MODULE 1
TUBERCULOSIS CASE MANAGEMENT FOR NURSES
OVERVIEW OF PUBLIC HEALTH AND PUBLIC HEALTH NURSING
INTRODUCTION - The purpose of this module is to provide an overview of public health, focusing on:
– Its role in the management of tuberculosis (TB) cases and
– Factors that differentiate public health nursing from other nursing specialtiesThe public health nursing section ends with a discussion of nursing within the framework of the Core Functions of Public Health and Scope and Standards of Public Health Nursing, as presented in the American Nurses Association (ANA) publication prepared by the Quad Council of Public Health Nursing Organizations.
LEARNING OBJECTIVES - After completion of this learning module, you will be able to:
OVERVIEW OF PUBLIC HEALTH - According to the World Health Organization (WHO), health is “a state of complete physical, mental, and social well-being and not merely the absence of disease (1958). This encompassing definition is implicit in the discipline of public health, which is the science and art of preventing disease, prolonging life, and promoting health. Looking at the definition from a holistic perspective, the Institute of Medicine defined public health as “what we, as a society do, collectively, to assure the conditions in which people can be healthy” (1988).
The mandate for public health activities comes from public health laws that consist of legislation, regulations, and court decisions enacted by federal, state, and local governments to protect the community’s well being. Public health laws identify the policies and procedures that guide the process of preventing disease and protecting and promoting health. On the basis of public health laws, efforts to control TB have been undertaken. The practice of public health requires that the rights of individuals be balanced with the need to protect society.
The objectives of public health are to generate organized efforts that address the public’s
health, by applying scientific and technical knowledge to prevent disease and promote health
(Institute of Medicine, 1988). Public health objectives may be accomplished by individuals or by public and private groups. However, government has a special role in public health, ensuring the placement of essential components to adequately address the objectives of public health. Public health activities may include sanitation, control of communicable infections, such as tuberculosis, and the education of populations on how to protect their health. Government achieves public health objectives through the implementation of the core functions of public health.
THE CORE FUNCTIONS OF PUBLIC HEALTH - The following are examples of how the core functions of public health are applied to tuberculosis.
Assessment refers to systematic data collection, monitoring and providing information on
the health of a community. As it relates to TB control, data are collected regarding the
number of TB cases in a community and analyzed to measure the success of efforts to
treat and control the occurrence of new cases.
Policy development refers to the provision of leadership in the advancement of rules and
regulations that support the health of populations and utilizes scientific knowledge in decision- making regarding policy. TB control policies are related to the identification and
reporting of people who have TB infection and disease, their treatment, and follow-up.
Assurance refers to the role of public health in making sure that essential health services
are available community-wide, including a competent healthcare workforce in both the
public and private sectors. In the treatment of tuberculosis, assurance addresses the issue
of availability of appropriate TB services provided by personnel who are knowledgeable
about TB, as well as ensuring that private healthcare providers are informed about the
proper management of TB.
SELECTED CONCEPTS IN NURSING PRACTICE - The 1996 revision of the ANA’s Social Policy Statement suggests that definitions of nursing should “illustrate the consistent orientation of nurses to the provision of care that promotes wellbeing in the people served.” In addition, the document acknowledges the influence that the science of caring has had on nurses’ diagnoses and treatment of human responses to health and
illness (ANA, 1996). Therefore, the Social Policy Statement states that definitions of nursing must acknowledge the four essential features of contemporary nursing practice that follow.
The definition of nursing has evolved as the knowledge base and practice of the discipline has
advanced. The ability of nursing to progress, as knowledge and human health experiences change, makes it a dynamic and multifaceted profession. In summary, nursing may be defined as a profession that addresses human responses to the full range of health experiences by:
The nursing process is the problem-solving method used in nursing practice. Its holistic perspective serves as a tool for evaluating and improving care. In addition, it helps avoid duplications and omissions while contributing to comprehensive and consistent care.
Elements of the nursing process
Assessment is the systematic collection and analysis of data culminating in a nursing diagnosis. Assessment is the initial phase of the nursing process and is identified by the American Nurses Association as the first standard for professional nursing practice (1996). It is a continuous aspect of the nursing process and involves collaboration with patients, caregivers, and healthcare providers who contribute to the patients’ care. After information about a patient’s health situation is obtained, analyzed, and documented, the nurse makes a nursing diagnosis. The nursing diagnosis is a statement of clinical judgment that conveys the nursing assessment. It provides the basis for the selection of nursing strategies to achieve patient care outcomes for which the nurse is accountable.
During the diagnostic phase, data are analyzed and interpreted. Conclusions are drawn regarding patients’ needs, problems, concerns, or human responses. Nursing diagnostic statements are identified and documented and provide direction for the remainder of the nursing process. They serve as the basis for planning, implementing, and evaluating care.The most widely accepted structure for the nursing diagnostic statement is that advocated by the North Atlantic Nursing Diagnosis Association (NANDA). Regardless of the selected structure, the diagnostic statement should include the following components:
The first part of the statement communicates the functional behaviors that can be improved
through nursing actions. These behaviors may promote, protect, maintain, or restore health.
Modifiers for the first part of the diagnostic statement may be “alteration in” or “potential alteration of”. The second part of the diagnostic statement identifies the causes or factors that nurse works to improve or influence. This part of the statement describes factors that contribute to the current healthcare situation. The following are examples of nursing diagnostic statements that may be typical of those used in nurse case management of TB:
The first example acknowledges that TB medications, if not carefully monitored, may have deleterious effects. The second nursing diagnosis identifies a change in a patient’s usual health pattern when the TB treatment regimen is not followed. Both diagnoses imply the nursing action to be taken, the desired patient behaviors, and the expected outcomes.
The planning component of the nursing process involves the establishment of intervention strategies.
In the planning process, it is necessary that all interventions include:
Steps in the planning phase include:
The third phase of the nursing process is implementation, the execution and completion of nursing strategies identified in the planning phase. Implementation requires communication of the plan to all participants involved in the patient’s care, including the patient and family. The plan of care may be carried out by members of the health team, the patient, the patient’s family, and/or other caregivers. During this phase, the nurse continues to assess the patient and record progress. Documentation verifies that the plan has been implemented and can be used to identify the standard of care and evaluate the plan’s effectiveness.
Evaluation is the final, ongoing phase of the nursing process that documents both the patient responses and the extent to which the expected outcomes have been achieved. The nurse assesses the patient’s progress using expected outcomes as criteria for evaluation. Corrective measures and revisions to the care plan are employed, if needed.
The importance of documentation at each stage of the nursing process has been discussed. From the initial assessment through the final evaluation, the nurse must record relevant observations and interactions. Not only does accurate and detailed documentation influence patient care, but it serves to legitimize the contributions made by nursing. Cohen & Cesta (2001) suggest the use of standardized nursing language and classification systems to describe the elements of nursing care.
Examples are found in Table 1.
Table 1 Nursing Classification Systems CLASSIFICATION SYSTEM ELEMENT OF NURSING PROCESS WHERE UTILIZED NANDA Nursing diagnoses in all settings NIC Nursing interventions in all settings NOC Nursing outcomes in all settings Omaha System Diagnoses, interventions, outcomes in community setting The sources for these classification systems can be found in the Bibliography at the end of this unit and used by individual practitioners to enhance patient care at all levels. The use of standardized language in the nursing care plan will result in documentation that is
more efficiently retrieved and more easily analyzed. In addition, other disciplines can use the same
language to document their care, facilitating communication among professionals.Regardless of the area of specialization, nurses are expected to demonstrate competence in their
practice. Competency is the integration of knowledge, skills, attitudes and behaviors, and the
delivery of care according to expectations or standards. Standards are authoritative statements
intended to foster quality patient care and excellence in practice, and they provide the means for
measuring the professional performance of nurses and the quality of care they provide. Standards,
both internal and external, also define the legal and professional responsibilities of the nurse and
serve as a measure of appropriate professional nursing practice.Internal standards are criteria for practice that are established by or within an institution
or agency, including:
Nursing care plans are the most direct evidence of nursing judgment and serve as documentation
of a nurse’s knowledge of the standard of care for a given healthcare situation. If a nurse establishes
a plan of care and then deviates from that plan, s/he may be deviating from a “reasonable”
standard of care.External standards are those set by an authority outside an institution or agency, including:
External standards always supersede internal standards. For example, if a job description
required a nurse to work outside the legal scope of nursing practice, regulations identified in a
state’s Nurse Practice Act would take precedence over the job description. Knowledge of internal
and external standards is a vital component of a nurse’s professional competence.The nursing profession distinguishes among standards of care, standards of professional performance,
and standards of nursing practice.
by the nursing process
of behavior in the professional role
of care or performance that is common among professional nurses and may be used to judge
the quality of nursing practice (Kelly & Joel, 1999; Quad Council of Public Health Nursing
Organizations, 1999).
The professional standards for public health nursing practice can be found in Appendix 1.PUBLIC HEALTH NURSING - Public health nursing in the United States evolved primarily from programs that were developed in Western Europe, particularly Great Britain. In the early 1860s, trained nursing school graduates were assigned as visiting nurses to provide care for the poor in their homes. They were called “District Nurses,” and although they provided nursing care for the sick poor, they did not provide direct care to persons with communicable diseases. To avoid disease transmission from one household to another, these nurses provided care indirectly by teaching family members how to perform
tasks and providing the family with the necessary equipment (Kalisch & Kalisch, 1995).
Visiting nursing began in the United States in 1877 when the New York City Mission instituted what
was called “district” or “block” nursing. The major focus was religious, although nurses also emphasized
health care. Later, the Ethical Society took a more nonsectarian approach and visiting nurses
taught cleanliness, proper feeding of infants and children, as well as aspects of preventive care.
In 1893, Lillian Wald and Mary Brewster, both trained nurses, established the Henry Street
Settlement House in a tenement on the Lower East Side of New York City. There, they recruited
other nurses and combined visiting and district nursing within the broader scope of what Lillian
Wald called, “public health nursing” (Dieckmann, 2000).The nurses at the Henry Street Settlement House provided care to many patients with TB. Through
the 19th century, statistics showed tuberculosis to be the leading cause of death due to infectious
diseases. City tenement dwellers, such as those living on Manhattan’s Lower East Side, were often
too poor to be hospitalized. Wald and Brewster and their staff provided health services in the
home to all in need, regardless of ability to pay or religious affiliation. They emphasized that fresh
air, a healthy diet, and sanitary living conditions were keys to recovery from disease. Lillian Wald,
as the first public health nurse, employed epidemiology and statistics to explain environmental and
social causes of TB morbidity and mortality (Dieckmann, 2000).
From 1895-1899, patients with TB were cared for by visiting nurses, whose practice was considered
general. In 1899, a physician at Johns Hopkins University founded the Laennec Society of Baltimore, to
investigate the social conditions of people with TB. The society believed that the answers to treatment and containment of TB could be found in the home (Kalisch & Kalisch, 1995). In the first organized study of its kind, several common factors among people with TB were discovered: overcrowded living conditions, nonexistent ventilation, poor diet, and sharing of beds and utensils. In 1903, nurses were assigned to the full-time care of TB patients in their homes. Nurses located persons with TB, brought them to the dispensary and taught them the importance of fresh air, good food, and rest. The nurses not only reported substandard living conditions, but attempted to improve them with the help of relief agencies. They also provided bedside care to the sick and established precautionary measures to avoid infection of others. Nurses managed the complete care of patients with TB, including direct care, case finding, contact tracing, coordination of relief services, and patient and community education for prevention. Today, these nurses would be called “case managers” for patients with TB. Finally, in 1904, through contributions from Baltimore citizens, additional nurses were hired to work exclusively with TB cases under the supervision of the Visiting Nurse Association of Baltimore. The Visiting Nurse Association of Baltimore was the first in the United States to offer specialized nursing care for those infected with TB (Kalisch & Kalisch, 1995).Williams (2000) defines current public health nursing practice as the synthesis of nursing theory
and public health theory applied to promoting and preserving the health of populations. The focus
of public health nursing practice is the community as a whole and the effect of the community’s
health status (resources) on the health of individuals, families, and groups. Care is provided within
the context of preventing disease and disability and promoting and protecting the health of the
community as a whole.The practice is population focused and community oriented. The goal is prevention of disease and
disability “through the creation of conditions in which people can be healthy” (Quad Council of
Public Health Nursing Organizations, 1999). Public health nursing practice is a specialized field
within the broad arena of community health nursing practice.The public health nurse generalist holds a bachelor of science degree and applies basic concepts of
public health and comprehensive healthcare planning in collaboration with communities. The
nurse is knowledgeable about social, economic, ecologic, and political issues related to the needs
of populations at risk. The public health nurse specialist has completed a masters or doctoral
program and enhances services to populations through application of advanced knowledge in
areas such as public health sciences, humanities, management theory, health policy, program planning
and evaluation, and research (Williams, 2000). Both the generalist and specialist work at the
aggregate level, incorporating concepts and theories from public health, social, behavioral, and
nursing sciences.The goal of the public health nurse is to combine public health core functions with nursing practice
to achieve health goals for a population. On the next page are some examples of TB case
management activities performed by the public health nurse within the framework of the core
functions of public health.APPLICATION OF CORE FUNCTIONS IN TB NURSING
Assessment
Policy Development
Assurance
The Association of State and Territorial Directors of Nursing (ASTDN) has developed a model of
public health nursing practice that demonstrates the interaction. This model can be found in
Appendix 2.SUMMARY - This learning module presented key information related to public health, such as the definition of public health, its objectives, and the core functions of assessment, policy development and assurance. The selected topics in nursing practice reviewed in this module provide notable concepts
from nursing, including the definition of nursing, the nursing process, and standards of practice. A
greater comprehension of public health nursing established through its definition, a brief history of
the inception of public health nursing, and its role in TB management serve to increase awareness
of the role of the public health nurse. To further expand the topic, the Quad Council of Public
Health Nursing Organization’ tenets of Public Health Nursing, Standards of Public Health Nursing
Practice, and Standards of Professional Performance can be found as Appendix 1, and the ASTDN
model for public health nursing is presented in Appendix 2.APPENDIX 1
The following standards were created by the Quad Council of Public Health Nursing Organizations
as a means to prepare public health nurses for the coming changes in public health services.
The Quad Council of Public Health Nursing Organizations
In the publication, Scope and Standards of Public Health Nursing, the Quad Council indicates that
future public health services “will be driven by local community needs, resources, and preferences
of the people” (1999). The council suggests that all public health nurses will need “a broad range
of population-focused skills to be strong public health team partners” (1999).The following tables provide an overview of the Scope and Standards of Public Health Nursing
Practice and categorize the information contained within the publication. It is recommended that all
public health nurses read the complete document to gain a full understanding. Scope and
Standards of Public Health Nursing Practice may be obtained from the American Nurses Association.
The following information is reproduced with permission of the American Nurses Association.
The Quad Council emphasizes that adherence to the tenets of public health nursing with the overall
goal of promoting and protecting population health is what distinguishes public health nursing
from other nursing specialties. Although other nursing specialties may address some of these
tenets, they do not incorporate all eight tenets into their practice. In addition, the council stresses
that the focus of care, rather than the location of care, is what separates public health nurses from
those in other nursing specialties.Tenets of Public Health Nursing
and comprehensive
economic conditions in which people can thrive
might benefit from an intervention or service
population
health benefit gain
with members of other professions and organizations
(Quad Council of Public Health Nursing Organizations, 1999).STANDARDS OF CARE FOR PUBLIC HEALTH NURSING PRACTICE
Standard I. Assessment
The public health nurse assesses the health status of populations using data, community
resources identification, input from the population, and professional judgment.
Standard II. Diagnosis
The public health nurse analyzes collected assessment data and partners with the people
to attach meaning to those data and determine opportunities and needs.
Standard III. Outcomes Identification
The public health nurse participates with other community partners to identify expected
outcomes in the populations and their health status.
Standard IV. Planning
The public health nurse promotes and supports the development of programs, policies,
and services that provide interventions and improve the health status of populations.
Standard V. Assurance: Action Component of the Nursing Process for Public
Health Nursing
The public health nurse assures access and availability of programs, policies, resources,
and services to the population.
Standard VI. Evaluation
The public health nurse evaluates the health status of the population.
(Quad Council of Public Health Nursing Organizations, 1999).STANDARDS OF PROFESSIONAL PERFORMANCE
Standard I. Quality of Care
The public health nurse systematically evaluates the availability, accessibility, acceptability,
quality, and effectiveness of nursing practice for the population.
Standard II. Performance Appraisal
The public health nurse evaluates his or her nursing practice in relation to professional
practice standards and relevant statutes and regulations.
Standard III. Education
The public health nurse acquires and maintains current knowledge and competency in
public health nursing practice.
Standard IV. Collegiality
The public health nurse establishes collegial partnerships while interacting with healthcare
practitioners and others, and contributes to the professional development of peers,
colleagues, and others.
Standard V. Ethics
The public health nurse applies ethical standards in advocating for health and social policy
and delivery of public health programs to promote and preserve the health of the population.
Standard VI. Collaboration
The public health nurse collaborates with the representatives of the population and other
health and human service professionals and organizations in providing for and promoting
the health of the population.
Standard VII. Research
The public health nurse uses research findings in practice.
Standard VIII. Resource Utilization
The public health nurse considers safety, effectiveness, and cost in the planning and
delivery of public health services when using available resources to ensure the maximum
possible health benefit to the population.
(Quad Council of Public Health Nursing Organizations, 1999)APPENDIX 2
ASTDN Public Health Nursing Practice Model
Reproduced with permission from The Association of State and Territorial Directors of Nursing and American Nurses Association.
REVIEW QUESTIONS
SECTION REVIEW-OVERVIEW OF PUBLIC HEALTH
SECTION REVIEW-CORE FUNCTIONS OF PUBLIC HEALTH
health.SECTION REVIEW-SELECTED CONCEPTS IN NURSING PRACTICE
process?SECTION REVIEW - PUBLIC HEALTH NURSING
terms of:
a. Educational preparation
b. Scope of practice
SECTION REVIEW-APPENDICES
and the core functions of public health.
REFERENCES
American Nurses Association (1996). Nursing’s Social Policy Statement. Washington, DC: American
Nurses Publishing.
American Public Health Association, Public Health Nursing Section. (1996). The Definition and Role
of Public Health Nursing: A Statement of APHA Public Health Nursing Section. Washington, DC:
American Public Health Association.
Association of State and Territorial Directors of Nursing (ASTDN). (2000).
Public Health Nursing: A Partner for Healthy Populations. Washington, DC: American Nurses
Publishing.
Cohen, E.L. & Cesta, T.G. (Eds.). (2001). Nursing Case Management: From Essentials to Advanced
Practice Applications. (3rd ed.). St. Louis: Mosby.
Dieckmann, J. (2000). History of public health and public and community health nursing. In M.
Stanhope & J. Lancaster (Eds.), Community & Public Health Nursing. (5th ed.). St. Louis: Mosby.
Institute of Medicine. (1988). The Future of Public Health. Washington, DC: National Academy Press.
Kalisch, P.A. & Kalisch, B.J. (1995). The Advance of American Nursing. (3rd ed.). Philadelphia:
Lippincott.
Kelly, L.Y. & Joel, L.A. (1999). Dimensions of Professional Nursing. (8th ed.). St. Louis: McGraw-Hill.
Quad Council of Public Health Nursing Organizations. (1999). Scope and Standards of Public
Health Nursing Practice. Washington, DC: American Nurses Publishing.
Williams, C.A. (2000). Community-based population-focused practice: The foundation of specialization
in public health nursing. In M. Stanhope & J. Lancaster (Eds.), Community & Public Health
Nursing. (5th ed.).St. Louis: Mosby.
World Health Organization. (1958). The First Ten Years of the World Health Organization. New
York: WHO.