Trends In Public Health
Trends in Public Health
Many macro-level changes are influencing the future of PH. These changes will force the U.S. PH system to face unprecedented challenges in the future. Some of these changes include natural and human-generated disasters, the aging of the population, changing patterns in the U.S. racial/ethnic populations, and changes in the health system. In addition, the explosion of information technology, changing needs in the PH workforce, and the growth of health-related public-private partnerships all directly impact the future of PH practice.
These trends have had, and will continue to have, a direct impact on CH nurses. To adapt, CH nurses have developed innovative models of service delivery, such as community-based counseling centers for health education, counseling, community resource referral, and screening for low-income populations. In addition, they have learned how to practice in a variety of specialized settings, such as schools, industrial sites, churches, clinics, and homes. Their skills are not just direct clinical care. They also include skills in teamwork, leadership, community organizing, and community activism. They also have recognized the importance of community-based research with at-risk populations. The dissemination of their research findings serves to increase the quality of life for vulnerable groups and populations.
Ethical Foundations and Theories in Community Health Nursing
In the United States, CH nurses face serious ethical dilemmas every clinical day. Many marginalized people in the U.S. go without any health care at all while affluent individuals have a wide variety of healthcare options. CH nurses are often confronted by this disparity when making ethical decisions about client care. Ethics and values are inextricably intertwined with professional decision making. Ethics comprises the values, practices, standards, and code of principles that guide the distinction between right and wrong. For nurses, the ANA Code for Nurses with Interpretive Statements (2001) provides a framework for the articulation of nurses’ professional ethical principles.
Seven fundamental principles guide CH nursing in making ethical decisions: respect, autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity. Respect refers to treating people as unique, equal, and responsible moral agents. It emphasizes people’s importance as members of the community and the healthcare team. Autonomy refers to self-determination (i.e., clients have the freedom to make choices that enhance their personal well-being and do not infringe on the rights of others). Beneficence means doing good and benefiting others; nonmaleficence means avoiding or preventing harm to others as a consequence of a person’s own choice or actions. Justice refers to the fair distribution of benefits and costs among members of a society, whereas the principle of veracity refers to telling the truth. Finally, fidelity means keeping promises and involves issues of trust and trustworthiness between the nurse and the community. Table 2 provides examples of these principles.
Table 2: Examples of Ethical Principles
Treating people as unique, equal, and responsible moral agents
Helping families complete advanced directives or informed consent
Screening for communicable diseases; implementation of cost-effective health and wellness program
Seatbelt laws, smoke-free environments, legislation regarding leaded paint
Making community programs available, accessible, and fairly distributed to all
Notifying the community of a Hepatitis A outbreak or exposure to a communicable disease as soon as possible
Completion of all scheduled programs, meetings, and deadlines; being on time for appointments
Although ethical rules and principles provide the philosophical foundation for CH nursing, models and theoretical perspectives have usefulness for guiding educational approaches, clinical practice, and research. Systems models have particular usefulness in CH nursing because communities, which are made up of multiple subsystems and groups that interface with each other, can be analyzed, interpreted, and understood from a systems theory perspective. The Neuman Systems Model can be effectively used to guide CH nursing practice. It depicts an open system where people are in dynamic interaction with the environment. The model’s interactions encompass physiological, psychological, socio-cultural, developmental, and spiritual variables. In addition, the Neuman model includes primary, secondary, and tertiary intervention modes, which are central to CH nursing.
The Omaha System Model is unique in that it is the only model with comprehensive vocabulary developed initially by and for practicing community-oriented nurses. This system follows specific principles and consists of a problem classification scheme, an intervention scheme, and a problem rating scale for outcomes. It offers benefits in three areas: practice, documentation, and data management. These two models are complementary and can be used in conjunction without losing the integrity of either approach.
A variety of learning theories are also used in CH. Some of these include the behavior theory, also known as stimulus-response or conditioning theory; cognitive learning theory; humanistic theories, which believe learning flourishes in an encouraging environment; and adult learning theories that focus on the self-concept, experience, and readiness of the student.
In addition, health belief models are used to explain the behaviors and actions taken by people to prevent illness and injury. Finally, health promotion models focus on predicting behaviors that influence health promotion. The ability to predict health promotion behaviors enhances the CH nurse’s ability to work with clients.
Case in Point
A CH nurse is conducting a survey on the health needs of older adults. She is sampling a large high rise for older adults in Seattle’s inner city. At one apartment, an elderly man opens the door; as he does so, an odor of decaying flesh passes out of the apartment. The nurse is invited in to talk. The man is in a wheelchair, with a sheet over his legs. He says he is 77 years old and “doesn’t need anything from anyone.” He states he has no family and talks only to the neighbor down the hall who brings him food. He is oriented and cognitively competent.
The study-specific interview concludes, and they continue talking. He states that he only has one concern and that is a ‘little” problem with his left leg. The nurse offers to look at it. As he removes the sheet, she finds that the left leg is black from the toes up to the knee with what looks like gangrene. Purulent drainage is leaking from the leg, and the odor almost makes the nurse gag. The right foot looks the same, but the darkened skin ends at the ankle. He refuses to go anywhere (ER, clinic, doctor’s office) to have his legs evaluated.
In this situation, the nurse applied the values of respect and autonomy to the patient’s condition and did not try to force him to do something he did not want to do. She came back to visit 2 more times and, within a period of 2 weeks, he had agreed to be evaluated.
The conflict of values seen in this case, that is, the nurse’s desire to have him receive care and the client’s desire to be left alone, raises several ethical questions: When (or do) health practitioners have the right or duty to override a competent individual’s preferences? When do the neighbors’ rights (e.g., the odor seeping into their apartments) supersede one renter’s rights? Should the nurse become responsible when there is no family to take action?
What do you think?