NURS 4211 – Role of the Nurse Leader in Population Health Assignment

NURS 4211 – Role of the Nurse Leader in Population Health Assignment

NURS 4211 – Role of the Nurse Leader in Population Health Assignment

The focus of this course is on application of theories and concepts from nursing and public health sciences in assessing health status; preventing and controlling disease; and promoting a healthier population by working with families, aggregates, communities, and healthcare systems. Students apply systems thinking by using epidemiological and community assessment techniques to examine populations at risk, health promotion, and levels of prevention with special emphasis on ethnically diverse and vulnerable populations. NURS 4211 – Role of the Nurse Leader in Population Health Essay.Major local, state, and national health issues are considered including communicable disease, chronic illness, environmental and occupational health, bioterrorism, emergency and disaster preparedness, and response. Practice experiences provide learning experiences in population-based health promotion by collaborating with interdisciplinary public health partners in a local community.

Since the early 1900s, community health nurses have been working to improve population health in the United States, managing and providing care across entire groups, identifying and examining the impact of diseases on societies, and promoting wellness across a broad range of settings.

Community health nurses, sometimes called public health nurses, are registered nurses (RNs) who are trained to work in public health settings such as county or state health departments, schools, jails, and businesses. Because of their roles in the community as caregivers, they often form close bonds within the communities they serve and form lasting relationships. They become area experts on health and wellness.  NURS 4211 – Role of the Nurse Leader in Population Health Essay.

On any given day, community nurses can be found running wellness clinics, coordinating emergency preparedness for disaster relief, or treating injuries and illnesses.

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Community nursing integrates evidence-based research with community health needs to provide care based on science and evidence. They must determine the cultural and socioeconomic needs of the community and adjust care as needed. In this role, RNs may be required to have a baccalaureate nursing education with studies in population-based health and community health nursing. RN to BSN programs allow nurses to study the theory and research behind public health practices and apply them to everyday practice.

“They are educated to see each person for whom they care in the context of his or her life—all the factors that impact that person’s life and well-being,” the Robert Wood Johnson Foundation, the nation’s largest healthcare philanthropic organization, said in a call to action for improved public health. “Indeed, nurses have a responsibility and an obligation—by virtue of their education—to promote population health no matter where and how they practice.” NURS 4211 – Role of the Nurse Leader in Population Health Assignment

NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Community Health Nurses’ Roles

Working as a community nurse is unlike any other nursing position. By helping whole communities, community nurses act as educators, disease and injury prevention specialists, research scientists, community advocates, emergency preparedness experts, public health liaison, and healthcare professionals. In more detail, the roles of public health nurses are:

1. Disease prevention specialist

Community health nurses focus on long- and short-term care for disease prevention. Their work includes averting or controlling the spread of the flu and other communicable diseases. They work with patients to support diabetes self-management and improve diabetes control.  NURS 4211 – Role of the Nurse Leader in Population Health Essay.They also work with mothers of newborns to reduce the rate of infant mortality and in schools to identify gaps in services.

2. Community educator

As educators, community health nurses focus on presenting materials in a clear and understandable format. They provide information to individuals, families, and communities that create a framework for healthy living and healthy choices. In schools they may teach sex education and HIV education classes. In the public, they hold classes and seminars on diabetes management. Overall, they focus on community health education as a step to preventive healthcare.

3. Leader

Community health nurses use evidence to implement policy changes and quality-based practices. They lead collaborative efforts to produce successful health outcomes and provide critical medical and social services in communities.

4. Researcher

As researchers, community health nurses collect and use evidence to execute positive changes for better health. Research is used to validate funding for public health programs, reduce inequalities in healthcare, and increase access to services. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

5. Advocate

Public health nurses advocate on the local, state, and federal level to provide better access to healthcare, protect funding for public health programs, and reduce or eliminate health disparities. They help families arrange assistance through social services programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides healthcare and nutritional services for low-income pregnant women, breastfeeding mothers, and children under age 5.

6. Caregiver

Community nurses cross cultural, language, and literacy boundaries to shape the health and well-being of children and adults. NURS 4211 – Role of the Nurse Leader in Population Health Essay.They provide prenatal care and education for expectant mothers, including information about maternal nutrition, referrals for childbirth classes, and postpartum assistance. They also provide resources for parents to understand proper childhood development and discipline techniques.

In addition, community nurses play other varied roles, said Virginia Crandall, Senior Community Health Nursing Director for the Florida Department of Health in Hernando County. She said working as a public health nurse provides an opportunity to use skills not used in a hospital setting.

“Whether it is Ebola, Zika, budget challenges, hurricanes, clinic operations, dog bites, tuberculosis, sexually transmitted diseases or HIV, there is always a new challenge and a new opportunity to make a positive difference,” she said. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Future Of Community Health Nursing

Healthcare experts say public health has made great strides in the past decades, allowing people to live longer and healthier lives. The smoking rate is down and more people have health insurance. Health reform efforts have improved the quality of healthcare and slowed the growth rate of medical costs, the U.S. Centers for Disease Control and Prevention (CDC) said.

Even with that, however, the United States falls short of providing equitable access to healthcare, the CDC said. Racial, socioeconomic, and ethnic disparities continue in healthcare, the federal agency said. A vital component to change is local communities taking leading roles in public health and continued support by community health nurses.

The Association of Public Health Nurses (APHN) said partnerships between public health nurses, communities, populations, and organizations are essential to the future of public health. The association said public health nurses could bridge the gaps between siloed clinical health and public health, ensuring optimal well-being for communities and populations.

“Public health nursing remain the largest discipline in the public health field, consistently providing leadership in an unsettled health system environment,” the association said in a position paper titled “The Public Health Nurse: Necessary Partner for the Future of Healthy Communities.”

“As public health nurses continue to move beyond traditional public health settings and integrate their practice with community systems, their value and strength will continue to evolve as well.”

he 1996 American Public Health Association Public Health Nursing Section
definition statement and affirms the original definition.1 This statement addresses some of the evolving
economic, health, political, and societal trends that shape the context of public health nursing practice.


Public health nursing is the practice of promoting and protecting the health of populations using
knowledge from nursing, social, and public health sciences. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Public health nursing is a specialty practice within nursing and public health. It focuses on improving
population health by emphasizing prevention, and attending to multiple determinants of health. Often
used interchangeably with community health nursing, this nursing practice includes advocacy, policy
development, and planning, which addresses issues of social justice. With a multi-level view of health,
public health nursing action occurs through community applications of theory, evidence, and a
commitment to health equity. In addition to what is put forward in this definition, public health nursing
practice is guided by the American Nurses Association Public Health Nursing: Scope & Standards of
Practice and the Quad Council of Public Health Nursing Organizations’ Core Competencies for Public
Health Nurses.

Elements of Practice
Key characteristics of practice include: 1) a focus on the health needs of an entire population, including
inequities and the unique needs of sub-populations; 2) assessment of population health using a
comprehensive, systematic approach; 3) attention to multiple determinants of health; 4) an emphasis on
primary prevention; and 5) application of interventions at all levels—individuals, families, communities,
and the systems that impact their health.

Public Health Nursing Perspective
Public health nursing aims to improve the health outcomes of all populations. Applying their clinical
knowledge and expertise in health care from an ecological perspective, public health nurses acknowledge
the complexity of public health problems and the contextual nature of health—including cultural,
environmental, historical, physical, and social factors. Public health nurses apply systems-level thinking
to assess the potential or actual assets, needs, opportunities, and inequities of individuals, families, and
populations and translate this assessment into action for public good. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Public Health Nursing Activities and Practice Settings

Public health nursing activities comprise the domains depicted by the Public Health Intervention Wheel
and the 10 Essential Public Health Services.

These activities include community collaboration, health teaching, and policy development, in response to priorities derived from ongoing, comprehensive population focused assessment. Public health nurses are members and leaders of interprofessional teams in diverse settings and in many different types of agencies and organizations including all levels of government, community-based and other nongovernmental service organizations, foundations, policy think tanks, academic institutions and other research settings. Increasing numbers of public health nurses work in global health in an effort to promote global responsibility and connectivity. Public health nurses that work with individuals and families do so within the context of a population focus—applying a systems perspective to factors that impact health.

Determinants of Health

Eliminating population health disparities by addressing multiple determinants that lead to poor health is a national goal.
Public health nurses are in a position to provide leadership through public policy reform
efforts, community-building, and system-level change.

Environmental, physical, and social determinants explain most health disparities in the United States.11,12,13,14,15 Socioeconomic disadvantages such as poverty, low levels of education, and belonging to a racial or ethnic minority group, are more robust risk factors of poor health than a lack of access to health care or predominantly genetic factors of disease.

While the discipline of nursing was founded on improving environmental conditions to facilitate health at the bedside, public health nurses focus on improving population health in the environments where people live, work, learn, and play. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Opportunities & Challenges

Adherence to public health nursing’s key characteristics requires that the practice must evolve to address
current societal needs. Public health nursing has faced multiple challenges over its history while
engaging in leadership opportunities that have shaped nursing practice, addressing environmental and
social justice issues, affecting population health, and exploring health promotion concepts. One example
is the Patient Protection and Affordable Care Act (ACA).

The ACA has greatly altered the landscape for health care and health improvement in the U.S., creating the potential for new public health nursing roles and responsibilities. The ACA includes goals to 1) improve the individual health care experience; 2) reduce the cost of health care; and 3) improve the health of populations. With their positions embedded within communities, public health nurses are vital to the interprofessional teams needed to assure that all people have equitable access to high quality care and healthy environments through health system reform. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Their assessment skills, primary prevention focus, and system-level perspectives can assure that
local and state needs are met, services and programs are coordinated, and communities are engaged.
Public health nurses are prepared to lead efforts that align emerging systems of care for population health improvement, health promotion, risk reduction, and disease prevention efforts that are within the nucleus of a reformed health system. Fewer public health nursing positions and decreased public health funding influence leadership roles and access to health care in communities. 22 Within the context of healthcare reform these challenges offer opportunities to emphasize a strong, well-educated public health nursing workforce to lead and carry out system coordination and change at local, state, national, and international levels.

An emerging healthcare model that requires public health nursing leadership is the integration of primary care and public health.

Primary care and public health share a focus on prevention, population health, transitional care, and care coordination across settings to promote health through collaboration. With a unique focus from individuals and families to populations and systems, public health nurses are well positioned to integrate new health system models and meet the demands of an ever-changing health system.

Public Health Nursing Education

The baccalaureate degree in nursing (BSN) is recommended for entry-level public health nurses. 26
The Essentials of Baccalaureate Education for Professional Nursing Practice emphasize fundamental
concepts for public health nursing practice such as clinical prevention, population health, healthcare
policy, finance, and regulatory environments, and interprofessional collaboration. 27 The graduate is
prepared to conduct community assessments and apply the principles of epidemiology among other

Nurses with a master’s degree or higher, and with specialization in population health, demonstrate the
knowledge and skills required for leadership positions. Competencies include mastery of interprofessional collaboration, health policy and advocacy, population assessment, prevention strategies, and program planning and evaluation. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

The doctor of nursing practice (DNP) degree, with a public health emphasis, has emerged in the last decade, and provides the foundation for advanced practice in executive leadership, systems development, and the translation of research into practice. The doctor of philosophy (PhD) and other research-focused doctoral degrees remain the preparation for public health nurses to develop the science relevant to public health nursing and to generate the evidence needed to guide practice. In some states a public health nursing certification is needed to signify a nurse’s specific competence and expertise in public health nursing. National advanced public health nursing certification is available via portfolio assessment through American Nurses Credentialing Center.


Public health nurses provide leadership for emerging advances in population health and health care—
particularly in terms of addressing health inequities. Equipped with a baccalaureate degree or higher,
public health nurses are prepared to address multiple determinants of health and participate fully in the
challenges of attaining and maintaining population health. With a scope of practice that includes
community-building, health promotion, policy reform, and system-level changes to promote and protect
the health of populations; public health nurses have an essential role and responsibility as leaders in health improvement and promoting health equity.  NURS 4211 – Role of the Nurse Leader in Population Health Essay.

1 American Public Health Association, Public Health Nursing Section. (1996). Definition and role of
public health nursing: A statement of the public health nursing section. Washington, DC; Author.
2 American Nurses Association. (2013). Public health nursing: Scope and standards of practice. (2nd ed.), Washington, DC: American Nurses Publishing.

The American Academy of Nursing recognizes the need for strengthening the U.S. public health workforce and supports efforts to increase the capacity of public health nursing (PHN) to promote and protect the health of communities and populations. PHN has distinguished itself as a nursing specialty by defining its practice as that of “promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (American Public Health Association, PHN Section, 2013). PHN, the largest profession within the public health workforce, has a long and successful history of promoting and protecting the health of the public. Over the past decade, however, the public health infrastructure has been decimated by budget cuts and declining resources affecting the capacity of PHN to effectively impact population health outcomes. Ironically, this comes at a time when the U.S. has adopted a comprehensive set of health system reforms focused on the “triple aim” of improving population health, lowering per capita costs, and improving the patient experience of care. The triple aim, first outlined in 2007 by the Institute for Healthcare Improvement, calls for a shift from clinical services to the prevention of the deleterious effects of chronic illness and an increased emphasis improving overall population health outcomes (Institute for Healthcare Improvement, 2016).

PHN’s proven potential to contribute to population health outcomes is crucial to the ability of the public
health infrastructure to support a renewed focus on health promotion and disease prevention within
health care (Hassmiller, 2014). NURS 4211 – Role of the Nurse Leader in Population Health Essay.As a result, there is a call to specifically enlist public health nurses as leaders in population-focused health improvement as the key to a healthier future and better health outcomes. In 2014,the National Advisory Council on Nurse Education and Practice (NACNEP) submitted its 12th Annual Report to Congress, Public health nurses: Key to our nation’s health, asking both Congress and the Secretary of the U.S.

Department of Health and Human Services (USDHHS) to enhance supports for PHN education and practice as a means to ensuring a healthier future and better health outcomes for all NURS 4211 – Role of the Nurse Leader in Population Health AssignmentAmericans (NACNEP, n.d.). In 2016, the NACNEP reinforced this position in its 14th Annual Report to Congress, Preparing nurses for new roles in population health management (NACNEP, 2016) by calling for  increased investment in population health science and training and increased funding for research on population health management, measures, and metrics. Renewed support and economic investment in PHN is expected to improve the capacity of the public health workforce to build a culture of health as the United States strives to meet the triple aim goals of health care reform.


Despite a century of public health advances in reducing and eliminating diseases and increasing life expectancy, the U.S. health system faces many challenges today. These challenges include an aging population increasingly burdened with chronic illness, declining life expectancy, and inferior health systems performance on measures of quality, access, efficiency, equity, and healthy lives compared with other highincome countries (Institute of Medicine [IOM], 2012).

Challenges specific to the public health infrastructure include increasing health care costs, limited resources, and a declining public health workforce (Bekemeier,  Zahner, Kulbok, Merrill, & Kub, 2016).
* Corresponding author: Joan E. Kub, 1103 Spy Glass Dr. Arnold, MD, 21012.
E-mail address: (J.E. Kub).
0029-6554/$ – see front matter 2017 Published by Elsevier Inc.

Population Health and PHN

These U.S. health system challenges are occurring at the same time that there is a growing focus on what is called population health. Although the term “population health” is not new, its definition is a source of
some debate. It has been defined as the distribution of health outcomes within a population, the determinants that influence distribution, and the policies and interventions that affect determinants
(Kindig & Stoddart, 2003). PHN has a rich history of caring for populations within communities, beginning with Lillian Wald’s work at the Henry Street Settlement in New York City in the early 1890s.

Furthermore, PHN has distinguished itself as a nursing specialty by defining its practice as that of “promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (American Public Health Association, PHN Section, 2013).

For well over a century, public health nurses have been critical to the functioning of our health care system by improving the health of vulnerable populations and entire communities. Not unlike other public health efforts, however, evidence of these achievements has not always been well documented or studied. A recent review of studies focusing on health education, behavior change, and screening over a period of 20 years (1990e2010) found evidence for the effectiveness of PHN interventions in close to half of the studies (Swider, Levin, & Reising, 2017). Public health nurses have the ability to care for individuals and communities through effective case management, which has been shown to improve chronic illness outcomes (Kneipp et al., 2011). In addition, a systematic literature review of home visiting interventions published between 2005 and 2015 found that home visitation interventions can mitigate social determinants of health and empower people to avoid injury and manage and prevent illness (Abbott & Elliott, 2017).  NURS 4211 – Role of the Nurse Leader in Population Health Assignment

One home visitation program, the NurseeFamily Partnership, targeting at risk mothers and infants, is an
example of the long-term benefits of PHN interventions (NurseeFamily Partnership, n.d.). Started in the 1970s as a nurse visitation program targeting at-risk firsttime mothers, this program has been implemented at the policy and practice level and continues to be delivered throughout the United States as well as in other countries. Although evidence has demonstrated the ability of the program to improve maternal child health outcomes of the mothers and newborns taking part in the 2-year intervention, even more striking are the long-term effects of this program on those who participated and have long since left the program.

Participation in the NurseeFamily Partnership has been found to have continuing health benefits for
children as far out as 15 and 18 years after their participation, including being less likely to be involved
in criminal activity, less dependent on social welfare, and less likely to have had teenage pregnancies
themselves (Eckenrode et al., 2010). This is only one program but demonstrates the lasting impact of strategic and appropriate use and training of the PHN workforce and the critical need and potential of public health nurses to assist with the health of those who most need it. The loss of PHN for such communities could be devastating, especially in rural areas and with at-risk populations who most depend on the work of public health nurses for the health and well-being of themselves and their families.

In addition to traditional roles of public health nurses in home visiting, with the advent of the
Affordable Care Act, there has been a national health care shift toward primary care. Public health nurses are making substantial contributions to the implementation of the Affordable Care Act and the expansion of primary care. Their efforts include the integration of primary care and public health, providing clinical preventive services, care coordination, patient navigation, establishment of private and public partnerships, and focusing on population health assessment, analysis, and health planning strategies (Edmonds, Campbell, & Gilder, 2017). NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Enlisting PHN to Strengthen the Public Health

Infrastructure and Improve Health

Although the focus on health care reform and primary care has been positive, there have been unintended consequences of these efforts. The continuing decline in the number of public health nurses, as a result of budget cuts, the use of less expensive providers for services, and changing PHN roles (Association of State and Territorial Health Officials, 2014), has resulted in a public health nurse-to-population ratio that would concern early leaders of the field. Although provider to-population ratios were once critical in the planning of workforce adequacy in PHN, these ratios have received little attention for some time. In 2008, the Association for State and Territorial Directors of Nursing (ASTDN) (now the Association of Public Health Nurses) prepared a detailed report on the history of public health nurse-to-population ratio expectations.

Their recommendation was to establish a minimum “standard national ratio of 1 public health nurse to
5,000 population” (ASTDN, 2008, p. 1). The report also pointed out that this ratio would need to be lower for communities with more vulnerable or impoverished populations.

Public health nurses remain the largest group of health professionals of the public health workforce
(Beck, Boulton, & Coronado, 2014). However, with an estimated 47, 270, public health nurses in local, state, and federal agencies and a population of 316.4 million in 2013, the ratio of public health nurses to population is 1 to 6,693. This ratio is well above the recommended minimum of 1:5,000 and does not account for communities with at-risk populations. To meet this 662 Nurs Outlook 65 (2017) 661 e 664
minimum recommendation, the United States would need more than 63,000 public health nurses. Additional significant recommendations that would further increase the number of public health nurses needed to promote population health is a ratio of “1 supervisor to no more than 8 public health nurses” and the requirement for the baccalaureate degree for PHN practice (ASTDN, 2008, p. 52).

More broadly, unintended consequences of the emphasis on primary care has been decreasing attention to the role of the public health nurse in the community, a loss of Title VIII funding for public health
nurses, and a loss of traineeships for advanced education of public health nurses. With the dynamic
changes in health care reform and attention to the triple aim of improving population health, lowering per capita costs, and improving the patient experience of care, it is time to refocus care once again on the community and to renew the role of PHN.

Strengthening the public health workforce, however, requires renewed efforts to increase funding opportunities to provide education for public health nurses and create career pathways for advanced public health nurses. Funding is critically important, especially considering the 2012 eligibility changes made to Title VIII, outlining traineeship preferences for nurse practitioners and nurse midwives (USDHHS, 2012). NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Renewed support and economic investment in PHN
will strengthen the public health workforce to promote
a culture of health as the U.S. health care system
strives to meet the triple aim and assure the effective
implementation of health care reform. Public health
nurses will have the capacity to care for individuals in
the community, as well as vulnerable communities
and populations.  NURS 4211 – Role of the Nurse Leader in Population Health Essay.Well-prepared advanced public
health nurses will be able to address care management
needs of individuals, a renewed priority of health care
reform, as well as population and system level factors
including social determinants and health disparities
through PHN practice and research.

Responses and Policy Options

PHN’s proven potential to contribute to population
health outcomes is crucial to the ability of the public
health infrastructure to support a renewed focus on
health promotion and disease prevention within
health care (Hassmiller, 2014). The NACNEP, which is
authorized by Section 851 of the Public Health Service
Act and amended by Public Health Law 105 to 392, is
charged with providing recommendations to Congress
and the Secretary of the USDHHS concerning policy
matters relating to the nurse workforce, education, and
practice improvement. The 12th Annual Report to
Congress (NACNEP, n.d) outlined this strategy clearly
and succinctly. This report calls on Congress and the
Secretary of the USDHHS to strengthen PHN education
and practice and identifies PHN as key to a healthier
future and better health outcomes. The NACNEP report
asserts that the health of a nation is strongly dependent on the strength of its public health workforceda
workforce with PHN as its largest profession. Moreover,
the 14th Annual Report to Congress (NACNEP, 2016)
highlights the need to prepare nurses for roles in
population health management, which are historically
within the purview of PHN. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

These two reports are complementary and provide
strong arguments for investment in public health
and population health science infrastructure,
training, and research. Such action would acknowledge and leverage the capacity of the nursing profession to lead population health and quality
improvement in diverse and changing communities
in the United States and around the world. PHN led
the nursing profession with its focus on social determinants of health in the early 20th century. With
enactment of the NACNEP recommendations, PHN
will assume a transformative role in achieving
healthy populations through primary prevention and
population-based efforts.

The Academy’s Position

The American Academy of Nursing (the Academy) fully
supports efforts to increase PHN capacity, to
strengthen the public health infrastructure, and to
promote and protect the health of communities and
populations. NURS 4211 – Role of the Nurse Leader in Population Health Essay.The Academy endorses the 12th Annual
NACNEP report, Public health nursing: Key to our nation’s
health, and the 14th annual NACNEP report, Preparing
nurses for new roles in population health management. One
of the most essential aspects of these NACNEP reports
is the recommendation for increased training and education for nurses in the area of public health and
population health management, under Title VIII of the
Public Health Services Act.


B Encourage key stakeholders including the American Nurses Association, American Association of
Colleges of Nursing, National League for Nursing,
Quad Council Coalition, American Public Health
Association, Association of State and Territorial
Health Officials, Center for Disease Control and
Prevention, National Association of County
Health Officials, Public Health Foundation, and
the Robert Wood Johnson Foundation to review
and respond to the 12th and 14th Annual NACNEP
B Urge Congress to enact legislation and appropriate funding for the development of advanced
PHN traineeships, repayment programs, and stipend support through Title VIII.
3Quad Council of Public Health Nursing Organizations. (2011). Core competencies for public health
nurses. Washington, DC: Quad Council of Public Health Organizations.
4 Keller, L.O., Schaffer, M., Lia-Hoagberg, B., Strohschein, S. (2002). Assessment, program planning,
and evaluation in population-based public health practice. Public Health Management Practice, 8 (5),
31-32. NURS 4211 – Role of the Nurse Leader in Population Health Assignment

Today’s healthcare crisis offers distinct
opportunities for the clinical nurse leader
(CNL) to develop and evolve as a community healthcare practitioner delivering high-quality, patientcentered, safe, and efficient care on a microsystem
clinical level. Chronic diseases are reaching epidemic proportion in the United States. The risk for several chronic diseases, such as type 2 diabetes, heart
disease, stroke, arthritis, asthma, and certain cancers, are attributed to obesity or overweight.
Currently, two-thirds of US adults and one-fifth of
US children are obese or overweight.
Nurse Leader 25
The CNL, the newest nursing leadership role, was created
to bring about fundamental change in the healthcare
delivery system. As a catalyst, this role can help to reverse the
epidemic of overweight, obesity, and associated chronic diseases through coordinated multidisciplinary efforts grounded
in evidence-based practice. Locally, the CNL will transform
communities by promoting healthy lifestyle choices.
The purpose of this article is to highlight three health conditions (overweight, obesity, and diabetes type 2, some of the
most debilitating and costliest chronic conditions affecting the
American population and the healthcare system) where the
CNL can significantly improve outcome within a community
setting. The assimilation of the CNL, a lateral integrator of care
within the community, can be an effective complement to
primary care in combating these health conditions.  NURS 4211 – Role of the Nurse Leader in Population Health Assignment

As the health crisis unfolds and resources dwindle,
chronic diseases maintain unrelenting pressure on our
healthcare system and the community. The Institute for
Healthcare Improvement (IHI) recognized that chronic
conditions are negatively affecting the fabric of some communities psychologically, physiologically, and financially and
are increasing the demands on the healthcare systems.1 A
case can be made to strategically use the CNL at the community level and bolster the work being conducted at the
primary care and inpatient units, in order to address prevention and treatment of chronic conditions related to overweight and obesity.


The American Association of Colleges of Nursing (AACN)
in 2004 implemented a new leadership role, the CNL. The
CNL is the most contemporary nursing leadership role introduced into nursing practice within the past 40 years. This role
is designed to bring leadership to the microsystem level of
healthcare. The CNL is an advanced practice nurse generalist
with a master’s degree level of education. The CNL is trained
to provide high-quality, effective, and safe nursing care in very
complex healthcare environments.
The guiding principles for the CNL Partnership Model view
the CNL as an overseer of unit-based clients’ clinical plans aimed
at improving care and reducing cost. The CNL accepts the tasks
of improving clinical or client outcomes and advancing nursing
practice through the application of evidence-based care to
clients and their families. The CNL is a lateral integrator of care
and services; decision making is driven by outcome, based on
evidence-evaluated strategies to improve performance within the
microsystem or the front line of care.2,3  NURS 4211 – Role of the Nurse Leader in Population Health Essay.


Microsystems may comprise the following: patients, clinicians, processes, and recurring patterns such as cultural, information flow, and results.4,5 Clinical microsystems are the
building blocks or the front-line units where most care is
rendered to most people. The CNL is a member of the clinical microsystem that can be described as: “…a small group of
people who work together on a regular basis to provide care
to discrete subpopulations of patients. It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes. Microsystems
evolve over time and are complex adaptive systems, and as
such they must do the primary work associated with core
aims, meet the needs of internal staff, and maintain themselves over time as clinical units.” NURS 4211 – Role of the Nurse Leader in Population Health Assignment


The 2009 Commonwealth Fund’s State Scorecard on Health
System Performance reports the findings of 2007 performance
that have created urgency for improving healthcare systems to
eliminate disparities and improve states’ efforts to address
population health needs and accessibility.6 At the macrosystem level, the scorecard is used as the framework for a state’s
health systems to identify opportunities for improvement. It is
uniquely based on benchmarks for 38 indicators that look at
access, quality, costs, and health outcomes.
The most recent scorecard depicts an image of a healthcare system experiencing tremendous pressure. This year,
Vermont leads the nation in improved performance and ranks
in the top quartile of all states on most of the indicators, and
the rationale for its success is the driver for this article. In
2006, Vermont put in place several healthcare reforms that
centered on preventing and managing chronic diseases.6


Obesity is a logical physiological response to sedentary
lifestyles and poor nutrition in children and is rapidly reaching epidemic proportion in the United States. It is developing
onto one of the gravest health distresses for American children and adolescents.7–9This epidemic is already contributing
to high blood pressure and other circulatory illnesses, depression and other mental illnesses, asthma, arthritis, cancer, and
type 2 diabetes, a disease that was manifested only in adults
until recently.

Over the past 20 years, a steady increase in prevalence of
obesity in children and adolescents has been observed
across all racial–ethnic backgrounds, gender, and age.8–11
The severity of the health concern can be further broken
down according to data from the National Health and
Nutrition Examination Survey (NHANES) surveys from
1976–1980 and 2003–2006 for different children age
groups. The following increases in obesity prevalence have
been recorded: children 2–5 years old, from 5.0% to 12.4%;
ages 6–11, from 6.5% to 17.0%; and ages 12–19, from 5.0%
to 17.6%.10,12 In 1998, some of the subgroups within that
population were experiencing a 30% rise in obesity or at
risk for overweight. NURS 4211 – Role of the Nurse Leader in Population Health Essay.9

The challenge for the CNL, when working with this
subgroup, is to aim for interventions that can prevent or halt
the increase of health-related comorbidities that decrease
quality of life before adulthood. It is estimated that, without
successful interventions, this population group will become
35% of obese adult Americans, which in turn will represent
an additional 30% above the previous two decades.8The most
disturbing challenges facing healthcare professionals today are
26 Nurse Leader April 2010
the current state of childhood obesity and the negative
healthcare projections on adulthood, if left uncorrected.8–10


According to the Centers for Disease Control and Prevention
(CDC), America is evolving into an “obesogenic” society.
Americans live an environment that encourages increased
intake of nonhealthy foods and minimum physical activities.13
Overweight and obesity have been on the rise for the past
three decades, primarily from poor nutrition and decreased
activity levels. The US obesity rates increased 37% from 1998
to 2006.13,14
Duly noted is the direct link of diabetes type 2 to obesity.15
According to the 2009 National Health Statistics Reports, the
prevalence of diabetes is 14.1% for people age 55–64, 19.2% for
ages 65–74, 18.2% for ages 75–84, and 13.0% for ages 85 and
older. It was estimated that by the end of 2009, 19.5 million
people age 24 to 85 were diagnosed with type 2 diabetes and
another 4.25 million went undiagnosed. 16 NURS 4211 – Role of the Nurse Leader in Population Health Assignment

When focusing on adults 55 and older, the CNL will
focus on the prospect of creating healthy aging, which is an
emerging public health opportunity, according to the 2009
National Health Statistics Reports.16 Life expectancy has
greatly increased since the turn of the last century. In the
early 1900s, the life expectancy for a 65-year-old was another
12 years, and in 2005, that figure increased to 18.7 years.16
The US Census Bureau projects that by 2030, adults 55 and
older will compose approximately one-third, or 31.1%, of the
population.17 As our aging population increases, the likelihood of living with chronic conditions also increases. NURS 4211 – Role of the Nurse Leader in Population Health Essay. Living
with multiple morbidities increases psychological distress.18 As
a response, the CDC in 2007 released an action plan for
aging Americans that included injury prevention, decreased
selected chronic health conditions, and improved health promotion and preventive health.19


The US Department of Health and Human Services (HHS)
reports that overweight, obesity, and directly linked health
problems have a significant negative impact on the US economy.20The burden for treatment is estimated to account for
9.1% of total US medical expenditures, or $78.5 billion in
1998.21 Health Affairs reports that medical spending related to
obesity has doubled in the past 10 years. The annual rate was
estimated to be $147 billion in 2008.14,15 Yearly, diabetic
patients experience diagnosis-related expenses of $11,744 and
directly attributed expenses of $6,649. For the next 25 years,
the projected cost for the treatment of diabetes and related
complications are $336 billion as the size of the diabetic pool
continues to increase.14,15,21–24 NURS 4211 – Role of the Nurse Leader in Population Health Assignment


The caseload for the chronically ill typically is carried by
primary care providers. This model is more provider focused
and less patient centered.25–27 The complexity of the tasks
requires the CNL to be versed in the application of several
frameworks and models. The most frequently used Chronic
Care Model (CCM) has a component for self-management
support. CCM includes both patient and specific program
supports in primary care to achieve optimal health outcomes.
The patient-oriented interventions are multifaceted and
comprise educational activities, individualized and group
sessions, multidisciplinary care meetings, and assessments of
established behavior patterns (such as self-efficacy) to identify
barriers that can impede behavior changes.28–34
The Patient Centered Medical Home (PCMH) model
encourages coordination of all healthcare services with active
communication across the continuum. This patient-driven,
team-based approach delivers comprehensive, efficient, and
comprehensive care. PCMH have such expected achievables
as increased patient engagement and shared decision making
in recommended care, decreased hospitalization for chronic
diseases, improved health outcomes, reduced mortality rate,
increased patient and staff satisfaction, and reduced emergency room (ER) visits.35–39


The effective contribution of the CNL is based on clinical
microsystems, intervention development and evaluation,
translation of evidence that is practice-based, research findings, and interdisciplinary partnership developments. The
role design is small, functional, and in the front line, yet is
nimble and powerful enough to deliver healthcare to most
people within the context of population-based services.
The CNL is also an expert in providing nursing care to
groups of patients and trained in dealing with patient situations that require complex and an all-encompassing level of
understanding. This higher comprehension enables the
CNL to seek suitable resources in acquiring supplemental
theoretical or technical information when caring for a
challenging client or group.2,3
The focused involvement at the microsystem level will eventually translate to the creation of local programs that promote
healthy lifestyle choices. This transformation will lead to policy
and environmental changes and initiatives at state and national
levels, providing necessary guidelines and resources in fighting
obesity and its related chronic diseases that burden society psychologically, physiologically, and economically.3,4 Nurse Leader 27
Focused involvement at the
microsystem level will translate
to local programs that promote
healthy lifestyle choices. NURS 4211 – Role of the Nurse Leader in Population Health Assignment


The CNL is well positioned to tackle the current and future
states of overweight, obesity, and obesity-related chronic illnesses
affecting American communities. At the microsystem level, the
CNL, as an advocate for health prevention and promotion, can
positively impact a society that is becoming obesogenic. The
CNL has an opportunity to apply patient-driven, interdisciplinary interventions for disease prevention and management,
assisting young and old populations in living healthier and
longer lives and thus bending the cost curve for chronic illnesses
and decreasing the financial burden on the healthcare system
November 11, 2013

5 Leischow, S., Milstein, B. (2006) Systems thinking and modeling for public health practice. AJPH
96(3): 403-404
Swider, S., Krothe, J., Reyes, D., Cravetz, M. (2013). The Quad Council practice competencies for
public health nursing. Public Health Nursing. doi: 10.1111/phn.12090
Public Health Nursing Section (2001). Public health interventions–applications for public health
nursing practice. St. Paul: Minnesota Department of Health.
8 Centers for Disease Control and Prevention. (2010). National public health performance standards
program, 10 essential public health services. Retrieved from:
9 U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion.
(2011). Healthy People 2020. Washington, DC. Retrieved from:
10 United States Department of Health and Human Services, Healthy People 2020. (2012). Public health
infrastructure: Overview. Retrieved from:
11 Marmot, M. (2000). Multilevel approaches to understanding social determinants. In Berkman LF,
Kawachi I (Eds), Social Epidemiology (347-367). New York, NY: Oxford University Press.
12 Braveman, P. (2011). Accumulating knowledge on the social determinants of health and infectious
disease. Public Health Reports, 126 (3), 28-30.
13 Braveman, P., Egerter, S., Williams, D.R.(2011). Determinants of health: Coming of age. Annual
Review of Public Health, 32, 381-98.  NURS 4211 – Role of the Nurse Leader in Population Health Essay.
14 Woolf, S.H., Braveman, P. (2011). Where health disparities begin: the role of social and economic
determinants–and why current policies may make matters worse. Health Affairs, 30, 1852-1859.
15 Marmot, M., Wilkinson, R.G. (2000). Social Determinants of Health. Oxford: Oxford University Press.
16 Blane, D., Brunner, E., Wilkinson, R. (1996). Health and Social Organization: Towards a Health
Policy for the Twenty-First Century. London: Routledge.
17 Krieger, N. (2005). Embodying Inequality: Epidemiologic Perspectives. Amityville, NY: Baywood
Publishing Company, Inc.
18 Berkman, L.F., Kawachi, I. (2000) Social Epidemiology. Oxford: Oxford University Press.
19 Buhler-Wilkerson, K. (1993). Bringing care to the people: Lillian Wald’s legacy to public health
nursing. American Journal of Public Health, 83,1778-86.
20 Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §2702, 124 Stat. 119, 318-319
November 11, 2013

21 American Public Health Association. (2013). ACA basics and background. Retrieved from:

22 Robert Wood Johnson Foundation. (2011) Recession Takes Bite Out of Nation’s Public Health Nursing
Infrastructure. Retrieved from:
23 Institute of Medicine. (2010). The future of nursing: leading change, advancing health. Washington,
D.C.: The National Academies Press. Retrieved from:
24 Institute of Medicine. (2012). Primary Care and Public Health: Exploring Integration to Improve
Population Health. Washington, DC: The National Academies Press.
25 Robert Wood Johnson Foundation. (2012) RWJF Fellow Works to Push Public Health Nursing
Forward. Retrieved from:
26 American Nurses Association. (2013). Public health nursing: Scope and standards of practice. (2nd
ed.), Washington, DC: American Nurses Publishing.
27 American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for
professional nursing practice, Washington, DC: American Association of Colleges of Nursing.
28 American Association of Colleges of Nursing (2011). The essentials of master’s education in nursing,
Washington, DC: American Association of Colleges of Nursing.  NURS 4211 – Role of the Nurse Leader in Population Health Essay.

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