Population-Based Nursing
ISBN: 978-0-8261-3673-2 |
3rd_Edition
Curley, Ann
(Print pagebreak 1)
CHAPTER 1
Introduction to Population-Based Nursing
Ann L. Cupp Curley
INTRODUCTION
Some of the most significant figures in the history of nursing made their reputations by providing population-based care. Their
influence on nursing has been such that their names live on and their achievements continue to be recognized because of their
important contributions to nursing and to healthcare. A brief look at the stories of some of these nurses helps to provide a
background for understanding population health.
Although she started her career as a teacher, Clarissa (Clara) Barton won her greatest acclaim as a nurse. Horrified by the suffering
of wounded soldiers in the American Civil War (many of them were former neighbors and students) and struck by the lack of
supplies needed to care for them, she worked to obtain various supplies and put herself at great risk by nursing soldiers on the front
lines of several major battles. Her experience would eventually lead to her becoming the founder and first president of the
American Red Cross (Evans, 2003).
During the Crimean War, Florence Nightingale used statistical analysis to plot the incidence of preventable deaths among British
soldiers. She used a diagram to dramatize the unnecessary deaths of soldiers caused by unsanitary conditions and lobbied political
and military leaders in London for the need to reform. She worked to promote the idea that social phenomena could be objectively
measured and subjected to mathematical analysis. Along with William Farr, she was one of the earliest healthcare practitioners to
collect and analyze data in order to persuade people of the need for change in healthcare practices (Dossey, 2000; Lipsey, 1993).
Mary Breckinridge started the Frontier Nursing Service (FNS) in Kentucky in 1925 and remained its director until her death in
1965. Educated as a nurse and midwife, (Print pagebreak 2) she devoted her life to improving health in rural areas, especially
among women and children. She believed in working with the communities that were served by the FNS and formed and worked
with committees composed of community members to help plan and provide care. Similar to Florence Nightingale, she believed in
the use of statistics to measure outcomes. From its onset, the FNS was so successful that there was an immediate drop in infant and
maternal deaths in the communities served by the FNS (Frontier Nursing University, 2019; January, 2009).
These three nurses all worked to improve the health of at-risk populations. They met with political leaders to advocate changes in
polices to benefit those populations, and both Nightingale and Breckinridge used statistical analysis to both support the need for
change and to evaluate their interventions. Breckinridge was an early advocate of engaging communities to help address
community health issues. They were all pioneers of nursing and, although perhaps not in name, certainly in fact, among the first
nurses working in advanced practice.
For decades, community health nurses have recognized the importance and the impact of population-based care, but large segments
of nursing practice focused primarily on caring for individual patients. Nursing remains, and should remain, a practice-based and
caring profession, but nursing practice is changing. There is an awareness of the need to provide evidence-based care and to design
interventions that have a broad impact on the populations that nursing serves, no matter the setting. Population health obligates
healthcare professionals to implement standard interventions, based on the best research evidence, to improve the health of targeted
groups of people. It also obligates nurses to discover new and effective strategies for providing care and promoting health.
Although clinical decision-making related to individual patients is important, it has little impact on overall health outcomes for
populations.
Interventions at the population level have the potential to improve overall health across communities.
This book addresses the essential areas of content for a doctorate in nursing practice (DNP) as recommended by the American
Association of Colleges of Nursing (AACN), with a focus on the AACN core competencies for population-based nursing. The
goal is to provide readers with information that will help them to identify healthcare needs at the population level and to improve
population outcomes. Although the focus is on the essential components of a DNP program, the intent is to broadly address
practice issues that should be the concern of any nurse in an advanced practice role.
This chapter introduces the reader to the concept of population-based nursing. The reader learns how to identify population
parameters, the potential impact of a populationbased approach to care, and the importance of designing nursing interventions at the
population level in advanced nursing practice.
chamberlain999 | 172.70.45.212 | 01 September 2021 1:52:13
, Population-Based Nursing
ISBN: 978-0-8261-3673-2 |
3rd_Edition
Curley, Ann
BACKGROUND
For all the scare tactics out there, what’s truly scary—truly risky—is the prospect of doing nothing.
—President Barack Obama, The New York Times, August 16, 2009
(Print pagebreak 3)
The first two decades of the 21st century have been witness to a growing and contentious debate on healthcare reforms. President
Barack Obama’s stated goals in pushing for reforming health insurance were to extend healthcare coverage to the millions who
lacked health insurance, stop the insurance industry’s practice of denying coverage on the basis of pre-existing conditions, and cut
overall healthcare costs. Driven by a need for change in how healthcare is paid for, the Patient Protection and Affordable Care Act
(ACA) was signed into law by President Obama in 2010. It went into effect over the span of 4 years beginning in 2011. Currently,
there are three different “markets” for insurance through the ACA. The federal marketplace is run solely by the federal
government. The state marketplace is run solely by the state, and in partnership marketplaces, states run many of the important
functions and make key decisions but the marketplace is operated by the federal government. The ACA includes an option that
allows states to expand Medicaid eligibility to uninsured adults and children whose incomes are at or below 138% of the federal
poverty level (there is also a provision for people living with mental illness).
One of candidate Donald Trump’s campaign promises was to repeal the ACA. Since his inauguration, the Trump administration
has issued many regulations that have effectively undermined enrollment in the ACA by cutting funding for education, marketing,
and outreach. While targeting enrollment, the Trump administration has, for the most part, enforced the law as written although the
federal role in enforcement has decreased (Jost, 2018). In December 2018, the U.S. District Court in Fort Worth, Texas, ruled that
the individual mandate requiring people to have health insurance is unconstitutional and that the remaining provisions of the ACA
are also invalid. In March 2019 the Justice Department sent a letter to the 5th U.S. Circuit Court of Appeals in New Orleans to
affirm the judgment issued by the U.S. District Court in Fort Worth, Texas (Robson, 2019). This action signaled a revival of the
current administration’s efforts to repeal the entire ACA. Three days after this letter was issued an announcement was delivered
from the White House that a Republican replacement for the ACA would not be introduced until after the 2020 elections ( Pear &
Haberman, 2019). As of this writing, the fate of the ACA remains uncertain and the contentious debate surrounding healthcare
legislation and reform in the United States continues.
There is ample evidence of a need for healthcare reform in the United States. The gross domestic product (GDP) is the total market
value of the output of labor and property located in the United States. It reflects the contribution of the healthcare sector relative to
all other production in the United States. In 1960, the health sector’s proportion (NHE) of the GDP was 5% (i.e., $5 of every $100
spent in the United States went to pay for healthcare services). By 1990, this figure had grown to 12% and by 1996, 14%. A report
issued by the Committee on the Budget of the U.S. Senate in 2008 warned that unless changes were made in how the United States
provides care to its citizens, the GDP for the healthcare sector would grow to 25% by 2025 and 49% by 2089 (Orszag, 2008). In
2017, the NHE was $3.5 trillion and accounted for 17.9% of the GDP. The Centers for Medicare & Medicaid Services (CMS)
published its forecast of healthcare costs for 2018 to 2027. It estimates that health spending will grow 0.8 percentage point faster
than the GDP per (Print pagebreak 4) year over the 2018 to 2027 period and, as a result, the health share of GDP is expected to
rise from 17.9% in 2017 to 19.4% by 2027. According to the CMS, income growth, the aging of the U.S. population, and the rising
costs of medical goods and services are the three major factors driving healthcare costs at this time (CMS, 2019). The Organization
for Economic Cooperation and Development (OECD) provides a global picture of healthcare spending. It reports that U.S.
expenditures for healthcare as reflected by the GDP is the highest among OECD countries and nearly double the average for
OECD countries.
One interesting fact that can be gleaned from that report is that the OECD attributes the difference in costs (U.S. costs as compared
to other countries) is due to private health sector prices, primarily pharmaceuticals (OECD, 2019).
The rising cost of healthcare is reflected in the insurance industry. According to the Henry J. Kaiser Family Foundation (2019a), the
average annual premium for employersponsored family health coverage in 2017 was $18,687 and the average annual contribution
from employees was $5,218.
Unfortunately, although the United States ranks first in spending on healthcare among industrialized nations, it ranks lower than
most industrialized countries in important health indicators. Two commonly used indicators for measuring a country’s health are
infant mortality and life expectancy at birth. Worldwide, the United States ranked 43rd for life expectancy at birth (life expectancy
at birth in the United States is 80 years) and 55th for infant mortality (infant mortality rate in the United states is 5.87 per 1,000
live births) in 2017 (Central Intelligence Agency [CIA], n.d.). A report issued by the Institute of Medicine (IOM, 2010) argues that
the system used in the United States for gathering and analyzing health measures is part of the problem. A second problem is the
inadequate system used in the United States for gathering, analyzing, and communicating information on the underlying factors
that lead to chronic health conditions and other risk factors that contribute to poor health. Readers can refer to Chapter 12,
chamberlain999 | 172.70.45.212 | 01 September 2021 1:52:13
, Population-Based Nursing
ISBN: 978-0-8261-3673-2 |
3rd_Edition
Curley, Ann
Implications
chamberlain999 | 172.70.45.212 | 01 September 2021 1:52:13
ISBN: 978-0-8261-3673-2 |
3rd_Edition
Curley, Ann
(Print pagebreak 1)
CHAPTER 1
Introduction to Population-Based Nursing
Ann L. Cupp Curley
INTRODUCTION
Some of the most significant figures in the history of nursing made their reputations by providing population-based care. Their
influence on nursing has been such that their names live on and their achievements continue to be recognized because of their
important contributions to nursing and to healthcare. A brief look at the stories of some of these nurses helps to provide a
background for understanding population health.
Although she started her career as a teacher, Clarissa (Clara) Barton won her greatest acclaim as a nurse. Horrified by the suffering
of wounded soldiers in the American Civil War (many of them were former neighbors and students) and struck by the lack of
supplies needed to care for them, she worked to obtain various supplies and put herself at great risk by nursing soldiers on the front
lines of several major battles. Her experience would eventually lead to her becoming the founder and first president of the
American Red Cross (Evans, 2003).
During the Crimean War, Florence Nightingale used statistical analysis to plot the incidence of preventable deaths among British
soldiers. She used a diagram to dramatize the unnecessary deaths of soldiers caused by unsanitary conditions and lobbied political
and military leaders in London for the need to reform. She worked to promote the idea that social phenomena could be objectively
measured and subjected to mathematical analysis. Along with William Farr, she was one of the earliest healthcare practitioners to
collect and analyze data in order to persuade people of the need for change in healthcare practices (Dossey, 2000; Lipsey, 1993).
Mary Breckinridge started the Frontier Nursing Service (FNS) in Kentucky in 1925 and remained its director until her death in
1965. Educated as a nurse and midwife, (Print pagebreak 2) she devoted her life to improving health in rural areas, especially
among women and children. She believed in working with the communities that were served by the FNS and formed and worked
with committees composed of community members to help plan and provide care. Similar to Florence Nightingale, she believed in
the use of statistics to measure outcomes. From its onset, the FNS was so successful that there was an immediate drop in infant and
maternal deaths in the communities served by the FNS (Frontier Nursing University, 2019; January, 2009).
These three nurses all worked to improve the health of at-risk populations. They met with political leaders to advocate changes in
polices to benefit those populations, and both Nightingale and Breckinridge used statistical analysis to both support the need for
change and to evaluate their interventions. Breckinridge was an early advocate of engaging communities to help address
community health issues. They were all pioneers of nursing and, although perhaps not in name, certainly in fact, among the first
nurses working in advanced practice.
For decades, community health nurses have recognized the importance and the impact of population-based care, but large segments
of nursing practice focused primarily on caring for individual patients. Nursing remains, and should remain, a practice-based and
caring profession, but nursing practice is changing. There is an awareness of the need to provide evidence-based care and to design
interventions that have a broad impact on the populations that nursing serves, no matter the setting. Population health obligates
healthcare professionals to implement standard interventions, based on the best research evidence, to improve the health of targeted
groups of people. It also obligates nurses to discover new and effective strategies for providing care and promoting health.
Although clinical decision-making related to individual patients is important, it has little impact on overall health outcomes for
populations.
Interventions at the population level have the potential to improve overall health across communities.
This book addresses the essential areas of content for a doctorate in nursing practice (DNP) as recommended by the American
Association of Colleges of Nursing (AACN), with a focus on the AACN core competencies for population-based nursing. The
goal is to provide readers with information that will help them to identify healthcare needs at the population level and to improve
population outcomes. Although the focus is on the essential components of a DNP program, the intent is to broadly address
practice issues that should be the concern of any nurse in an advanced practice role.
This chapter introduces the reader to the concept of population-based nursing. The reader learns how to identify population
parameters, the potential impact of a populationbased approach to care, and the importance of designing nursing interventions at the
population level in advanced nursing practice.
chamberlain999 | 172.70.45.212 | 01 September 2021 1:52:13
, Population-Based Nursing
ISBN: 978-0-8261-3673-2 |
3rd_Edition
Curley, Ann
BACKGROUND
For all the scare tactics out there, what’s truly scary—truly risky—is the prospect of doing nothing.
—President Barack Obama, The New York Times, August 16, 2009
(Print pagebreak 3)
The first two decades of the 21st century have been witness to a growing and contentious debate on healthcare reforms. President
Barack Obama’s stated goals in pushing for reforming health insurance were to extend healthcare coverage to the millions who
lacked health insurance, stop the insurance industry’s practice of denying coverage on the basis of pre-existing conditions, and cut
overall healthcare costs. Driven by a need for change in how healthcare is paid for, the Patient Protection and Affordable Care Act
(ACA) was signed into law by President Obama in 2010. It went into effect over the span of 4 years beginning in 2011. Currently,
there are three different “markets” for insurance through the ACA. The federal marketplace is run solely by the federal
government. The state marketplace is run solely by the state, and in partnership marketplaces, states run many of the important
functions and make key decisions but the marketplace is operated by the federal government. The ACA includes an option that
allows states to expand Medicaid eligibility to uninsured adults and children whose incomes are at or below 138% of the federal
poverty level (there is also a provision for people living with mental illness).
One of candidate Donald Trump’s campaign promises was to repeal the ACA. Since his inauguration, the Trump administration
has issued many regulations that have effectively undermined enrollment in the ACA by cutting funding for education, marketing,
and outreach. While targeting enrollment, the Trump administration has, for the most part, enforced the law as written although the
federal role in enforcement has decreased (Jost, 2018). In December 2018, the U.S. District Court in Fort Worth, Texas, ruled that
the individual mandate requiring people to have health insurance is unconstitutional and that the remaining provisions of the ACA
are also invalid. In March 2019 the Justice Department sent a letter to the 5th U.S. Circuit Court of Appeals in New Orleans to
affirm the judgment issued by the U.S. District Court in Fort Worth, Texas (Robson, 2019). This action signaled a revival of the
current administration’s efforts to repeal the entire ACA. Three days after this letter was issued an announcement was delivered
from the White House that a Republican replacement for the ACA would not be introduced until after the 2020 elections ( Pear &
Haberman, 2019). As of this writing, the fate of the ACA remains uncertain and the contentious debate surrounding healthcare
legislation and reform in the United States continues.
There is ample evidence of a need for healthcare reform in the United States. The gross domestic product (GDP) is the total market
value of the output of labor and property located in the United States. It reflects the contribution of the healthcare sector relative to
all other production in the United States. In 1960, the health sector’s proportion (NHE) of the GDP was 5% (i.e., $5 of every $100
spent in the United States went to pay for healthcare services). By 1990, this figure had grown to 12% and by 1996, 14%. A report
issued by the Committee on the Budget of the U.S. Senate in 2008 warned that unless changes were made in how the United States
provides care to its citizens, the GDP for the healthcare sector would grow to 25% by 2025 and 49% by 2089 (Orszag, 2008). In
2017, the NHE was $3.5 trillion and accounted for 17.9% of the GDP. The Centers for Medicare & Medicaid Services (CMS)
published its forecast of healthcare costs for 2018 to 2027. It estimates that health spending will grow 0.8 percentage point faster
than the GDP per (Print pagebreak 4) year over the 2018 to 2027 period and, as a result, the health share of GDP is expected to
rise from 17.9% in 2017 to 19.4% by 2027. According to the CMS, income growth, the aging of the U.S. population, and the rising
costs of medical goods and services are the three major factors driving healthcare costs at this time (CMS, 2019). The Organization
for Economic Cooperation and Development (OECD) provides a global picture of healthcare spending. It reports that U.S.
expenditures for healthcare as reflected by the GDP is the highest among OECD countries and nearly double the average for
OECD countries.
One interesting fact that can be gleaned from that report is that the OECD attributes the difference in costs (U.S. costs as compared
to other countries) is due to private health sector prices, primarily pharmaceuticals (OECD, 2019).
The rising cost of healthcare is reflected in the insurance industry. According to the Henry J. Kaiser Family Foundation (2019a), the
average annual premium for employersponsored family health coverage in 2017 was $18,687 and the average annual contribution
from employees was $5,218.
Unfortunately, although the United States ranks first in spending on healthcare among industrialized nations, it ranks lower than
most industrialized countries in important health indicators. Two commonly used indicators for measuring a country’s health are
infant mortality and life expectancy at birth. Worldwide, the United States ranked 43rd for life expectancy at birth (life expectancy
at birth in the United States is 80 years) and 55th for infant mortality (infant mortality rate in the United states is 5.87 per 1,000
live births) in 2017 (Central Intelligence Agency [CIA], n.d.). A report issued by the Institute of Medicine (IOM, 2010) argues that
the system used in the United States for gathering and analyzing health measures is part of the problem. A second problem is the
inadequate system used in the United States for gathering, analyzing, and communicating information on the underlying factors
that lead to chronic health conditions and other risk factors that contribute to poor health. Readers can refer to Chapter 12,
chamberlain999 | 172.70.45.212 | 01 September 2021 1:52:13
, Population-Based Nursing
ISBN: 978-0-8261-3673-2 |
3rd_Edition
Curley, Ann
Implications
chamberlain999 | 172.70.45.212 | 01 September 2021 1:52:13
