and conditions

Case management

• involves collaboration,  plan to bring health services and promote self management  

Engaging in Evidence-Based Practice

• Evidence-based nursing is the use of the best available research evidence, combined with the nurse's clinical expertise and the patient's values, preferences, and circumstances, to make decisions that improve health outcomes and the quality of care

• Evidence-Based Nursing = Best Research Evidence + Clinical Expertise + Patient Values & Preferences = High-Quality Care

Evidence-Based Public Health

• Public health nursing uses the best available evidence from nursing, public health, medicine, epidemiology, and the social sciences to guide programs, policies, and interventions that improve the health of populations and communities

• Epidemiology, the basic science used in public health, is the study of the distribution and determinants of states of health and illness in human populations. 

• It is used both as a research methodology to study states of health and illness and as a body of knowledge that results from the study of a specific state of health or illness

• identifies the condition (what), the populations it effects (who), the locations where it is occurring (where), and the time when it is occurring (when)

Public Health Nursing

• Public health nursing is a population-focused practice that combines nursing and public health principles to prevent disease, promote health, protect communities, and improve the well-being of entire populations—not just individual patients

• Key Idea

-Unlike clinical nursing, which primarily focuses on the care of individual patients, public health nursing focuses on the health of communities and populations, aiming to prevent health problems before they occur

-Eliminating barriers that block health equity 

Scope and Standards of Practice

• The American Nurses Association (ANA) establishes the scope and standards for professional nursing practice.

• Public Health Nursing: Scope and Standards of Practice defines the expectations and competencies for public health nursing practice and serves as an authoritative professional standard that guides safe, quality care.

-There are 18 standards that are divided into two categories: standards of practice, which focus on the nursing process (assessment, diagnosis, outcomes identification, implementation, and evaluation), and standards of professional performance, which focus on the professional role and include behaviors related to ethics, education, communication, collaboration, quality, research, and leadership

-Evidence-based strategies are focused on “(1) health promotion and restoration; (2) prevention of illness, disease, and injury; (3) alleviation of suffering; and (4) supportive care” (e-book, p. 76)

Competencies for Public Health Nursing Practice (1 of 2)

• Three tiers of practice

• Competencies associated with that level of practice

• Brief overview of Tiers 1-3 (dont need to know) 

-Tier 1 core competencies apply to entry-level public health professionals at the basic or generalist level. 

-Tier 2 core competencies apply to individuals with management and/or supervisory responsibilities and are considered specialists or mid-level practitioners. 

-Tier 3 core competencies apply to senior managers and leaders at the executive level who deal with multisystems

Competencies for Public Health Nursing Practice (2 of 2)

• Public health nurses must demonstrate competencies in eight domains that guide effective population-focused practice. 

• These domains describe the knowledge and skills needed to assess community needs, develop and implement programs, collaborate with partners, manage resources, and improve population health.

The domains include: 

1. assessment and analytic skills on community data 

2. policy development and program planning skills

3. communication skills

4. cultural competency skills

5. community dimension of practice skills

6. financial planning skills

7. evaluation and management skills

8. leadership and systems thinking skills.

Public Health Nursing Interventions and Wheeel pt1

• Population-based model

• Applied to individuals, families, communities, or within systems

• Focuses upon prevention

Public Health Intervention Wheel (1 of 2)

• The Public Health Intervention Wheel was developed to illustrate the key components of public health nursing practice.

• Public health nursing is population-based, meaning the primary focus is on improving the health of a defined population or community rather than caring for individual patients alone.

• Public health interventions can be implemented at three levels of practice: 

  • Individual/Family Level – working directly with individuals or families.

  • Community Level – addressing the health of an entire community or population group.

  • Systems Level – influencing organizations, policies, and systems that affect health outcomes.

Public Health Intervention Wheel (2 of 2)

• Third, the wheel defines 17 specific public health nursing interventions that are divided into wedges by grouping certain interrelated interventions.

• Actions taken on behalf of individuals, families, communities, and systems to protect or improve health status

• Use this site for most current update (as of July 2025)

• We will discuss more in class

  • Use Figure 1.7 in text and Table 1.2 for details

Education for Public Health Nursing Practice

• BSN: Entry-level public health nursing practice

• MSN, MPH, MSN/MPH: Advanced population health and public health nursing practice

• CNL: Graduate-prepared nurse leader focused on quality improvement and outcomes

• PhD, DNP, DrPH: Research, advanced practice, leadership, and public health policy

• NOTE: Some nurses pursue graduate preparation as a Clinical Nurse Leader (CNL), a role that focuses on improving quality, outcomes, and care coordination across populations.

• The CNL is a role/certification rather than the standard educational pathway into public health nursing

Response to Challenges for Public Health Nursing in the 21st Century

• Build a strong public health system.

• Improve coordination between public health and healthcare providers (follow local recommendations if differ govs are saying differ info)

• Respond to the health challenges created by climate change.

• Prepare for and respond effectively to emergencies and disasters.

• Promote health equity by removing barriers and addressing the social determinants of health.

Common health conditions in homelessness info

HTN, CVD, Diabetes, PTSD, Depression, HIV, etc 

^Two common are health conditions are chronic and mental health 

• Build rapport/trust by communicating with them respectful, nonjudgmental,

• Connect them with social worker

• Issues of income, housing, nutritious food, etc 

• Being their Advocate 

• Trauma informed care is important because it promotes trust, safety, and engages the client into the healthcare environment 

• What resources do nurses can use? What ways do homelessness deal with chronic conditions? 

• Resources: Food pantry, community health centers, shelters (violence/fear), etc  

• mainly chronic health conditions and mental health are common among homeless

• social and environmental influences homeless

*Reduce stigma by not being judgemental, listening, establishing trust, address them by how they address themselves, and asking what matters to them

Preferred Terms for people with conditions

• People experiencing homelessness

• People with lived experience of homelessness

• People who are currently unsheltered

• People residing in shelters or temporary housing

• People transitioning out of homelessness

*Person-first terminology and respectful communication (Ex: Person with ____) 

• Non-stigmized language and from uninformed place 

Why This Matters for homelessness (impacts)

• NYC housing instability and homelessness trends and population health impact

• New York City continues to experience historically high levels of homelessness

  • More than 80,000 people residing in the municipal shelter system on a “typical” night

• Thousands of adults, families, and children rely on emergency shelter services each year

  • Reflects challenges related to affordable housing, poverty, and access to supportive services

• Children remain disproportionately affected by housing instability

  • Makes homelessness an important population health and health equity concern

• Geographic & Community Impact

  • People experiencing homelessness come from every borough and almost every zip code in NYC

  • Rates of homelessness are highest in communities disproportionately affected by poverty, housing insecurity, structural racism, and limited access to resources

Drivers of Homelessness

• Housing, violence, employment, health, systems factors

  • Key drivers of homelessness

    • Lack of affordable housing

    • Eviction and housing instability

    • Job less or reduced income

    • Unsafe housing conditions

    • Domestic violence

    • Reentry following incarceration

    • Transition from military service

• Health Considerations

  • Serious mental illness

  • Substance use disorders

  • Chronic medical conditions

  • Consider that:

    • Serious mental illness affects 20- 25% of single adults experiencing homelessness nationally

    • Many New Yorkers experiencing unsheltered homelessness live with complex behavioral health and medical needs

Homelessness Demographics

• Disproportionate impact across communities

  • Black and Hispanic/Latinx New Yorkers experience homelessness at disproportionately higher rates than other racial and ethnic groups

  • Structural inequities in housing, education, employment, healthcare access, and wealth contribute to these disparities.

  • Addressing homelessness requires an equity-focused approach that targets both housing stability and the social determinants of health

• Disproportionate impact across communities

  • New York City Shelter Population

    • Approximately 55–58% of families and single adults in NYC shelters identify as Black, while approximately 27–36% identify as Hispanic/Latinx.

    • White and other racial/ethnic groups represent substantially smaller proportions of the shelter population.

Aging & Homelessness

• Accelerated aging and cohort effects

  • Older Adults Experiencing Homelessness (Age 50+)

  • Why this matters?

    • Approximately 146,000 adults age 55 and older experienced homelessness in the United States during the 2024 Point-in-Time Count (More Older Adults are Homeless—What Can Be Done to Help this Vulnerable Population with Unique Needs | U.S. GAO )

    • Older adults represent about 20% of the homeless population and are one of the fastest-growing groups experiencing homelessness (Same source as above)

    • Nearly half of homeless adults over age 55 are unsheltered, increasing their risk for injury, illness, and mortality (HOMELESSNESS PREVENTION SERIES: Spotlight on Older Adults )

• Accelerated aging and cohort effects: Considerations in your role as a nurse

  •  Health risks and challenges 

    • Chronic disease (HTN, COPD, heart disease, diabetes)

    • Falls and mobility impairment

    • Depressions, PTSD, serious mental illness, substance use disorders

    • Cognitive impairment and dementia

    • Malnutrition and dehydration

    • Limited access to preventive healthcare and medications

Nursing Considerations with the homelessness of assess and interventions

• Assess

  • Functional status (ADLs/IADLs): Brushing teeth, feeding, showering, toilet) 

    • IADLs (higher level of thinking): Cooking, driving, finances, transportation,   housework, managing medications, etc   

  • Fall risk and mobility

  • Mental health and cognition

  • Medication adherence

  • Nutrition and hydration

  • Housing stability and safety

• Intervene

  • Use trauma-informed, person-centered care

  • Connect patients to housing, social work, and community resources

  • Promote chronic disease management

  • Screen for depression, substance use, and cognitive impairment (follow-through needs to be there) 

  • Advocate for accessible shelter and supportive housing programs like this is when the dentist/barber is going to be here, etc 

Ethics in Population Health

• Balancing etic and emic perspectives

  • The concepts of etic and emic come from cultural anthropology and are useful in nursing when caring for vulnerable populations such as older adults experiencing homelessness

Ethic Perspective ("Outside Looking In")

• Balancing etic and emic perspectives

  • The etic perspective is the viewpoint of an outsider, such as a healthcare professional, researcher, or policymaker. 

  • It focuses on observable health concerns and professional assessments. 

  • However, clinicians may unintentionally become overly prescriptive or overlook what is most important to the patient.

Health Concerns (Ethical Perspective)

• Mental Health

  • Adjustment disorder - > Risk for SI (suicide ideation) 

  • Post traumatic stress disorder 

  • Untreated severe mental illness

• Substance Use

  • Addictions, harm reduction, reversal agents

• Healthcare Coverage

  • Inadequate and inconsistent medical care / inadequate insurance coverage

  • No known history or no identifying information

• Physiological Health and Wellbeing

•  Infection risk, Virus transmission

•  Weather concerns (freezing temperatures; heat exhaustion)

•  Poor nutrition

•  Dermatological and hygienic concerns:

  • exposure to bedbugs, mites; limited access to bathing and laundering facilities

Emic Perspective ("From Within")

• Balancing etic and emic perspectives

  • The emic perspective reflects the lived experience and insider knowledge of the population being studied or cared for. 

  • It focuses on what matters most to the individual rather than what professionals assume should matter. Balancing etic and emic perspectives

    • Qualitative and Quantitative studies

Patient Concerns (Emic Perspective): “What Matters To You”

•  Where to keep belongings

  • “My stuff got stolen again, this time while I was sleeping”

  •  “I keep forgetting to take my meds cause my stuff it is hard to keep track of my stuff”

•  Violence, attacks, trauma

  •  “I don’t feel safe, ever”

  •  “My shelter roommate assaulted me and he’s still living here”

•  Independence is Threatened

  •  “If I move in there, are the staff going to be watching me and bugging me all the time?”

  • Curfews, etc 

•  Addiction culture and social pressure

  •  “Some people use your addictions to support their own.”

•  Losing or Reuniting with Dependents and Loved Ones

  •  Children, spouses, animals

  •  “I don’t want to go indoors if it means I have to leave my bird behind.”

•  Trust

• Mistrust of healthcare providers 

• Don't want to be overmedicated 

Nursing Applications of homelessness ethics and emics

• When working with vulnerable populations, nurses should balance both Perspectives:

  • Etic- professional- what is the matter?

  • Emic- patient- what matters to you? 

  • Etic- professional- identifies health risks

  • Emic- patient-identify patient priorities

4Ms Framework

• The 4Ms Framework is the foundation of the Age-Friendly Health Systems Initiative, developed by the Institute for Healthcare Improvement (IHI) and The John A. Hartford Foundation to improve care for older adults.

• The framework encourages healthcare professionals to focus on four essential elements during every encounter with an older adult.

• Patient-centered care

The 4 Ms

1.  What Matters

• Ask: "What matters most to you?"

• Identify the older adult's health goals, care preferences, values, and priorities.

• Align the care plan with what is most important to the patient.

• Supports shared decision-making and person-centered care.

• Example with Homeless Older Adults:

  • Maintaining independence

  • Staying safe

  • Reuniting with family

  • Keeping personal belongings secure

  • Finding stable housing

2.  Medication

• Ask: "Are medications helping or harming?"

• Review all medications regularly

• Reduce polypharmacy when possible

• Avoid medications that interfere with:

  • What Matters

  • Mentation

  • Mobility

• Consider age-related changes in medication metabolism and elimination

• Nursing Focus:

  • Medication reconciliation

  • Beers Criteria

  • Monitoring adverse drug reactions

3.  Mentation

• Ask: "How is the person's mind and mood?”

• Screen for:

  • Dementia

  • Depression

  • Delirium

• Mentation emphasizes preserving cognitive functioning and emotional well-being

• Nursing Focus:

• Cognitive assessments

• Depression screening

• Delirium prevention and recognition

• Trauma-informed care

1.  Mobility

• Ask: "How can we help this person move safely every day?"

  • Maintain functional ability.

  • Prevent falls and deconditioning.

  • Promote safe movement and independence.

  • Support patients in doing what matters to them.

• Nursing Focus:

  • Fall-risk assessment

  • Strength and balance promotion

  • Assistive devices

  • ADL assessment

Sample Nursing Questions and Mentation in older adults

• Asking “What matters to you?”

• "What is your biggest concern right now?”

• "Do you have a safe place to store your medications?”

• "How have your mood, memory, and sleep been recently?"

• "Have you fallen or had difficulty walking recently?"

Mentation in Older Adults

• Depression, delirium, dementia

• Mentation is one of the 4Ms of Age- Friendly Care and focuses on maintaining an older adult's cognitive and emotional well-being by assessing conditions such as depression, delirium, and dementia.

Depression- loss of interest

• Depression: Physical symptoms, rather than just sadness

Delireum

• Acute change in alert and cognition

• UTI- infections in older women because it goes undiagnosis

• Electrolyte imbalance

• Medication 

Dementia

• Progress decline in memory and cognitive function 

• Impact judgement like did i turn stove off or not 

Telehealth Opportunities with vulnernable population

• Improving access to care

  • Telehealth has become an important tool for supporting the Mentation component of the 4Ms Framework by improving access to mental health, cognitive, and geriatric services, particularly for older adults with mobility limitations, transportation barriers, or unstable housing situations

  • Consider this:

    • Telehealth can be highly effective for:

    • Depression screening (PHQ-9, GDS)

    • Psychiatric consultations

    • Counseling and psychotherapy

    • Medication management and follow-up

    • Monitoring treatment response

  • Nursing example:

    • A nurse conducting a telehealth visit may notice:

      • Decreased eye contact

      • Flat affect

      • Social withdrawal

      • Poor sleep or appetite

    • These observations can prompt further assessment and referral.

Medication Considerations + Beers with homelessness

• Medication and the older adult

  • Medication management is one of the 4Ms (Medication) and is especially important in older adults because age-related physiologic changes increase the risk of adverse drug events, polypharmacy, falls, delirium, and hospitalization.

  • Start low, go slow then monitor before increasing the dose 

  • Monitor kidney and liver function (absorption/excrete) - GFR, liver/kidney size decreases 

  • Watch for polypharmacy

  • Use the Beers Criteria*

  • Avoid medications that impair mobility or mentation

  • Assess for medication-related falls, delirium, and confusion

  • Consider barriers to adherence

  • Align medication decisions with “What Matters” to the patient

Beers criteria

• The Beers Criteria (also called the Beers List) is a guideline developed by the American Geriatrics Society (AGS) to help healthcare providers identify medications that may be potentially inappropriate or higher risk for adults aged 65 years and older. 

• It is widely used to improve medication safety and reduce adverse drug events in older adults.

• Why it matters

• As people age, changes in: 

  • drug absorption,

  • metabolism, 

  • kidney function, and

  • sensitivity to medications

•  Can increase the risk of side effects, falls, delirium, confusion, hospitalization, and other adverse outcomes

• Ex: Lithium and warfarin need careful monitoring 

• Benzodiazepine increases risk of falls and confusions

• Benadryl (1st gen anti-histamine in general)- Anticholinergic effects

• Antipsychotics 

The Housing Process in New York

Places People Reside

•  Streets

•  Transitional housing sites: safe havens & shelters

•  Supportive Housing sites: scatter site or congregant care

Places People Get Healthcare

•  Streets

•  Transitional Housing Sites: Safe Havens & Shelters

•  Supportive Housing Sites: Scatter Site or Congregant

•  Urgent Care

•  Primary Care / Private Practices

•  Hospitals

Streets Living programs

•  Street-to-home programs

• ”Breaking Ground”

  • One of NY largest and influential nonprofit in helping homeless- supportive housing and street in-take (affordable housing) 

  • Housing first model - homeless assistance approach that prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness and serving as a platform from which they can pursue personal goals and improve their quality of life

  • Wrap around- services to keep person at a housing  

• ”Manhattan Outreach Committee”

Code Red & Code Blue

• What do they mean? Emergency weather protocol for those homeless

  • Code red- extreme heat outside (heat index 100 or higher for 1 day, multiple days is 95 and higher)

    • Outreach goes out and moves people to cooling shelters and places with air conditioning

    • Set up additional cooling places + don’t need to do intake papers

  • Code blue- extreme cold conditions risk for hypothermia and frostbite 

    • Street outreach teams makes efforts to go on the streets and reach out to shelters or homeless on the streets (welfare checks) 

    • Has to be an open door policies for those without shelter

• Why is it important to public health?

Shelters - safe haven

• Safe Haven Ethical alternative to Shelter System

  • No curfew- or flexible attendance scheduling

  • Fewer restrictions

  • For chronic homeless and unable to use traditional shelter homes

  • More privacy and attention. 

  • Ability to maintain a bed, voluntary services 

  • Keep people longer by reducing barriers and engaging them more 

Supportive Permanent Housing + Categories

• Scatter Site

  • Housed at various sites throughout the city

  • Limited support available

• Congregant Care

  • Tends to be more restrictive

  • One building housing many tenants

  • Support staff offices located in lobby or basement

• Help with chronic, mental, HIV conditions 

Supportive Housing: Housing Categories

• Cat A: Serious Mental Illness

  • Chronically single adults with mental illness

  • Could be chronic mental illness with substance intake

• Cat B: OMH (office mental health) 

- Single adults leaving a psych center/ transitional home 

• Cat C: <25 years old 

  • Just that, its only 18-24 (age) not for families

  • Single person

  • Psychiatric needs/ cares

• Cat D: Families 

  • Chronically homelessness families who are able to share rooms and onsite support

• Cat E: Active Substance use

• Cat F: Sustained sobriety

• Cat G: Families w/HIV

• Cat H: Individuals w/HIV

• General Population 

• ***Bonus Classification: NY 1515 Homeless for 10+ Years

Serious Mental Illness: Options for Care

• Long-Acting Injectables

  • Most often are antipsychotics could be injected every several months or weeks instead of using pills

  • For schizophrenia, schizoaffective disorder, or bipolar or other serious mental illness

• Medication monitoring programs

  • Coordinative program to know if the medication is taken effectively, adherence,  note any side effects

• ACT teams

  • Assertive Community Treatment-  provides community-based supports to help people remain housed

• PROS programs

- Personalized recovery orientated services 

IMT Teams:

• Intensive mobile treatment teams

• For clients who have had recent and frequent contact with the mental health, criminal justice, and homeless services systems, and recent escalating behavior. 

• For clients who move frequently across the behavioral health, homeless services, and judicial systems. 

• IMT teams provide intensive, individualized support, whether at home, in the streets, jails or hospitals.  (bringing healthcare to them) 

Substance Use Disorder: Harm Reduction

•  Narcan training and kit distribution

•  Needle exchange programs

  • A place where ppl can exchange their needs with hopes that they wont pick one Random one to use. 

  • Promotion use of drug use 

• Methadone treatment programs

• Where is the best place to have them? 

•  Suboxone prescriptions

•  12-step programs

  • AA- alcohol anonymous

  • Private meetings and where is the best place to have those

Why Disaster Preparedness Matters

Consider (1)

• "What disaster has had the greatest impact on healthcare during your lifetime?"

  • COVID-19, 9/11, Hurricane Sandy/Katrina, wildfires, flooding, school shooting, cyberattack, or mass casualty incident

  • Becoming frequent, complex, and interconnected  

    • Ex: Hurricane -> flooding -> evacuation, prolonged power outages, and communication failures 

Consider (2)

• The last decade has demonstrated that every nurse is a disaster nurse. 

  • Can impact anywhere in healthcare so nurses have to be prepared to respond and pivot 

  • Preparedness, response, recovery, and mitigation 

    • Hospital: Managing surges of patients, performing triage, coordinating care, and helping maintain safe operations under challenging conditions  

    • Community: Surveillance, education, vaccination efforts, shelter operations, and community recovery initiatives 

      • School nurses: protect, support emergency planning, and provide care during public health emergency disasters 

      • Long-term care nurses: protect their population, coordinate evacuations, and maintain continuity of care

• The nursing workforce is a critical component of disaster response in hospitals, public health agencies, schools, long- term care facilities, and communities.

  • Backbone of healthcare who need to be skilled, adaptable, resilient, and collaborate across disciplines 

  • How do you think the nursing role changes during a disaster compared with day to day practice?  

    • Adaptable, resilient, disaster ready/preparedness, effective assessment, and coordination

What is Disaster?

• A disaster is an event that overwhelms local resources and requires external assistance. 

  • Key characteristic: Outside assistance is required like local emergency services, hospitals, and public health agencies need regional, state, and federal support 

  • Have different meanings depending on location 

    • Ex: Flood, hurricane, tornado, wildfire, earthquake, blizzard, COVID-19, power-grid failure, chemical spill, and transportation accident involving mass casualties 

• They are often unforeseen, serious, and unique events that disrupt essential community services and cause human morbidity (injuries) and mortality (death) that cannot be alleviated unless assistance is received from others outside the community.

  • Services Examples: Transportation, communication, utilities

Variation factors in disasters

• It helps nurses determine level of nursing response needed during disaster 

• Type of onset (they often occur without warning/gradual): Earthquake vs drought 

  • Influence how quickly healthcare systems must mobilize resources and personnel 

• Duration of the crisis (short/long): Tornado vs pandemic 

  • Longer duration events can play significant physical and emotional strain on healthcare workers,

    • Increase challenges = staffing, supplies, and continuity of care

• Magnitude or scope of the incident = depending # of casualties, geographic area affected, amount of infrastructure damage, and resources required for recovery 

  • Larger events need coordination among multiple agencies with state/federal/international assistance 

    • Healthcare need to respond to surge capacity plans and crisis standards of care 

• Extent to which the event affects the community depending on population size, vulnerability, and extent of resources 

  • Power outage, loss of housing, transportation disruption, school closures, and limited access to healthcare services 

Disaster Preparedness in nursing

• Foundation of effective disaster management 

• Although disasters do not occur with frequency, planning with vulnerability assessment can reduce the impact on the community.

  • Nurses participate in planning, training, drills, and community ed efforts 

    • 1. Identification of hazards allows organizations to plan for the most probable emergencies  

    • 2. Analysis of vulnerability

      • Older adults? Children? People with chronic health conditions/disabilities? Staffing shortage? Infrastructure? Supply chain disruptions? 

      • To see if population need additional support during emergency 

    • 3. Assessment of risk

      • Combines likelihood of hazard occurring with its potential impact 

• National Response Framework: nation’s guide for coordinating responses to disasters and emergencies

  • Outlines how local, state, tribal, territorial, federal agencies work together during incidents 

  • Emphasize flexible and scalable response based on size and complexity of the event  

Disaster Management

• Preparation to build readiness before disaster occurs: planning training and drills 

• Risk assessment by identifying likely threats and evaluate their potential impact 

• All-hazards vulnerability plan: Address a wide range of emergencies, including natural, disease-outbreaks, and man-made

• Federal response networks (FEMA/CDC) to provide resources, help coordination, and support during large event  

• State response networks (Emergency management/public) coordinate resources within their jurisdiction 

• Point-of-distribution plans

  • Establish sites to rapidly distribute medications, vaccines, food, water, or other emergency supplies to the public 

Point-of-distribution plans

• Point of distribution (POD): temporary site to provide essential supplies 

  • respond at local level and responders are then deployed 

• Emergency Dispensing Site (EDS): type of pod specifically designed to rapidly dispense medications or vaccines to the public 

  • Activated when normal healthcare facilities can’t meet the demand 

  • Evaluating effectiveness by assessing response and effects of intervention

Disaster Preparedness Training

• Tabletop exercise: discussion-based training activity in which participants are going to work through a simulated disaster scenario 

  • Team members will review the response plan, discuss roles/responsibility, and identify any potential gaps in the preparedness 

  • Takes place before real event occurs 

• Human simulation training: Use of realistic scenarios, standardized patients/mannequins or mock disaster victims to mimic emergency situations  

  • Will practice triage, patient assessment, communication/teamwork, and clinical skills in a controlled environment 

Disaster Preparedness process

• Mitigation focuses on reducing the likelihood or the impact of disasters before they occur 

  • Ex: Hazard resistance building design, flood protection measures, vaccination programs, and community preparedness education 

• PPE protects from exposure to infectious agents, chemicals, and other hazards 

• Response begins immediately after disaster occurs

  • Incident command system is a standardized structure to manage emergency operations to help designated clear leadership 

  • Field triage prioritizes patients based on severity of their injuries and likelihood of survival

    • Goal is provide the greatest good for greatest number of people   

• Recovery involves restoring healthcare services, infrastructure, community function after the disaster 

  • Can continue some time based on the disaster (weeks, months, years) 

• Accurate Documentation of patient care, what resources used, response to put in place 

  • Continuity of care, as well as legal protection and post-disaster analysis  

• Evaluation of what worked well and what needs improvement 

  • Strengthen future disaster preparedness and interventions

Roles of Nursing in Disaster Management

• Public health nurses as first responders in protecting the entire community

• Assess community needs as events unfold

  • Asking what are our resources, where are the resources short, who are our vulnerable population?  

• Conduct surveillance for communicable disease

  • Monitor outbreaks/unusual disease patterns, collect and report data to public health agencies 

• Prevent and control spread of disease with promoting infection prevention measures and strategies to reduce diseases transmission during emergency: PPE and vaccines

• Maintain communication channels between public health agencies 

• Organize and manage PODs

• Provide on‐site triage by prioritizing care based on urgency 

• Manage behavioral responses to stress 

  • Provide psychological first aid, emotional support, and recognize signs of anxiety/trauma

• Ensure health and safety of self, colleagues, and the public

• Document events and interventions help with continuity of care

Emergency

• Is typically managed using available local resources. 

• They are considered events that require a swift, intense response on the part of existing community resources. 

  • Does not overwhelm the local resources and doesn’t require outside assistance 

• Examples: Motor vehicle accident that has multiple injuries, residential/small commercial fire, localized hazardous material spills, severe weather events, or small outbreak of hepatitis from a restaurant 

Bioterrorism: biological agents used to intentionally cause illness, death, fear, and social disruption

• History of being used but modern concerts increases after 2001 anthrax attacks in US

• Categories of bioterrorism agents set by the CDC

  • Can be easily disseminated or transmitted from person to person 

  • Result in high mortality rates 

  • Have the potential for major public health impact 

  • Might cause public panic and social disruption and require special action for public health preparedness

    • Ex: Anthrax, smallpox, botulism, plague  

• Early Detection limit illness and prevent further spread 

  • Healthcare workers are first to recognize unusual disease patterns/clusters of illness 

    • Warning signs: unexpected increase in severe illness, unusual symptoms, or rare disease appearing in the community 

Bioterrorism Agents

• Anthrax caused by spores (bacillus) 

  • Can be inhaled, ingested, or enter through the skin 

• Botulism caused by clostridium botulinum 

  • Leads to muscle paralysis and respiratory failure 

  • Not spread person to person 

• Plague 

• Smallpox is a highly contagious viral disease 

  •  Fever and distinctive rash 

• Tularemia 

• Viral hemorrhagic fevers 

• Ebola precautions

  • PPE: gown, glove, mask, eye protection

  • careful donning/doffing procedures to prevent contamination and limit exposure to blood/body fluids  

  • Report suspected cases

Mass Casualty Incident (MCI) + CMS Emergency Preparedness Rule (2016)

• One of the most important healthcare policy changes of the decade was the Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Rule. 

  • Established emergency preparedness requirements across healthcare organizations receiving medicare and medicaid funding 

• The rule became effective in 2016 and required healthcare organizations to develop comprehensive emergency preparedness programs.

  • 4 core requirements: Assessment, emergency planning, communication planning, and training/drills

CDS Disaster Required components + Nursing Implications

• Risk assessment using an all-hazards approach to identify and assess all potential hazards 

  • Forms foundation for emergency preparedness planning 

• Emergency plan to outline how the facility is going protect patients, staff, and operations 

• Communication plan on how information is shared with staff, patients, and families  

• Policies and procedures 

  • Ex: Evacuation plan, shelter in place, patient tracking, resource management, and continuity of operations 

• Training and exercises

  • Ex: Tabletop/full scale drills

Nursing Implications

• Nurses must understand

  • Incident command systems on chain of command and how is care coordinated 

  • Emergency communication pathways within organization like notifications and reporting procedures

  • Their organization's emergency operations plan outline procedures for evacuation, surge, staffing, and continuity of care 

Hurricanes Harvey, Irma, and Maria (2017)

• Lessons Learned

  • Hospital evacuations are hard to do so it's essential to have a plan and practice 

  • Long-term power failures so need for stronger backup power systems and emergency preparedness plans 

    • Impacts ventilation, medication refrigeration, and access to clean water 

  • Medication shortages so important to encourage emergency medication stockpiles 

  • Continuity of care challenges due to displacement of residents and health providers coordinating services (treatment)

• Nursing Roles

  • Shelter operations of assessment, med administration, triage, and monitoring vulnerable populations

  • Evacuation assistance with coordinating patient movement, prioritize care needs, and ensure patient safety during evacuations 

  • Chronic disease management with access to meds and supplies + referrals accessible at the time

  • Public health education of prevention and post-disaster recovery 

Increasing Wildfires (2018–2025)

• Major wildfire disasters in California, Oregon, Hawaii, and Canada affected air quality and healthcare systems nationwide.

• Nursing Concerns

  • Respiratory illness of coughing, shortness of breath, bronchitis, etc 

  • Asthma exacerbations

  • Heat-related illness like risk of dehydration, heat exhaustion, and heat stroke

  • Mental health consequences including anxiety, depressed, sleep disturbances, and PTSD 

COVID-19 Pandemic (2020–2023)

• Major impacts: 

  • Healthcare workforce shortages 

  • Crisis standards of care 

  • PPE shortages 

  • Moral distress and isolation

  • Telehealth expansion

• Nursing Lessons 

  • Infection prevention 

  • Resource allocation 

  • Vaccine education 

  • Public health communication 

  • Community resilience

Cybersecurity Events in Healthcare (2021–2026)

• Healthcare organizations increasingly experienced cyberattacks and ransomware incidents. 

  • Hack in organization and demand payment to restore access

  • Healthcare rely on electronic health records, medication management systems, and communication technologies 

• Nursing Implications 

• When electronic systems fail: 

  • Documentation may revert to paper 

  • Medication systems may be disrupted so manual medication verification processes 

  • Communication systems may fail so may not use phones

  • Nurses must be prepared to deliver safe care under degraded conditions.

    • Maintain patient safety, confidentiality, continuity of care, and ongoing patient education

Climate-Related Disasters

• The 2024 National Preparedness Report emphasizes the growing impact of: 

  • Extreme weather are more frequent and causes injuries/stress

  • Flooding can disrupt transportation, available drinking water, increase water borne illnesses, and damage homes

  • Heat events can cause dehydration, heat stroke, and significantly impact vulnerable populations such as children and older adults

  • Infrastructure disruption results in damaged roads, medical equipment, and transportation of patients

• These events disproportionately affect vulnerable populations

  • Low income communities, older adults, homelessness

  • Nurse should educate, disaster plan, advocate, and understand local emergency response plans

Four Phases of Emergency Management 

• Mitigation reduce likelihood or impact of disaster before they occur 

  • Long term investment in community safety, resilience, and health outcomes

  • Actions taken before a disaster to reduce risk to the community and healthcare systems 

  • Examples: 

    • Flood barriers, levees, drainage improvements that protect against flood damage

    • Backup generators maintain essential services by sustaining equipment, medication, refrigeration, communication, and electronic health records

    • Vaccination campaigns prevent outbreaks of vaccine preventable diseases

    • Building design improvements make buildings more resistant against disasters to protect occupants and reduce disruption of healthcare services

• Nursing Examples 

  • Community risk assessments help healthcare organizations prioritize how prepared they are and where they should allocate their resources

    • Early identification helps to reduce injuries, illnesses, hospitalizations and deaths

  • Identifying vulnerable populations at increased risk

• Preparedness before a disaster occurs

  • Actions taken to enhance readiness such as mitigatory precautions

  • Examples: 

    • Emergency planning 

    • Drills 

    • Training

    • Stockpiling supplies 

• Nursing Examples

  • Participating in disaster drills helps us practice roles, identify gaps, and prioritize care

  • Learning triage systems 

  • Maintaining competency through ongoing education

• Response 

  • Immediate actions during a disaster is to reduce harm and maintain safety

• Nursing Actions 

  • Triage prioritize patients based on severity of injury and likelihood of survival 

  • Emergency treatment provides immediate care to stabilize patients to prevent further complications

  • Mass vaccination reduce transmission and protect public health

  • Evacuation assistance to safely relocate patients and assisting those with special needs

  • Crisis communication is sharing clear, accurate information with patients, families, and healthcare teams

• Recovery 

  • Restoring normal function after a disaster and helping communities and individuals heal

  • Can continue for months or years

  • Goal is to rebuild health services and community resilience

• Nursing Roles 

  • Mental health support: addressing stress, anxiety, grief, or trauma

  • Community outreach: connecting with healthcare services and support programs

  • Chronic disease management

  • Long-term rehabilitation: help regain optimal function and independence

Disaster Nursing Competencies aspects

• Assessment 

  • Hazard identification: floods, power outages, earthquakes

  • Population needs assessment: who is at risk

  • Surveillance: monitor for injuries, disease outbreaks, and emerging public health concerns

• Communication 

  • Chain of command helps nurse understand their roles and responsibilities and reporting structure

  • Interprofessional collaboration promotes teamwork among healthcare providers, emergency responders, and community agencies

  • Public messaging helps provide accurate information, reduce fear, and guiding community members on protective actions

• Safety

  • PPE use protect nurses, patients and responders from injury and exposure

  • Decontamination procedures help prevent the spread of hazardous substances

  • Infection prevention measures reduce disease transmission and protect public health

• Leadership

  • Delegation to distribute tasks according to team members, skills and responsibilities

  • Team coordination promotes communication and collaboration

  • Resource management ensures personnel and supplies are used efficiently during shortages

Hospital Incident Command System (HICS) is used to manage emergencies in a structured or organized way

• Helps healthcare teams respond efficiently during disasters or mass casualty incidents

• Good to be aware that hospitals will use during an emergency: 

• Benefits

  • Clear leadership ensures that decisions are made quickly and consistently

  • Improved communication helps information flow effectively throughout the organizations

  • Defined responsibilities ensures everyone understands their roles

• Nurse Responsibilities

  • Understand reporting structure: know who to report to during an incident

  • Follow emergency roles to support organized response

  • Document actions appropriately to maintain patient safety, accountability, and records

Disaster Triage

• Is the process of sorting patients when resources are limited

• Goal is to provide the greatest good for the greatest number

Triage Overview (priority of treatment needs)

• Care focuses on resource allocation and comfort measures when possible

• Red –Immediate

  • Life-threatening but survivable and require immediate treatment

• Yellow –Delayed

  • Serious injuries that require medical attention, but not immediately life threatening

  • Stable condition

    • Treatment can be delayed without significant risk

• Green –Minor

  • Walking wounded and can care for themselves

• Black –Expectant/Deceased

  • Dead or unlikely to survive with available resources

Ethics in Disaster Nursing

• The American Nurses Association identifies nurses as essential responders during disasters. 

• Ethical Challenges 

  • Scarce resources

  • Ventilator allocation 

  • Staffing shortages 

  • Personal risk

• How should decisions be made? : Shift from individual centered to community centered care

Public Health and School Nursing Roles

• Responsibilities

  • Disease surveillance monitoring for outbreaks 

  • Vaccination efforts prevent spread of infectious disease

  • Health education teaching student, families, and communities

  • Family preparedness education help families develop their own emergency plan and disaster kits

  • Emergency planning for schools is about testing and developing plans in the likely event of emergency

  • Reunification planning safely connects students with families after an emergency

Shelter in Place + Personal Preparedness for Nurses

• Shelter in place is used for short‐duration incidents, when moving would result in a greater hazard or it is impractical to evacuate.

• Indoor is safer than evacuating outside

  • Ex: hazardous material release, severe weather, insecurity threats

• Nurses roles is to ensure safety and the accountability of patients, students, or occupants

  • Monitor for urgent health needs while maintaining normal operations

  • Communicate instructions clearly and provide reassurance to reduce anxiety

  • Follow organizational emergency procedures and remain alert for updates

Personal Preparedness for Nurses

• Family Plan

  • Emergency contacts: who are they? Can they come over immediately in the event of an emergency?

  • Meeting locations: where is a safe place? 

  • Childcare arrangements and pet care plans

• Go-Bag basics

  • Water

  • Medications

  • Flashlight

  • Phone charger

  • Identification

• Professional Readiness

  • Current licensure

  • Emergency contacts

  • Organizational emergency plans

  • If your hospital called you right now to disaster staff for the next 72 hours, would you feel personally prepared to respond?

    • Just go in and tell them what you can offer and the skills you know, there is always something to do. Ex: bringing food to the surgeon, educating others, help pharmacy or respiratory team etc.

Evacuation involves moving people out of a facility or a dangerous area to a safer location

• Evacuation occurs when there is potential for massive explosions and fire as well as for long duration‐ events. 

• Invacuation occurs when people in a hospital or residential facility are moved to another floor or area within the facility because of danger in a specific part of the facility and where leaving the facility is unnecessary or unsafe.

• Prioritize vulnerable patients that needs extra assistance

• Maintain communication and documentation

Radiologic Disasters

• The health outcome depends on the following:

  • The amount or dose of radiation absorbed

  • The type of radiation affect body in different ways

  • The route of exposure: inhaled, ingested, absorbed through skin, etc

  • The length of time exposed to the dose 

• Nursing considerations

  • Assess for possible exposure and contamination

  • Use PPE and follow decontamination procedures

  • Monitor patients for radiation associated illnesses

  • Provide accurate information and reassurance to patients and families

Blast injuries (not tested on exam)

• Explosions in confined spaces are associated with higher morbidity and mortality. 

• Communication with victims may be difficult due to sudden temporary deafness. 

• Many injuries are not life threatening due to blunt force‐ trauma from flying debris. 

  • Bursting eardrums and possible infection etc

• Open wounds have an increased chance to become infected. 

• Triage and lifesaving efforts should not be delayed because of the possibility of a dirty bomb detonation. 

• Detailed assessments and on site evaluations are‐ counterproductive to decreasing mortality.

Public Health Disaster Response summary

• Scope and magnitude of response determined by size, severity, and impact of disaster

• Communication during a disaster is clear, timely, and essential for effective response

  • Reduce confusion, helps with better coordination and promotes safety

• Recovery and after-action evaluation focus on restoring normal operations and reviewing what worked well and what needs improvement

Remember

• Nurses play an important role in all phases of disaster response. 

• All practicing nurses should become familiar with disaster phases and their role during an event. 

• Public health nurses practice principles of disaster response daily.

• Disasters are increasing in frequency, complexity, and impact 

• Preparedness includes mitigation, planning, training, recovery, and resilience

• Disaster nursing requires clinical expertise, communication, leadership, ethical decision making, and adaptability

Health + Health promotion

• Health—a quality, an ability to adapt to change, or a resource to help cope with challenges and processes of daily living 

  • More absence of disease 

  • Includes physical, mental, and spiritual aspects 

    • Ex: Community and population that impacts them, but doesn't dictate them

• Well-being—a subjective perception of full functional ability as a human being

  • Based on a person’s perception and opinion 

  • They adapt to their health challenges

Health Promotion, Disease Prevention, and Risk Reduction as Core Activities of Public Health

• Providing essential input to interdisciplinary programs 

• Evaluating health trends and risk factors (surveillance and monitoring) 

  • Making assessment and knowing the source of the outbreak

  • Prioritization 

• Working with communities or specific population groups within the community

  • Good collaboration skills 

• Participating in assessing and evaluating healthcare services

Healthy People Initiatives

• To increase quality and years of healthy life

• To eliminate any barriers to accessing care, specifically through health disparities

• Healthy People 2030: Fewer higher priority goals 

  • Access to nutritious foods and resources like transportation and maternal health  

  • Affordable medications 

  • Mental health care access 

  • Vaccination education 

Functions of public health surveillance 

Look at trends, outbreaks, and emerging risks 

• Local gov look for treads at endemic level 

  • Public health nurses look at modifiable factors 

• Estimating the impact of a disease or injury

• Portraying the natural history of a health condition

• Determining the distribution and spread of illness

• Generating hypotheses and stimulating research

• Evaluating prevention and control measures

• Facilitating planning for program activities

• Detecting outbreaks

Primary Prevention

• When an individual or a group is considered in good health and shows no signs or symptoms of disease or physical challenges, nurses in interdisciplinary teams and community partnerships are involved in primary prevention. 

  • Occurs before diseases occur

• Public health nurses seek to maximize health and wellness, using a variety of strategies.

  • Help clients have some level of control of their health/illness 

Examples of primary prevention

• Immunizations

• Driver’s safety classes

• Healthy water quality

• Healthy air quality

• Health education classes

• Improving safety designs of equipment

• Fire safety

• Decreasing exposure to sun

• Use of environmentally safe products

• Using seat belts

• Using earplugs and safety glasses 

Secondary prevention

• A planned effort to minimize the impact of a disease or injury once it is in effect. 

• Secondary prevention is used at an early stage of pathogenesis or physical or emotional challenges. 

• Secondary prevention involves the science of screening to make an initial recognition of the stage of an illness or physical challenge, which can progress either to greater or lesser severity over time. 

  • Early detection 

Examples of secondary screening

Mass screening: applied to entire populations

• Blood lead level screening

• Papanicolaou (Pap) smears

• Phenylketonuria of newborns

Examples of secondary screening

• Selective screening: performed for specific high-risk populations

  • Mammography for young women at high risk for cancer

  • Tuberculin tests for hospital employees

  • Occupational diseases

  • Exposure to radiation

Effective screening measures

• To screen effectively for the presence of conditions, a test should be: accurate 

1. cost-effective; 

2. easy to use;

3. available to large sectors of the population at risk;

4. sensitive and specific enough to identify true positives and true negatives;

5. backed by a healthcare infrastructure that can implement programs of care for people who have a verified risk of disease or physical challenge;

6. acceptable to clients.

Tertiary prevention

• Long-term management and treatment of clients with chronic conditions. 

• Tertiary prevention includes both rehabilitation and palliative care.

• AIDS-related cancers such as lymphoma are not uncommon.

• Cardiovascular disease, diabetes, and pulmonary disease may be present as well and require clinicians such as nurses to plan clients’ cancer treatment, continue to assess HIV/AIDS disease progression, watch for opportunistic infections, and control pain or other side effects of the treatment. 

• Care also includes supporting life choices that bring emotional comfort to clients.

  • Quality of life and symptom management 

  • Decrease isolation and support spiritual involvement 

Example

• For example, rather than envisioning end-stage cardiac rehabilitation as the focus of prevention after a cardiovascular event, or when cardiovascular disease is prominent in a community, nurses involved in cardiac care could think about approaches to prevention that are inclusive of all stages of health promotion and prevention. 

How interdisciplinary teams might work

• Primary prevention programs: Clients and families who are at risk for heart disease because of family history are treated. 

• This level of prevention focuses on evaluation of personal risks in light of family history to help clients reach their heart health goals.

  • Public health nurses is apart of this 

• Rehabilitation: Cardiac rehabilitation programs assist clients and families in recovery from heart attacks, angioplasty, and cardiac surgery and provide them with important information to make lifestyle changes to prevent recurrence.

Make the connection as PH nurse and client

• To promote health and well-being, one of the key approaches of primary, secondary, and tertiary prevention is using behavior change models, which assist clients, groups, and communities to change behaviors that have a negative impact on the natural history of disease and to promote behaviors that have a positive impact on the natural history of disease. 

Advice for you as a PH Nurse

• Approaching individuals and groups about behavior change must incorporate knowledge of diverse client perspectives and include the use of counseling skills and motivational interviewing.

  • Respect client autonomy/perspective 

  • If you push too hard, they might resist so start with their strengths and needs 

Behavior Models

• Motivational interviewing—client-centered communication style for eliciting behavior change by helping clients and groups explore and resolve ambivalence to change

  • Collaborative and client centered to help the client identify their own behavior to change 

• Behavior change models—models that assist clients, groups, and communities to redirect activities toward health and wellness 

  • Reflective listening: restating or paraphrasing on what the patient is saying to show that you understand 

  • Stay open and affirm on what they are saying 

Learning Model

• A behavior change model emphasizing reinforcement of social competence, problem-solving, autonomy, and sense of purpose

• Reinforce through rewards and support to continue behavior changes

Health Belief Model

• A behavior change model that considers the severity of the potential illness or physical challenge, the level of conceivable susceptibility, the benefits of taking preventive action, and the challenges that may be faced in taking action toward the goal of health promotion

  • Ex: App to remind people to do certain things like getting up off the bed or calendar alerts

Transtheoretical Model

change is a process, not a single event.  

• Precontemplation - no screening/no intention to change 

• Contemplation- there is no screening, but they are thinking of starting 

• Preparation- taking action to do the program, getting feedback

• Action - they into it and getting ready to do it 

• Maintenance

• Relapse

Theory of Reasoned Action

• A behavior model that emphasizes that individual performance of a given behavior is primarily determined by a person's intention to perform that behavior

  • Intentions strongly influence behavior 

  • Social expectations are also a factor and could affect outcome

Other theories not needed to know

Social Learning (or social cognitive theory)

• A behavior change model that considers environmental influences, personal factors, and behavior as key components of change

• Discuss self-efficacy like knowledge and confidence to perform and incentive to do so 

  • 4 stages: attention, retention, reproduction, and motivation

Theories of Social Support (not testing on this one) 

• Family members, friends, neighbors, and adjacent communities influencing change by offering instrumental assistance, informational support, emotional support, and/or appraising support

The Relapse Prevention Model (not testing on this one) 

• Part of behavior changes and it happens (learning opportunity) 

  • Negative emotional states

  • Lack of or limited coping skills

  • Decreased motivation

  • Stress

  • High-risk experiences

Ecologic Model

• Belief that all processes occurring within individual people and their environment should be viewed as interdependent (happens at multiple levels) 

  • Can a person change their behavior if the environment doesn't support them 

Use of the Ecologic Model: Evidence for Health Promotion Intervention #1

• Emphasize the unique developmental nature of variables that influence behaviors

• Use a multilayered understanding of influence on behaviors

• Test variables from each of the identified systems in the model to guide the assessment, development, implementation, and evaluation of targeted interventions

  • Look at multiple things when changing behavior rather than one factor 

Use of the Ecologic Model: Evidence for Health Promotion Intervention #2

• Ontogenic system—personal factors

• Microsystem—relationship between people and the environment

• Exosystem—formal and informal social structures

• Macroculture—values and beliefs of culture

Health Literacy

Could also incorporate teach back from the patients

• Information literate

• Visually literate

• Communication literate

• Computationally literate

• Analytically literate

• Computer literate 💤

Health Literacy and Health Education

• Establishing supportive learning environment

• Effective questioning

• Evidence-based health literacy universal precautions

• Healthy People 2030 and health literacy

Populations at Risk for Low Health Literacy + Promotion

• Adults over 65 

• Individuals with limited education or low income

• Non-native speakers of English

• Racial and ethnic minorities

• Recent refugees and immigrants

• Adults with any type of disability, difficulty, or illness

Health Literacy and Health Promotion

• Build healthy public policies

• Create supportive environments

  • Teach back method  

• Strengthen community action

• Develop personal skills

• Reorient health services

Role of Nurses with health literacy

• Knowledge of the three levels of health literacy allows the community health nurse to intervene at the individual, provider, and community level:

  • Functional: making sure patients have basic level reading and writing and apply it 

  • Interactive: promotes shared decision making and shared responsibilities 

  • Critical: when patient read 7 articles and have lots of questions 

Epidemiology: The Science of Prevention chapter highlights

Chapter Highlights #1 

• Defining epidemiology

• Development of epidemiology as a science

• Epidemiologic conceptual frameworks

• Applying epidemiologic principles in practice

• Assessment of health needs and assets (finding patterns) 

Chapter Highlights #2 

• Using assessment data for planning and implementing data interventions

• Promoting healthy lifestyles

• Preventing and controlling outbreaks

• Contributing to a safe and healthy environment

• Evaluating the effectiveness of health services

Defining Epidemiology 

• Study of the distribution and determinants of states of health and illness in human populations

• Used both as a research methodology for studying states of health and illness and as a body of knowledge that results from the study of a specific state of health or illness

  • Epidemic—an outbreak that occurs when there is an increased incidence of a disease beyond that which is normally found in the population 

    • when COVID started before turning into pandemic

    • Cholora? Where epidemiology was born  

  • Rates—the primary measurement used to describe either the occurrence or the existence of a specific state of health or illness

Review the terms

• Natural history 

  • The progression of the disease

• Risk 

  • refers to a probability that an event will occur 

• Risk factors 

  • Things that increase the likelihood of developing the disease