Unit 1 Module 1 OBJECTIVES: MODULE 1: Introduction to Community Nursing 1.

Define community health nursing (CHN) and public health nursing (PHN) Community health nursing o Synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations o Directs care to individuals, families, or groups o Broader and more general specialty o A community can be geopolitical (has boundaries/physical place) or phenomenological (no boundaries, abstract; relational, interactive group; example churches, universities, online group) Public health nursing o The practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health services o Population focused, with the goals of promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy o Nursing practice generally delivered within official or governmental agencies o Focus is on the community as a whole and the effect of community health status (resources) on the health of individuals, families and groups o Consideration of the health of individuals, families, and groups and their effect on the health of the community as a whole 2. Differentiate upstream thinking from downstream intervention in CHN/PHN practice Upstream Thinking (Macroscopic Approach) Society is the locus of change (prevention/early intervention) Focuses on modifying economic, political and environmental factors that are the precursors of poor health throughout the world Nursing interventions may include modifying social or environmental variables May involve social or political action Downstream Thinking (Microscopic Approach) The individual is the locus of change (cure) Emphasizes behavioral responses to illness or lifestyle patterns Nursing interventions aimed at the individual to change lifestyles or to change perceptions/belief system 3. Compare and contrast CHN with clinical nursing, community-based nursing, and public health nursing according to goals, clients, processes used, and settings for practice Goals Clients Processes Used Settings for Practice CHN Emphasizes Community the nursing process Where individuals, families and groups preservation and live, work or go to school protection of health Clinical Improve the health Patients of Nursing process, Inpatient nursing of patients the health treatment and patient care system care procedures Community Emphasizes Individual Nursing process, Where individuals and families need -based managing acute or and the diagnosis and nursing care outside the hospital or nursing chronic conditions; family treatment nursing home. help them manage Acute and chronic care (home health illness among health nursing, nursing in outpatient or care settings ambulatory settings, school clinics) Public Protect and promote Population/c Nursing, social and Home health nursing, palliative & health the health of the ommunity public health services hospice nursing, public health nursing nursing entire population (official agencies), school nursing, occupational health nursing, correctional nursing 4. Explain determinants of health and indicators of health for individuals and communities Determinants of health Health and illness are influenced by a web of factors, some that can be changed (diet, exercise) and some that cannot (genetics, age, gender)

CH nurses must work with policy makers and community leaders to identify patterns of disease and death and to advocate for activities and policies that promote health at the individual, family, and community levels Policies & Interventions physical environment, behavior, biology, social environment access to quality of health care [these determinants are in a revolving circle] o Policies and interventions can improve health by targeting detrimental or harmful factors related to individuals and their environment (example policies against smoking in public places, seat belt and child restraints) o Physical environment is that which is experienced with the senses (examples natural environment, worksites, schools, recreational settings, housing, homes, neighborhoods, exposure to toxic substances, physical barriers, aesthetic elements) o Behaviors are the individuals responses to internal stimuli and external conditions. Behaviors interact with biology in a common relationship as one may influence the other. (example one chooses behaviors such substance abuse or smoking, his or her biology may be changed as a result. If an individual has a family history or colon cancer they may choose to have regular screenings to prevent advanced cancer development) o Biology is an individuals genetic makeup, family history, and any physical and mental health problems developed in the course of life. Aging, diet, physical activity, smoking, stress, alcohol or drug abuse, injury, violence, or a toxic or infectious agent may produce illness or disability that changes an individuals biology. o Social environment includes interactions and relationships with family, friends, co-workers, and others in the community. (examples availability of resources, social norms and attitudes, exposure to crime and violence, social interactions, exposure to emerging technology, transportation options) o Access to quality of health care: expansion of health care access is essential to decrease health disparities and to increase the quality of life and the quantity of years of healthy life Leading Health Indicators: physical activity overweight and obesity tobacco use substance abuse responsible sexual behavior mental health injury and violence environmental quality immunization access to health care Changes in mortality reflect a number of social, economic, health service and related trends. 5. Describe the historical development of community/public health nursing Pre 1850: home visiting to sick as an act of charity 1850 1900: home visiting to sick 1900 1960: nursing in community centers for the poor 1900 1960: communicable disease control and immunizations; rise in PHN, home visits, schools and OH nsg 1960 1980: care provided in public health clinics 1980 present: health promotion and education, health care access improvement

6. Identify theories applicable to CHN/PHN practice Health Belief Model Focuses on a persons perceptions of a threat or a health problem and related appraisal of a recommended behavior to elicit change Addresses attitudes and beliefs of individuals Focus was on increasing the use of preventive health services Primary assumption is that people fear disease and that health actions are motivated based on the extent of the fear and belief in benefits obtained by preventative action 5 primary constructs: o perceived susceptibility ones belief regarding the chance of getting a given condition o perceived severity ones belief regarding the seriousness of a given condition o perceived benefits ones belief in the ability of an advised action to reduce the health risk or seriousness of a given condition

perceived barriers to action ones belief regarding the tangible and psychological costs of an advised action o cues to action: strategies or conditions in ones environment that activate readiness to take action Example used for this model: perceived risk of infection in drug users Health Promotion Model explores biophysical factors that influence individuals to pursue health promotion activities o prior related behavior o personal factors o behavior specific cognitions and affect o perceived benefits of action o perceived barriers to action o perceived self-efficacy o activity-related affect o interpersonal influences o situational influences o commitment to a plan of action o immediate competing demands and preferences o health-promoting behavior Transtheoretical Model based on the assumption that behavior changes takes place over time, progressing through a sequence of stages Precontemplation the individual has no intention to take action toward behavior change in the next 6 months. In the phase due to lack of information about the consequences of the behavior, or due to failure on previous attempts to change Contemplation the individual has some intention to take action toward behavior change in the next 6 months. Weighing pros and cons to change Preparation the individual intends to take action within the next month and has taken steps toward behavior change. Has an action plan Action the individual has changed overt behavior for less than 6 months. Has changed behavior sufficiently to reduce risk of disease Maintenance the individual has changed overt behavior for more than 6 months. Strives to prevent relapse. This phase may last months to years Example used for this model: Bereavement Critical Social Theory Societal awareness to expose social inequalities that keep people from reaching their full potential by promoting equality and reduce disparities Aims to provide an environment in which individuals can become empowered (encourages people to undertake activities to improve their situation), enlightened (raising the consciousness of the oppressed) and emancipated (new arrangements replace oppressive ones) Example used for this model: Respite services for caregivers o 7. Discuss the preventative approach to health care and give examples of health promotion and the levels of prevention Health Promotion Activities that enhance resources directed at improving well-being Disease Prevention Activities that protect people from disease and the effects of disease Levels of Prevention Primary Prevention: relates to activities directed at preventing a problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Consists of 2 elements general health promotion and specific protection o Example: promotion of good nutrition, provision of adequate shelter, encouraging regular exercise, immunization Secondary Prevention: refers to early detection and prompt intervention during the period of early disease pathogenesis. Implemented after a problem has begun but before signs and symptoms appear and targets those populations who have risk factors o Examples: mammography, blood pressure screening, scoliosis screening, Pap smears Tertiary Prevention: targets populations that have experienced disease or injury and focuses on limitation of disability and rehabilitation. Aims of this level are to keep health problems from getting worse, to reduce the effects of disease and injury and to restore individuals to their optimal level of functioning

Examples: teaching how to perform insulin injections and disease mgmt. to a patient with diabetes, referral of a patient with spinal cord injury for occupational and physical therapy; leading a support group for grieving parents. 8. Describe the purpose of Healthy People 2020 and give examples of focus areas that encompass the national health objectives Purpose challenges individuals, communities, and professionals to take specific steps to ensure that good health, as well as long life, are enjoyed by all. Goals to attain high quality, longer lives free of preventable disease, disability, injury and premature death; achieve high equity, eliminate disparities and improve the health of all groups; create social and physical environments that promote good health for all; and promote quality of life, healthy development, and healthy behaviors across all life stages. Access to health services Adolescent health Diabetes Disability & secondary conditions Educational & Community-based programs Early & middle childhood Environmental health Family planning Food safety Genomics Heart disease and stroke HIV Mental health and mental disorders Occupational safety and health Older adults QOL and wellbeing Respiratory disease STDs

Arthritis, osteoporosis, chronic back conditions Blood disorders & blood safety Cancer

Hearing & other sensory or communication disorders Global health Healthcareassociated infections Health communication and health IT

Immunization and infectious diseases Injury & violence prevention Maternal, infant and child health Medical product safety

Oral health Physical activity and fitness Public health infrastructure

Chronic kidney disease

Substance abuse Social determinants of health Tobacco use

9. Identify potential public health nursing interventions for a variety of health issues emphasizing health promotion Surveillance: describes and monitors health events through ongoing and systematic collection, analysis and interpretation of health data for the purpose of planning, implementing and evaluating public health interventions Disease and other health event investigation: systematically gathers and analyzes data regarding threats to the health of populations, ascertains the source of the threat, identifies cases and others at risk, and determines control measures Outreach: locates populations of interest or populations at risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained Screening: identifies individuals with unrecognized health risk factors or asymptomatic disease conditions Case finding: locates individuals, families, groups, organizations, and/or communities to identify and access necessary resources to prevent or resolve problems or concerns Referral and follow-up: assists individuals, families, groups, organizations and/or communities to identify and access necessary resources to prevent or resolve problems or concerns Case Management: optimizes self-care capabilities of individuals and families and the capacity of systems and communities to coordinate and provide services Delegated functions: direct care tasks that are registered professional nurse carries out under the authority of a health care practitioner as allowed by the law Health teaching: communicates facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices of individuals, families, systems and/or communities Counseling: establishes an interpersonal relationship with a community, a system, and a family or individual, with the intention of increasing or enhancing their capacity for self-care and coping Consultation: seeks information and generates optional solutions to perceived problems or issues through interactive problem solving with a community system and family or individual Collaboration: commits 2 or more persons or an organization to achieve a common goal through enhancing the capacity of one or more of the members to promote and protect health Coalition building: promotes and develops alliances among organizations or constituencies for a common purpose

Community organizing: helps community groups to identify common problems or goals, mobilize resources, and develop and implement strategies for realizing the goals they collectively have set Advocacy: please someones cause or acts on someones behalf, with a focus on developing the community, system, and individual or familys capacity to plead their own cause or act on their own behalf Social marketing: utilizes commercial marketing principles and technologies for programs designed to influence the knowledge, attitudes, values, beliefs, behaviors, and practices of the population of interest Policy development and enforcement: places health issues on decision makers agendas, acquires a plan of resolution, and determines needed resources, resulting in laws, rules, regulations, ordinances, and policies. Policy enforcement compels others to comply with laws, rules, regulations, ordinances and policies.

10. Analyze opportunities to apply community health nursing standards in all areas of nursing practice. Module 2 OBJECTIVES: At the conclusion of this module, the student should be able to:

1.

Describe the focus of public health and differentiate it from personal health care. a. The major focus of the public health system is prevention of disease and illness. It is required by law to address the health of populations. Public health refers to the efforts organized by society to protect, promote, and restore the peoples health. It is concerned with the health of the population, a healthy environment, and promoting good health. Public health activities are covered at the local, state and federal level. It provides services for the general population, special populations (veterans, native americans, prisoners, armed forces etc.) and international health b. Personal health care efforts are curative, meaning they focus on, diagnosing, treating, and curing illness and disease, rather than preventing it. Its functions sometimes overlap with public health functions. Services include health promotion, prevention and early detection of disease, diagnosis and treatment of disease, rehabilitative care, and custodial care. These services are provided in physicians offices, hospitals, hospital ambulatory centers, skilled care facilities, and homes.

2.

Describe the sources of Public Health law in the U.S. and the legal basis for governmental involvement in health care. a. Public Health law focuses on legal issues in public health practice and on the public health effects of legal practice. Public health law typically has 3 major areas of practice: police power, disease and injury prevention, and the law of populations. Public health law consists of legislation, regulations, and court decisions enacted by government, at the federal, state, and local levels to protect the publics health. Describe the organization of the public health care system on the local, state, national and international levels a. At the federal level, the federal government protects the population through regulation and funding. Congress enacts laws and writes rules and regulations. Federal policies and practices have an increasing influence on local and state governments. Most health related activities at the federal level are implemented and administered by the Department of Health and Human Services. The federal government targets health areas for the general population, special populations, and international health. General population- protection against hazards, maintains vital and health statistics, scientific research, disaster relief, WIC, food stamps Special populations- protects workers against hazardous occupations and work conditions, provides health care for veterans, native americans, Alaska natives, federal prisoners, and members of armed services. International arena- works with international organizations (WHO and Red Cross) to promote vatrious health programs throughout the world. b. At the state level, states are responsible for the health of their citizens, and are the central authorities in the public health system. They establish health codes, regulate the insurance industry, and license health care facilities and personnel. Each state is responsible for its own public health laws, therefore public health services, policy, and activities vary widely from state to state. Each state has a health officer, usually an MD. This officer sometimes directs the health department. However, the state health department does not stand alone and depends heavily on the federal level for funds, other resources, and guidance. The state is responsible for the collection of data pertaining to vital statistics, health facilities,

3.

and human resources, epidemiological activities, such as communicate disease control, health screening, lab analysis, and participation in research projects. They also formulate goals, develop health plans, and set standards for local health agencies. They are also involved in inspections, licensing, health education, environmental safety, personal health services, and resource development. c. At the local level, local health departments are generally responsible for the direct delivery of public health services and protection of the health of citizens though not all communities/counties have local health departments. LHDs establish local health codes, fund public hospitals, and provide services to populations and individuals at risk who often lack health insurance. The 2010 Healthcare reform act addresses improvement of quality and access to care. It promotes establishment of local consortiums of health care providers to coordinate services for low-income uninsured and underinsured populations. It also substantially increases funds for community health centers and finances newly developed school based health centers and nurse-managed health clinics. Local Health departments services fall into four major categories including: community health services, environmental health services, personal health services, and mental health services.

4.

a. b. c. d.

e. f. g. h. i. j.

Identify major agencies and types of programs provided at each level. The US Department of Health and Human Services is composed of several agencies that provide different servces related to US health care. They include Administration on Aging- coordinates home & community services for older persons and their caregivers. Centers for Medicare and Medicaid Services- administers those services? Administration for Children and Families- provides Welfare, child support, head start, etc. to strengthen family unit. Centers for Disease Control and Prevention- provides programs to prevent and control infectious diseases, assists during epidemics; and promotes health, education, and professional development/training. Food and Drug Administration- surveils the safety and efficacy of foods, pharmaceuticals, and consumer goods. Health Resources and Services Administration- develops health facilities and health services programs. It has a division of nursing whos major focus is funding grants for nursing education/training. National Institutes of Health- performs and supports research programs, to develop and extend scientific knowledge. Substance Abuse and Mental Health Services Administration- funds research related to problems with substance abuse and mental health. Agency for Healthcare Quality and Research- works to improve quality, safety, efficiency, and effectiveness of healthcare for all Americans. Agency for Toxic Substances and Disease Registry.- prevents harmful exposures and diseases related to toxic substances by providing trusted health info, taking responsive public health actions, and using best science to do so.

5.

Describe the three core functions and ten essential services of public health; recognize examples of each a. The three core functions of public health are assessment, policy development, and assurance. Assessment is the regular collection, analysis, and information sharing about health conditions, risks, and resources in a community. Policy development uses the info gathered during assessment to develop local and state health policies and directs resources toward them. Assurance focuses on the availability of necessary health services through out the community. It includes maintain the ability of both public health agencies and private providers to manage day-to-day operations and the capacity to respond to critical situations and emergencies. b. 10 essiential services of public health include i. Monitor health status to identify community health problems. ii. Diagnose and investigate health problems and health hazards in the community. iii. Inform, educate, and empower people about health issues, iv. Mobilize community partnerships to identify and solve health problems. v. Develop policies and plans that support individual and community health efforts. vi. Enforce laws an regulations that protect health and ensure safety. vii. Link people to need personal health services and assure the provision of health care when otherwise unavailable. Assure a competent public health and personal health care workforce. viii. Assure a competent public health and personal healthcare work force. ix. Evaluate effectiveness accessibility and quality of personal and population-based health services. x. Research for new insight and innovative solutions to health problems.

6.

Examine CHN practice in terms of public healths core functions and essential services a. Community health nursing is the synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations. It directs care to individuals, families, or groups; this care in turn, contributes to the health of the total population. The 3 core functions of public health are assessment, policy development and assurance. Community health nurses should be competent in the following domains. Analytic assessment skills, program planning skills, communications kills, cultural competency skills, community dimensions of practice skills, basic public health sciences skills, financial planning and management skills, and leadership and systems thinking skills. (See table 1-3 on page 11 for full description). With these skills, CHNs will be able to monitor/identify community health problems/ hazards, inform, educate, and empower people on health issues, develop policies and plans that support individual and community health efforts, etc. (see 10 essential functions in previous question). Define health policy and explain the social and political processes that influence health policy development a. Health policy is a statement of a decision regarding a goal in health care and a plan for achieving that goal. It is directed by values. The policies come from decisions made by legislative, executive, or judicial branches of one of the three levels of government (local, state, or federal). Policy should be determined by group need and group demand and the DHHS should rationally determine actions to create, amend, implement, or rescind health care policy. However, in the real world, health policy is the product of continuous interactive processes in which interested professionals, citizens, institutions, industries, an other interested groups compete with one another for health dollars and policy initiatives.

7.

Examine nurses roles in political activities and policy-making a. Registered nurses are the larges healthcare professional group. There are about 3 million registered nurses in the United States. It is estimated that about 1 in 44/45 voters are nurses, so if every registered nurse voted, the effect would be tremendous. Nurses are also, seen as professionals whose knowledge, skills, and caring concern are used to promote both the individuals and the communities well-being. They are affected by government funds and the private business sector. So, nurses must know how to participate in the political process. Nurses must know how to influence the creation of health care legislation and how to contribute to the election and appointment of key officials. Nurse lobbyists are also very important. A lobbyist basically represents him or herself, another individual, an organization, or an entity before legislation. To lobby is to try to influence legislators; it is an art of persuasion. Legislators rely heavily on lobbyists to educate them on issues and they usually want to hear from all sides before taking a position on an issue. Nurses can also form PACs, political action committees. These groups promote the election of candidate who support their ideals. Small donations from its members add up to make a significant donation to a campaign. Also, many nurses serve in legislature. There are currently 3 nurses in th the 111 Congress. Nurses can also form coalitions to maximize resources, increasing influence and chances of success. There are also REQUIRED READING: 8. Nies and McEwen - Chapter 10: The Health Care System Nies and McEwen - Chapter 12: Policy, Politics, Legislation, and Community Health Nursing

Module 3 OBJECTIVES: At the conclusion of this module, the student should be able to: Module 4- Population Health 1. Identify major indicators of the health status (morbidity, mortality, natality, and life expectancy) of children, adolescents, men, women, and seniors.

2. Relate the demographic characteristics of the population with the risk for disease, injury, disability or death. -

3. Describe the relationship between population size and density with the communitys risk for disease, injury, and disability - The communitys risk for disease, injury and disability increases on both spectrums of population size and density. - Health problems related to high density include crime, noise, environmental degredation, pollution, shortage of resources, increased traffic and related accidents, and spread of infectious diseases. - Health problems related to low density include isolation, depression/suicide, lack of resources, lack or access, accidents, and increased in morbidity and mortality Rural communities are an example of this concept: access to health care is limited, people in rural areas tend to smoke more than those in urban areas, there are limited economic opportunities, low wages, agricultural accidents, younger people are leaving the area, people leave and services are lost, and there are higher rates of poverty in comparison to urban communities. All of those factors lead to poor health among individuals living in rural areas, including higher numbers of uninsured individuals across all ages, higher infant mortality rates, and are more likely to die of unintentional injuries (eg. Unlicensed teens driving cars, not wearing seatbelts, more likely to consume alcohol) 4. Describe the relationship between population age and gender with the risk for disease, injury, disability, or death. - Age is the risk factor most strongly correlated with disease and death with the most vulnerable being those under age 1 and those over age 65. - Women live longer than men but have more chronic illnesses and are more likely to seek healthcare. 5. Describe the relationship between race and ethnicity with the risk for disease, injury, disability or death. - Blacks have higher mortality rates than do whites for all ages and income levels and they live 5 fewer years - African American men have almost twice as many strokes as white men - Diabetes is 33% higher for African Americans -Homicide is the most frequent cause of death for African American men 15-34 - AIDs is 3x higher in African Americans - Hispanics have higher rates of diabetes, higher rates of LBW babies, higher rates of substance abuse, and higher rates of HIV in comparison to whites - Hispanics also make up a larger portion of uninsured individuals in the United States, followed by American Indians, African Americans and then Asians -Higher rates of breast cancer, higher rates of liver cancer (due to higher rates of hepatitis B), and higher incidence of TB are found among Asian populations - Minorities are also more likely to receive poorer quality of care 6. Describe the relationships among education levels, culture, economic status, and occupation with the risk for disease, injury, disability or death. - Low educational status is associated with low socioeconomic status = poverty = inadequate nutrition, less access to health care, higher rates of disease, death and disability, more accidents, and less use of preventative practice. -Ones occupation is associated with level of education and influences economic status so the less education one has, the more likely he or she is going to have a hazardous occupation (fishing, forestry, hunting, mining, transportation and warehousing, construction, wholesale traders) 7. Analyze contributors to health disparities in the United States and suggest potential interventions to help reduce health disparities. -Contributors to health disparities in the United States include genetics, economics (lower income levels among minority populations) , inadequate access to health services (uninsured individuals), non adherence with medical care,

race and ethnicity, low education. Potential interventions include making healthcare more accessible (affordable health insurance, more healthcare providers in rural areas, transportation for the homeless to get to clinics, ect), overcoming cultural and linguistic barriers, and effective communication between patient and health care provider. 8. Analyze the concept of vulnerability of selected populations. -Populations affected by disabilities: limitations in functional abilities, limitations in activities of daily living and instrumental activities of daily living, underutilization of age-appropriate preventive health care, undertreatment of comorbid health conditions, inadequate health care provider knowledge of appropriate and effective treatments, barriers to effective communication between client, family, and providers and increased risk for accidental injuries. Also, people with disabilities earn less, are less likely to be employed and are more likely to live in poverty, which makes it difficult to pay for costs associated with their disabilities. - Homeless Population: lack of health insurance, increased risk of incarceration, serious mental illness; homeless women have higher rates of pregnancy and unintended pregnancy, preterm births and low birth-weight infants, experience intimate partner violence, physical or sexual assault, are more likely to abuse drugs or alcohol, and usually have limited education, limited earning power, and fragmented support networks; homeless children experience higher rates of mental health problems, are more likely to do poorly in school and repeat grades. Access to health care for homeless populations is limited by availability, accessibility, accommodation, affordability, and acceptability. - Rural and Migrant Population: members of rural populations are more likely to be older, to be less educated, to live in poverty, to lack health insurance, and to experience a lack of available health care providers and access to health care, they are more likely to die of unintentional injuries and have more problems associated with negative health behaviors (smoking, obesity, alcohol, and tobacco use) . Migrant workers may have the poorest health of any aggregate in the United States and the least access to affordable healthcare due to cultural, linguistic, economic and mobility barriers. Migrant workers experience higher incidences of accidents and injuries, higher occurrences of acute and chronic respiratory conditions, exposure to pesticides, herbicides and other chemicals combined with cultural, linguistic, economic and mobility barriers 9. Identify key legislation and policies related to caring for vulnerable populations. - Populations Affected by Disabilities: Americans With Disabilities Act: guarantees equal opportunities for people with disabilities related to employment, transportation, public accommodations, public services, and telecommunications Social Security Disability Insurance (SSDI): a program that receives disability trust fund monies (Social Security taxes paid by workers, employers, and self-employed workers) and to qualify, the person with disabilities must be insured through FICA earnings of self, parents and/or spouse. Those who qualify receive Medicare health benefits. - Homeless Populations: US Department of Housing and Urban Development works with state and local governments and nonprofit housing organizations to provide financial housing assistance to low-income families by giving: o o o Direct payment to apartment owners, who in turn lower rents for low income tenants Access to an apartment located in a public housing facility Housing choice vouchers, which may be used by low-income persons to pay all or part of their rent (Section 8 housing) - Rural and Migrant Populations: Community Health Centers Migrant Health Clinic Program Migrant Health Program

Medicares Rural Hospital Flexibility grant program- allows small hospitals the flexibility to reconfigure operations and be licensed as Critical Access Hospitals and provides cost-based reimbursement for inpatient Medicare and outpatient service.

Module 4 OBJECTIVES MODULE 4: EPIDEMIOLOGY 1. Define Epidemiology and Demography and discuss application of both to the community nursing process Demography is the study of the structure and characteristics (size, age, gender, etc) of the population Epidemiology is the science that allows us to study disease, etc in a population; the study of the factors that determine the occurrence and distribution of health, disease, defects, disability and death among groups of people in a particular place over a specific period of time. 2 types: o Descriptive focus on amount and distribution of disease in population (person/place/time) where and what o Analytic focus on causes of disease by determining why disease rate lower in 1 population group than in another why/causes Goal of epidemiology is to identify causes, identify solutions in order to prevent and improve the health of the entire population 2. Define and describe major epidemiological concepts and their role in community nursing practice: a. Multiple causation b. Agent, host and environment interaction and web of causation models c. Natural history of disease and levels of prevention associated with each disease stage d. Risk, risk factors and populations at risk Risk is the probability of an adverse event (i.e., the likelihood that healthy people exposed to a specific factor will acquire a specific disease) Risk factor refers to the specific factor, such as cigarette smoke, excessive stress, high noise levels, or environmental chemicals e. Morbidity, mortality and natality Morbidity disease incidence rates/prevalence rates Mortality crude mortality rates, specific mortality, case fatality Natality birth rates, fertility rates f. Incidence and prevalence Incidence measure of new occurrences of an event during a designated time period (new cases) Prevalence measures the probability that healthy people will develop a disease in a specified period of time [all cases (new and old)] g. Distribution of disease according to person, place and time Person who factors, such as demographic characteristics, health and disease status Place where factors, such as geographical location, climate and environmental conditions and political and social environment Time when factors such as time of day, week, or month and secular trends over months and years 3. Describe, recognize and be able to calculate biostatistical measures used in epidemiology: a. Proportions (percentages) b. Ratios c. Crude rates (mortality and birth rates) d. Specific rates (age, cause, gender and race specific mortality rates, infant and maternal mortality) e. Incidence and prevalence morbidity rates f. Case fatality 4. Describe principles of screening tests and recognize examples of sensitivity and specificity of the tests Screening tests purpose is to identify risk factors and diseases in their earliest stages. Screening is a secondary prevention activity because indications of disease appear after a pathological change has occurred Concern with accuracy of testing for diagnosis; establishment of diagnosis is essential and tests are considered either positive (abnormal) or negative (normal)

Sensitivity tests are important to use when dire consequences could occur for missing a disease diagnosis. Used to rule out diseases during diagnostic work-up. Most helpful when test result is negative. Want to find all true positives Specific Tests are useful in confirming or ruling in a diagnosis. A highly specific test is rarely positive in absence of disease or few false positives. Often used before patients are subjected to extensive treatments. Most helpful when the test result is positive. 5. Apply epidemiological concepts and measures to the description of the distribution of health problem in a community 6. Discuss the levels of prevention and their application to intervention in the community REQUIRED READING: Nies and McEwen Chapter 5: Epidemiology