Nursing science is developed through the work of nurse scientists and theorists who describe and explain what nursing is and what nurses do

Nursing science is developed through the work of nurse scientists and theorists who describe and explain what nursing is and what nurses do. Important to the development of nursing science are the foundational structures of nursing:

Nursing metatheory and nursing philosophies

Conceptual frameworks and grand theories of nursing, which are more abstract, give the discipline a unique perspective of the metaparadigm concepts and provide a path for more concrete theory development.

Locate a conceptual framework/grand nursing theory, explain how it relates to

Nursing metatheory and nursing philosophies

 

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Engaging Students in Wellness and Disease Prevention Services

COMMUNITY PHARMACY

Engaging Students in Wellness and Disease Prevention Services

Audra S. Anderson, PharmD* and Jean-Venable R. Goode, PharmD

School of Pharmacy, Virginia Commonwealth University

Pharmacy education has traditionally focused on medications and treatment of disease. However, as an accessible health care professional, pharmacists can influence healthy behaviors in their patients. En- couraging/promoting healthier lifestyles in the United States is essential because the leading causes of mortality are tobacco use, poor nutrition, and inactivity. In order to prepare pharmacists for this role, student pharmacists must be taught how to implement and deliver wellness and prevention services. Community advanced pharmacy practice experiences (APPEs) occur at an ideal point in the curriculum to engage students in these activities. This article provides preceptors with guidance and tools for restructuring the community APPE at their sites to incorporate wellness and disease prevention activities.

Keywords: wellness, disease prevention, health promotion, advanced pharmacy practice experiences, community pharmacy

INTRODUCTION Much of the morbidity and mortality associated with

chronic disease in the United States could be prevented though lifestyle and behavioral changes. Although the leading causes of death in the United States are heart disease and cancer, the actual leading causes of mortality are tobacco use, poor nutrition, and inactivity.1 Tradition- ally, pharmacy education has focused on medications and the treatment of disease. However, as accessible health- care professionals, pharmacists are in an ideal position to make an impact on patients’ behaviors. Furthermore, pharmacists have been identified as key healthcare pro- fessionals to help the nation meet the goals of Healthy People 2010.

2-4 Healthy People 2010 is a document re- flecting the nation’s health goals for reducing significant preventable threats to public health. There are 2 overarch- ing goals, which are to increase the quality and years of life of Americans and to eliminate health disparities.2 In order to accomplish these goals, as a profession, pharma- cists will need to be prepared to deliver wellness and disease prevention services.

The Center for Advancement of Pharmaceutical Ed- ucation (CAPE) recently revised the educational out- comes for colleges and schools of pharmacy.

5 The advisory panel identified public health as a major area for improvement and expansion in pharmacy education,

including teaching students strategies for promoting health improvement, wellness, and disease prevention to patients, communities, and at-risk populations, in col- laboration with other health care providers. Community advanced pharmacy practice experiences (APPE’s) are ideal areas of the curriculum for offering these learning experiences for students. Therefore, preceptors may need to restructure APPE learning activities to provide oppor- tunities for students to gain knowledge about wellness and disease prevention. This article will provide preceptors with ideas for incorporating wellness and disease preven- tion into student learning experiences.

ESTABLISHING A WELLNESS AND DISEASE PREVENTION FOUNDATION

Community practitioners should prepare for teaching wellness and disease prevention by building a basic foun- dation. The basic foundation for preceptors recommended by these authors includes the following:

(1) Creating a model of wellness and disease pre- vention in the advanced practice setting. This means being a role model for students by hav- ing at least one active service relating to well- ness or disease prevention in the practice.

(2) Providing students with pertinent literature about wellness, disease prevention, and health promotion and addressing these issues either during daily activities or during discussion sessions.2-4,6-9

From the foundation, preceptors can build on stu- dent’s knowledge using several different approaches in their practice. These include students actively participat- ing in the practice’s wellness and disease prevention

Corresponding Author: Jean-Venable R. Goode, PharmD. Address: VCU School of Pharmacy, PO Box 980533, Richmond, VA 23298-0533. Tel: 804-828-3865. Fax: 804-828-8359. E-mail: jrgoode@vcu.edu

*Dr. Anderson’s current affiliation is Ukrop’s Pharmacy, Richmond, Va.

American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.

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activities, creating new wellness and disease prevention activities for the practice, creating tools and educational materials, discussing pertinent wellness and disease pre- vention literature, writing newsletters or articles about wellness and disease prevention, marketing wellness and disease prevention services, and assessing outcomes of the programs and services (Figure 1). Ideally, students should be involved in a range of activities and discussions about wellness and disease prevention throughout an ad- vanced practice experience. Activities do not have to be complicated; however, depending on the activity, it may take more preceptor time, either through direct supervi- sion or reviewing and revising the materials students cre- ate. Preceptors will need to consider their ability to supervise and provide guidance and teaching as they de- sign activities and learning experiences around wellness and disease prevention. The following sections will focus on how to incorporate these approaches using several wellness and disease prevention strategies.

STUDENT ACTIVITIES Health Observances

The Office of Disease Prevention and Health Promo- tion publishes a comprehensive calendar of national health observances, eg, October is National Breast Cancer

Awareness Month.6 Most of the health observances have websites with additional information and materials. These materials are excellent resources for pharmacists and students developing wellness and disease prevention activities7 and can be used as a framework for many of the student activities during an APPE. Students should choose a health observance that interests them and that will occur during their experience. The student should develop an activity that can be accomplished during the rotation and be incorporated into the practice site. For example, during National Osteoporosis Awareness and Prevention Month, when dispensing a prescription, the student could counsel every female patient about the ap- propriate amount of dietary calcium and/or supplemental calcium. This would engage the student in health promo- tion activities directly with the patient.

Another activity based on the national health observ- ances includes the development of handouts and patient education materials to be made available at the pharmacy. For example, during National Stroke Awareness Month in May, students could develop handouts and patient educa- tion materials on the risk factors and signs and symptoms of stroke, and measures patients can take to prevent strokes. Students could also evaluate patient education materials that could be used by the practice site. Evaluation should

Figure 1. Algorthim for engaging students in wellness and prevention.

American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.

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include assessing the handout’s literacy level. If the prac- tice site has a population of patients whose primary lan- guage is not English, students should research the available educational materials in other languages.

If the pharmacy has space, students could develop a bulletin board or display with educational messages and handouts for a national health observance. The phar- macy could use these materials each year. If the pharmacy does not have space for a bulletin board or display, stu- dents could be involved in developing shelf-talkers or posters to convey a message about a national health ob- servance. For example, students could develop a message around National SAFE KIDS Week that could be put on the shelves displaying children’s products, toys, etc.

Students could also be involved in developing a pre- sentation about a national health observance. The presen- tation could be given in a meeting room or similar space at the pharmacy or at a community center, church, civic building, or library for various groups or associations. If the pharmacy has a newsletter or if other community pub- lications exist, a student activity could include developing an article about the national health observance.

National health observances can also be used as a plat- form for more advanced pharmacy activities such as risk assessments, screenings, lifestyle counseling, immuniza- tions, and targeted interventions. These activities will be discussed later in the article.

Students do not have to focus on a national health observance. Any of these activities could also center on other health-related issues including seasonal concerns (eg, sunscreen protection, allergies, bug bites, influenza) or disease prevention topics (eg, diabetes mellitus, obesity, depression).

Risk Assessment If the practice site or state laws do not allow pharma-

cists to conduct health screenings, risk assessments are another way to increase patient interaction and provide patients with valuable information.

10,11 Risk assessments may also be used in combination with screenings, such as the Framingham Risk Assessment for which obtaining cholesterol and blood pressure values are necessary. As mentioned previously, risk assessments may be an activ-

ity related to a national health observance or a standalone activity that is offered in the pharmacy.

Student activities can be related to designing and implementing a new risk assessment program. Part of this activity should include researching different risk assess- ment tools for a specific disease state and choosing a risk assessment tool that will be appropriate for the practice site. Table 1 contains some resources for locating risk assessments on the Internet. Some risk assessment tools are available in paper format and others are available for completion via the Internet. Once a risk assessment tool is chosen, students should design an educational handout with the risk assessment score and how to interpret the patient’s risk. Preceptors should have the students de- velop policies and procedures for the new risk assessment program.

After designing and implementing the program or if a risk assessment service is already in place at the practice site, student activities should center around identifying patients who should complete the risk assessment, per- forming and documenting the actual risk assessment, pro- viding patient counseling and education, recommending lifestyle changes or preventative measures, referring to other healthcare providers, and providing follow-up. To enhance this activity, preceptors should have the student present 1-2 patient cases from the risk assessments. The case presentations can be brief but should address patient demographics, pertinent information about the risk assess- ment, plan, education and/or counseling, and follow-up.

Health Screenings If the practice site and state laws permit pharmacists

to conduct health screenings, this is another way for stu- dents to become involved in wellness and direct patient care. Providing various screenings within the pharmacy allows students to have extensive patient contact and will assist in the development of their communication skills as well.

Students can assist with implementing a specific type of screening into the practice or they can improve and en- hance an existing screening program. Screenings that can be conducted within the community pharmacy include, but are not limited to, blood pressure, blood glucose,

Table 1. Selected Patient Risk-Assessment Resources for Use in a Community Advanced Pharmacy Practice Experience

Risk Assessment Web Site

Health Check Tools www.nlm.nih.gov/medlineplus/interactivetools/

Interactive Health Tools www.brighamandwomens.org/healthinfor/healthTools.asp

Framingham CHD Risk Calculator hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype5pub

Men’s Health www.ncpanet.org/knowyourscore/assessment.pdf

Breast Cancer bcra.nci.nih.gov/brc/q1.htm

American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.

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cholesterol, osteoporosis, Alzheimer’s disease, depres- sion, metabolic syndrome, and body fat analysis.12-22

For a practice site that does not already have established screenings in place, several steps may need to be taken.

Conducting non-invasive tests that do not require a human specimen, such as blood pressure or osteoporosis screening, have few or no regulations. Student activities for implementing these types of screenings include the development of screening forms, patient education materi- als, and a general policy and procedures guide for the site.

Tests that require human specimens, such as blood samples, are considered invasive and there are more strin- gent regulations and requirements for conducting those tests.

23 The Clinical Laboratory Improvement Act (CLIA) of 1988 was enacted to assist in the standar- dization of laboratory screening, personnel, and quality control. There are varying levels of laboratory testing based on the complexity of the test being performed. Most pharmacy-based screenings, such as blood glucose or cholesterol testing, are waived tests and are less regulated. These tests require the site to have a certificate of waiver from a local or regional Centers for Medicare and Med- icaid Services (CMS) office and to agree to follow good laboratory practices. To enroll in the CLIA program a pharmacy must complete and submit CMS Form 116 for a Certificate of Waiver. A CLIA waiver is required to allow pharmacy-based laboratory screenings. If there are multiple screening sites, each site must have its own CLIA waiver. Complete information regarding CLIA and the waiver process is available at www.cms.hhs.gov/clia. A full list of waived tests can be found at www.cms.hhs.gov/ clia/waivetbl.pdf. Students can learn about maintaining a pharmacy-based laboratory including good laboratory procedures, standard operating procedures, and quality control. Along with obtaining the CLIA waiver for per- forming screenings, pharmacies must also comply with the universal precautions for blood-borne pathogens regulations from the Occupational Safety and Health Administration (OSHA). OSHA regulates worksite safety and provides guidelines for protection, exposure actions, and proper policies and procedures. Complete information is available on the OSHA website at www. osha.gov.

Another activity for students is researching the vari- ous instruments and devices to perform screenings. For example, there are numerous lipid analyzers available for cholesterol screening. The most commonly used device is the Cholestech LDX. Obtaining information such as cost, supplies needed, and reliability of the instrument is im- portant in selecting the appropriate device.

For practice sites that already have patient screenings in place, students could assist with enhancing the current

program. Finding ways to increase the number of patients that take advantage of the screening services is an impor- tant task with which students could assist.

In addition to assisting with establishing and promot- ing the screening program, students can participate in administering the program, performing and documenting screening tests, providing counseling and education, rec- ommending lifestyle changes or preventative measures, referring patients to other healthcare providers, and fol- lowing up with patients to determine effectiveness/out- comes of the program. Preceptors should have students present 1-2 patient cases per week from the screening program. Students should be able to justify the recom- mendations made to their patients.

Involving students in planning and implementing a screening service in a pharmacy practice provides them with a unique and valuable experience, increased confi- dence, and the skills and tools for developing their own services and programs.

Specific Screenings Students can be asked to lead a presentation and

discussion of particular diseases, prior to conducting screenings. Providing appropriate and accurate patient counseling requires knowledge of the current guidelines and recommendations for the disease. For example, reviewing the JNC 7 Guidelines and all available anti- hypertensive medications with the student is a good way to increase his/her knowledge and confidence rela- ted to the screening and management of high blood pressure. Also, instruction in the proper operation of the equipment that will be used in the screening is impor- tant prior to the students’ interaction with patients. For example, prior to providing cholesterol screening, the student should observe how to obtain the blood sample, operate the lipid analyzer, and counsel the patient based on the results. Patient education after a screening should include discussing diet, exercise, and potential drug therapy alternatives. Observing the preceptor screening a patient and discussing the patient’s disease state will help the student become confident in providing patient care.

Immunizations Immunizations are another area of wellness and dis-

ease prevention that pharmacists can implement at their practice site. Pharmacists have the authority to administer immunizations in 44 states.24 Additionally, many col- leges and schools of pharmacy have incorporated vaccine science and vaccines into the curriculum; therefore, APPE students will usually have some knowledge of immuniza- tions. In 1997, the American Pharmacists Association’s Board of Trustees adopted guidelines for pharmacy-based

American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.

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immunization advocacy.25 The guidelines include 3 lev- els: advocacy, facilitation, and administration. Activities for students should be designed around these levels.

In states that do not allow pharmacist or student phar- macist administration of immunizations, students should be involved in recommending immunizations to at-risk populations, educating patients about the vaccines, and referring patients to an appropriate health care provider. Additionally, students could research vaccine controver- sies and create handouts for patients with the facts about the vaccine controversy. Students could also research anti-vaccine web sites so they have an understanding of the information patients may be exposed to on the Inter- net.

26 Students could be responsible for updating the phar- macy’s staff on the frequently changing recommendations regarding vaccines and for developing a vaccine record card for patients.

If the pharmacy practice is active in the second level, facilitation of immunizations (having another healthcare professional administer vaccines at the site), students could assist with screening patients for immunizations and processing paperwork. Students could also be in- volved with identifying at-risk patients, marketing the service, and answering questions.

In states that allow pharmacists to administer immu- nizations, students could assist with designing and imple- menting a new program or enhancing an existing one. For example, if the practice site offers only influenza vaccinations during October and November, students could design and implement a year-round immunization program, identifying patients at risk for other diseases for which immunizations are available such as tetanus- diphtheria or pneumococcal vaccine. Students could assist with the administration of vaccines if allowed by state law.

Preventative Services Another way to approach wellness and disease pre-

vention is to target patients based on their age. The US Preventative Health Services Task Force has a guide to preventative health services which is based on age and gender.

27 In addition, several other organizations publish preventative health checklists based on age and gender including the American Academy of Family Physicians (www.aafp.org), the American College of Physicians (www.acponline.org), and the American College of Obstetricians and Gynecologists (www.acog.com). Stu- dents could use these checklists to design a preventative services counseling program for the practice site. Ano- ther exercise is to have the student assess the usability of preventative health guidelines (ie, how difficult is it to identify the services recommended and determine

how frequently they should be performed), and sug- gest changes that would make the checklists easier to use.

Lifestyle Counseling Knowledge and training about educating patients on

proper lifestyle choices is one of the keys to actually helping them make positive changes. Realizing each patient’s specific situation and goals is essential in help- ing them attain those goals. Additionally, it is important to understand how patients make lifestyle changes. APPE activities could include researching and learning about the different theories addressing changing patient behav- iors. Several models have been used by pharmacists in- cluding the Health Belief Model, Fishbein-Ajzen Theory of Reasoned Action, and the Transtheoretical Model.

28-30

Students should observe preceptors using these models in patient counseling, and then employ them when working with patients trying to make lifestyle changes. Other techniques used for disease and wellness programs that students should learn include conducting motiva- tional interviewing and providing self-management education.31

Smoking Cessation Tobacco use is one of the leading causes of mortality

in the United States. Providing directed interventions to- ward patients who use tobacco is another way pharmacists and student pharmacists can become involved in wellness and disease prevention in their practice.

Students could provide brief interventions with patients, such as counseling them on the benefits of quit- ting, or more detailed interventions as part of a com- prehensive smoking cessation program that includes conducting one-on-one counseling, making drug ther- apy recommendations, and providing follow-up care/ counseling.32-34 Students could assist in the development of forms describing the various nonprescription and pre- scription smoking cessation products available and the advantages and disadvantages, side effects, and cost of each.35 Providing patients with detailed information re- garding available pharmacotherapy can help them make informed decisions. To assist in the implementation and delivery of a smoking cessation program within the prac- tice site, students could develop patient handouts, and patient interview and documentation forms.32,33

Students could also participate in one-on-one patient counseling sessions provided for patients. Additionally, some smoking cessation programs may include group ed- ucational sessions, students may be involved in creating and/or teaching these sessions. Offering smoking cessation therapy management and obtaining payment for the services will give the student a valuable experience in the

American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.

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delivery of wellness and disease prevention services within a pharmacy practice.

Basic Nutrition and Exercise Counseling A fundamental component of wellness and disease

prevention is good nutrition and adequate exercise. Stu- dents should learn the basic nutrition and exercise infor- mation needed for pharmacists to appropriately and effectively counsel their patients regarding either pre- vention or management of disease.

8-9 This topic is usually not stressed in pharmacy curriculums and APPE’s pro- vide an excellent forum for students to learn about nutri- tion and exercise and practice their patient counseling skills.

Preceptors can assign readings and have a topic discussion about nutrition and exercise.

8-9 Students can research and learn about the differences between fad diets and create a chart for the pharmacy staff. Stu- dents could also do this for vitamins and dietary sup- plements.

Nutrition and exercise counseling can be incorporated into patient counseling during risk assessment, disease screening, and targeted intervention programs. Students could be involved in developing, implementing, and mar- keting a new patient care service for weight management or starting a body composition screening service. Possible activities would be similar to activities discussed in pre- vious sections.

Targeted Interventions Targeted intervention programs are programs designed

to focus on promoting wellness, disease prevention, and healthy living for patients who already have a chronic disease. As with the other areas of wellness, student activities could include developing and implementing the target intervention program, including writing poli- cies and procedures, creating monitoring forms, and de- veloping or evaluating existing patient educational materials. For example, a targeted intervention program for patients with diabetes might center on ensuring that patients who have diabetes are receiving appropriate medications such as ACE inhibitors or aspirin therapy.

36

Even though this is not really wellness, it is prevention of future problems related to diabetes mellitus. A targeted intervention program for patients with diabetes mellitus could also include ensuring that these patients have access to appropriate preventative services, such as annual check-ups with a podiatrist and ophthalmologist and bi-annual check-ups with a dentist.

Conducting targeted intervention provides students with lessons in communicating with patients and pro- viders, and in managing chronic diseases. Other activities could include the preceptor conducting topic discussions

with the student that reinforce the student’s knowledge of the pathophysiology and the pharmacologic and non- pharmacologic (lifestyle modifications and preventative measures) treatment of the disease. Students could be re- quired to create a patient case and present all of this in- formation to the preceptor, or ideally, the preceptor and the student could discuss specific patients in the targeted intervention program.

Targeted intervention programs can be used to assess the outcomes of the practices’ patient care activities. These outcomes can be used by the pharmacists to market patient care services to self-insured employers or other payors. This gives the preceptor another opportunity for teaching APPE students. Students can be involved in the process of organizing the outcomes for presentation and developing materials for the meeting. Additionally, the preceptor can engage the student in discussions about compensation for patient care services.

Marketing Acquiring a basic knowledge of marketing is impor-

tant for APPE students since effectively marketing a phar- macy’s services to the appropriate patient population not only increases the site’s revenue stream, it ensures that patients are aware of the valuable and potentially life- saving services offered. Students should be involved with the marketing of any of the previously mentioned health promotion programs and preventative services. Students should be able to design marketing materials (signs, shelf talkers, brochures, and patient handouts) including a plan for how to inform patients about any new service or pro- gram. Students could also develop a marketing strategy that targets others such as caregivers, third-party payors, and family members. Preceptors could assign readings for students to learn more about marketing pharmacy services.

37-39 Another valuable activity is to have stu- dents participate in marketing the program to patients directly. Preceptors should use this activity to have discussion with the student about marketing, including the difference between product and service marketing. As another component, students could visit local physi- cians and their practices to market new programs and services.

Outcomes Assessment All pharmacy services should be evaluated to determine

the outcomes and success of the program and then this in- formation should be used for continuous quality improve- ment. A learning activity for students could be designing an evaluation process for the risk-assessment program or per- forming evaluation activities such as tallying numbers of patients, number at risk, and number of referrals. Students could be involved with designing or researching available

American Journal of Pharmaceutical Education 2006; 70 (2) Article 40.

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evaluation tools for the program (eg, patient satisfaction instruments).40,41

CONCLUSION A community APPE provides an excellent opportunity

for developing and implementing wellness and disease pre- vention activities. Additionally, preceptor involvement with these activities provides a positive role model for students. In turn, teaching and practicing wellness and dis- ease prevention for the benefit of patients and student phar- macists will help improve the professions’ capability of making an impact on the health of the nation.

REFERENCES 1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-45. 2. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. 2 vols. Washington, DC: U.S. Government Printing Office;2000. Available at: www.healthypeople.gov. Accessed January 18, 2006. 3. Babb VJ, Babb J. Pharmacist involvement in Healthy People 2010. J Am Pharm Assoc. 2003;43:56-60. 4. Calis KA, Hutchinson LC, Elliott ME, Ives TJ, et al. Healthy People 2010: challenges, opportunities, and a call to action for America’s pharmacists. Pharmacotherapy. 2004;24:1241-94. 5. Educational Outcomes 2004. Center for Advancement of Pharmaceutical Education. American Association of Colleges of Pharmacy. 2004. Available at www.aacp.org/Docs/MainNavigation/ Resources/6075_CAPE2004.pdf. Accessed February 17, 2005. 6. 2005 National Health Observances. National Health Information Center, Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Washington, DC. Available at: www.healthfinder.gov/library/nho/nho.asp. Accessed July 11, 2005. 7. Ciardulli LM, Goode JR. Using health observances to promote wellness in community pharmacies. J Am Pharm Assoc. 2003;43:61-8. 8. Dombrowski SR. Pharmacist counseling on nutrition and physical activity – part 1 of 2: understanding current guidelines. J Am Pharm Assoc. 1999;39:479-91. 9. Dombrowski SR, Ferro LA. Pharmacist counseling on nutrition and physical activity – part 2 of 2: helping patients make changes. J Am Pharm Assoc. 1999;39:613-27. 10. Giles JT, Kennedy DT, Dunn EC, et al. Results of a community pharmacy-based breast cancer risk assessment and education program. Pharmacotherapy. 2001;21:243-53. 11. Boyle TC, Coffey J, Palmer T. Men’s health initiative risk assessment study: effect of community pharmacy-based screening. J Am Pharm Assoc. 2004;44:569-77. 12. DeHart RM, Gonzalez EH. Osteoporosis: Point-of-Care Testing. Ann Pharmacother. 2004;38:473-81. 13. Rosenthal WM. Implementing bone mineral density testing in the community pharmacy. J Am Pharm Assoc. 2000;40:737-45. 14. Goode JV, Swiger K, Bluml BM. Regional osteoporosis screening, referral, and monitoring program in community pharmacies: findings from Project ImPACT Osteoporosis. J Am Pharm Assoc. 2004;152-60. 15. Elliot ME, Meek PD, Kanous NL, et al. Osteoporosis screening by community pharmacists: use of National Osteoporosis Foundation resources. J Am Pharm Assoc. 2002;42:101-10.

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Health Value, Perceived Social Support, and Health Self- Efficacy as Factors in a Health-Promoting Lifestyle Erin S. Jackson PhD a , Carolyn M. Tucker PhD a & Keith C. Herman PhD b a The Psychology Department, The University of Florida, Gainesville b Department of Child and Adolescent Psychiatry, Johns Hopkins University, Baltimore, MD Published online: 07 Aug 2010.

To cite this article: Erin S. Jackson PhD , Carolyn M. Tucker PhD & Keith C. Herman PhD (2007) Health Value, Perceived Social Support, and Health Self-Efficacy as Factors in a Health-Promoting Lifestyle, Journal of American College Health, 56:1, 69-74, DOI: 10.3200/ JACH.56.1.69-74

To link to this article: http://dx.doi.org/10.3200/JACH.56.1.69-74

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Health Value, Perceived Social Support, and Health Self-Efficacy as Factors

in a Health-Promoting Lifestyle

Erin S. Jackson, PhD; Carolyn M. Tucker, PhD; Keith C. Herman, PhD

Abstract. During their college years, students may adopt health- promoting lifestyles that bring about long-term benefits. Objec- tive and Participants: The purpose of this study was to explore the roles of health value, family/friend social support, and health self-efficacy in the health-promoting lifestyles of a diverse sample of 162 college students. Methods: Participants completed an Assessment Battery consisting of the following instruments: (1) a demographic questionnaire, (2) the Multi-Dimensional Support, (3) the Value on Health Scale, (4) the Self-Rated Abilities for Health Practices, (5) the Health-Promoting Lifestyle Profile II, and (6) the Marlowe-Crowne Social Desirability Scale. Results: Correlational analyses indicated that health value, perceived fami- ly/friend social support, and health self-efficacy were significantly associated with engagement in a health-promoting lifestyle. An analysis of covariance (ANCOVA) revealed that health value and health self-efficacy significantly predicted the level of engagement in a health-promoting lifestyle. Perceived family/friend social support was not significant in the model. As age increased, level of perceived family/friend social support decreased. Conclusion: Present findings suggest that health interventions programs focus on assessing and increasing health self-efficacy and health value of these youth. College health professionals can design and evaluate the effectiveness of such health-promoting interventions.

Keywords: health-promoting lifestyle, health self-efficacy, health value, social support

any college students are living away from home for the first time and are challenged with the responsibility of their personal health.1 They are

also challenged with greater autonomy, new demands, and stressors associated with a different structure to daily life.2 The behaviors that college students develop in the process of meet-

ing these challenges may become parts of their lifestyle into adulthood. These behaviors can promote health or increase the frequency of risk behaviors that lead to poor health.3 The promotion and maintenance of health-promoting lifestyles for college students are critical to prevent the development of chronic diseases.4 In addition, health-promoting behaviors make it more likely that students will be successful in school, by reducing absenteeism and fostering positive mental health.4 Research aimed at identifying the health-promoting needs of college students may assist in the adoption of healthy lifestyle behaviors throughout their life spans.

To improve the health of college students, it is imperative to reduce the frequency, delay the onset, and aim for the prevention of health-risk behaviors. Therefore, an impor- tant goal of researchers investigating college student health must be to identify factors that influence health-promoting behaviors, such as exercising frequently, eating healthy foods, and getting sufficient rest.

Pender5 proposed the Health Promotion Model to explain the multidimensional pattern of a health-promoting life- style and to guide future research. According to this model, performing health-promoting behaviors can be achieved through the direct and indirect effects of a combination of individual cognitive-perceptual factors, modifying factors, and cues to action.6 Cognitive-perceptual factors are moti- vational mechanisms that directly influence the maintenance of health-promoting behaviors. These factors may include definitions of health, health value, perceived health status, perceived control, perceived self-efficacy, perceived benefits, and perceived barriers. We used 2 key cognitive-percep- tual terms: health value and self-efficacy. Health value is an enduring belief that a specific health-promoting behavior is preferred to an alternative behavior. Self-efficacy is the belief that one can successfully engage in an expected health behav- ior. Modifying factors are variables that impact the decision-

Drs Jackson and Tucker are with the Psychology Department at the University of Florida, Gainesville. Dr Herman is with Johns Hopkins University’s Department of Child and Adolescent Psychiatry, Baltimore, MD.

Copyright © 2007 Heldref Publications

JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 56, NO. 1

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making process by influencing individual perceptions. These variables involve demographic factors (eg, age, gender, race, ethnicity, education, and income), biologic characteristics (eg, body weight, height, and body fat), interpersonal influ- ences (eg, social support), situational factors (eg, access to alternatives), and behavioral factors (eg, past experiences). A key modifying factor term used in this article is perceived social support, which is a perceived sense of social belong- ing or social connection influenced by the preferred versus desired frequency of social interaction and level of intimacy in those interactions. This modifying factor can serve as a cue to action. Cues to action are variables that may move the individual from the decision-making phase to the action phase. These cues may be personal awareness, advice from others, the impact of mass media, and social and political movements.

Pender’s Health Promotion Model5 can be viewed as an extension and elaboration of the more familiar Health Belief Model.4 Pender’s model is more comprehensive because it delineates multiple cognitive-perceptual variables and modifying variables that lead to health decisions and behaviors. For instance, one of the primary criticisms of the Health Belief Model has been its failure to account for self- efficacy and social support,4 2 central variables in Pender’s Model. Pender’s Model has been successfully applied to understanding the health-promoting lifestyles of several populations, such as older women,7 blue collar workers,8 ambulatory cancer patients,9 adolescent girls,10 and college students.11

Although the health behaviors of college students have been frequently studied,12–17 few studies have used Pender’s Health Promotion Model to guide such research.18 Pender’s Model may be particularly applicable to college students because of its emphasis on modifiable self variables, health value, and self-efficacy. Recent studies have supported its applicability to adolescents and diverse samples.19,20 We based our study on Pender’s Model and designed it to explore the factors associated with the health-promoting lifestyles of college students. Health value and perceived health self- efficacy were the cognitive-perceptual factors from Pender’s Model that we examined as motivational tools that may directly influence the adoption and upholding of positive health behavior. We examined social support as a modifying factor that may affect the decision-making process involved with engagement in positive health behavior. Aspects of social support, such as advice from others, serve as cues to action that may guide the college students from the deci- sion-making stage to the action phase of engaging in health promoting behaviors. In sum, we explored the roles of health value, self-efficacy, and social support in the engagement in health-promoting behaviors of college students.

METHODS Participants

Following Institutional Review Board approval, the first author recruited students from 2 introductory psychology classes at a large university located in the southeastern part of

the United States. We selected these classes because students from a wide range of majors and of varying backgrounds typi- cally enroll in these courses and because they provided easy access to a large pool of students. We distributed question- naires to 180 interested students and collected them during subsequent classes. We informed participants that participation was voluntary and anonymous. The response rate was 90%.

The sample included 162 participants; 49 were men and 113 were women. The median age of the participants was 20 years (standard deviation [SD] = 0.85). The ethnic backgrounds of the students comprised 3% Latino/Hispanic black, 7% Asian American/Pacific Islander, 8% Latino/His- panic white, 11% African American/black, 68% Caucasian/ white American, and 4% other. Table 1 shows additional descriptive data obtained from these participants.

TABLE 1. Descriptive Statistics for Research Participants

Demographic variable n %

Age (y) 18 6 3.7 19 38 23.5 20 43 26.5 21 35 21.6 22 22 13.6 23 and older 18 11.0 Gender Female 113 69.8 Male 49 30.2 Race/ethnicity African American/black 17 10.5 Asian American/Pacific Islander 11 6.8 Caucasian/white American 110 67.9 Latino/Hispanic black 4 2.5 Latino/Hispanic white 13 8.0 Other 7 4.3 Class Freshman 1 .6 Sophomore 30 18.5 Junior 73 45.1 Senior 56 34.6 Post-baccalaureate 2 1.2 Family income Less than $20,000 8 4.9 $20,001–$40,000 21 13.0 $40,001–$60,000 39 24.1 $60,001–$80,000 26 16.0 $80,001–$100,000 22 13.6 More than $100,001 40 24.7 Primary caregiver in home Mother/mother figure 82 50.6 Father/father figure 54 33.3 Other relative 3 1.9 Other 11 6.8 Adults mostly present in home Mother/mother figure 32 19.8 Father/father figure 2 1.2 Mother and father 124 76.5 Other 4 2.5

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Instruments We used an Assessment Battery consisting of the follow-

ing instruments: (1) a demographic questionnaire to obtain information including age, gender, race, current academic level, and family income; (2) the Multi-Dimensional Sup- port Scale21 to assess the frequency/availability and ade- quacy of perceived social support from family and friends (previously reported internal reliability coefficient alphas for the scale range from .81 to .9021); (3) the Value on Health Scale22 to assess the value placed on or the importance of different aspects of health, including fitness or good physical state, energy or vigor, endurance or stamina, maintaining an appropriate weight, and opposition to disease (the Value on Health Scale has good internal consistency [α = .77])22; (4) the Self-Rated Abilities for Health Practices Scale23 to assess health self-efficacy regarding exercise, well-being, nutrition, and general health practices (the internal consistency of the Self-Rated Abilities for Health Practices Scale is .92)23; (5) the Health-Promoting Lifestyle Profile II (HPL II)24,25 to measure the degree of engagement in a health-promoting lifestyle along 6 dimensions: spiritual growth, health respon- sibility, physical activity, nutrition, interpersonal relations, and stress management (the Cronbach alpha for the total scale is .94 and ranges from .79 to .87 for subscales24); and (6) the Marlowe-Crowne Social Desirability Scale, short form (M-C SDS [20],26 to measure the amount of variance in the data caused by the participant’s desire to present self in a socially desirable manner. (Reliability coefficients for the 20-item instrument range from .78 to .83.26) Researchers in prior studies with college students used all the scales that we used.

Procedure We recruited participants from 2 introductory psychol-

ogy classes. Extra course credit was provided for each study participant. We informed students that their participation was voluntary and anonymous and that at any time they could withdraw from the study or refuse to answer any question. We told students that the purpose of the study was to inves- tigate the relationships between beliefs and health behaviors. We asked those students interested in participating to demon- strate their interest by collecting a packet after class.

We distributed an Informed Consent Form and an Assess- ment Battery in an envelope to students who approached the investigator for a packet. We instructed participants to complete the assessments in the packets at home and return them at 1 of the following 2 class meetings, which were held 2 days and 4 days after the initial distribution of Assessment Batteries. We also informed participants of the contents of the packet. We then gave participants instruc- tions for completing the contents of the package. First, we instructed participants to read and sign the Informed Consent Form. Second, we told them to complete the Assessment Battery, which included the 5 assessments described above that totaled 113 items. Third, we instructed participants to complete the Demographic Questionnaire. To ensure confidentiality, we told participants to place the

completed Assessment Battery and Demographic Ques- tionnaire, which were stapled together, into the provided envelope and to seal the envelope. We told participants to drop the Informed Consent Form in a box that was separate from the box in which the envelopes with their completed questionnaires were collected to guarantee that their ques- tionnaire responses were kept confidential.

Upon submission of the completed Assessment Battery, we gave each participant a Debriefing Form to read and sign that was kept separate from the completed packets. The Debriefing Form outlined the nature and purpose of the study. We asked participants to return the signed Debriefing Form to the Principal Investigator immediately after read- ing it over carefully and having any questions addressed.

Finally, to obtain extra course credit, participants signed a roster upon submission of their signed Debriefing Form. We gave this roster directly to the class instructors or their teaching assistants to insure each student received extra credit for research participation.

RESULTS Preliminary Analysis

We performed preliminary Pearson product-moment cor- relation analyses to examine the relationship between social desirability and the other studied variables. The analyses revealed that social desirability significantly correlated with health-promoting lifestyle (r = .28, n = 144, p < .01), per- ceived family/friend social support (r = .17, n = 153, p < .05), and health self-efficacy (r = .17, n = 153, p < .05). Therefore, we used social desirability as a covariate in the analyses used to test the proposed hypotheses and research question.

Results Regarding the Hypotheses and Research Question

Correlation analyses revealed significant positive rela- tions between the health-promoting lifestyle variable and levels of health value (r = .51, n = 141, p < .01), perceived family/friend social support (r = .35, n = 141, p < .01), and health self-efficacy (r = .61, n = 141, p < .01). Table 2 pres- ents the correlational matrix from these analyses.

We conducted an analysis of covariance (ANCOVA) to determine the unique contribution of 3 independent vari- ables—health value, perceived family/friend social support, and health self-efficacy—in predicting health-promoting lifestyle when controlling for social desirability. The over- all model was significant, F(4,132) = 36.35, r2

adj = .51, p

< .01, and accounted for 51% of the variance in level of engagement in a health-promoting lifestyle. Significant main effects included health self-efficacy, t(1) = 7.03, p < .001, and health value, t(1) = 5.18, p < .001 (see Table 3).

We also performed a multivariate ANCOVA (MAN- COVA) to determine whether there was a significant dif- ference in the level of value of health, level of perceived family/friend social support, level of health self-efficacy, or level of engagement in a health-promoting lifestyle in association with gender, age, family income, or ethnicity

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(see Table 4). The dependent variables in the MANCOVA were health value, perceived family/friend social support, health self-efficacy, and health-promoting lifestyle. The independent variables included gender, age, family income, and ethnicity. We once again entered social desirability as a covariate. The multivariate tests revealed that race, Wilks’s lambda (Λ) = .675, F(20, 398) = 2.512, p < .05, and age, Λ = .924, F(4,120) = 2.468, p < .05, had statistically sig- nificant main effects. Univariate results indicated that race was significantly associated with level of engagement in a health-promoting lifestyle, F(5, 123)= 4.22, p < .01; how- ever, follow-up tests to determine the nature of these asso- ciations revealed no significant racial differences in level of engagement in health-promoting lifestyle. Univariate tests also revealed that age was significantly associated with level of perceived family/friend social support, F(1, 123) = 6.46, p < .05. Inspection of relationship direction indicated

that as participants’ age increased, level of perceived fam- ily/friend social support tended to decrease.

COMMENT Our research affirmed the importance of health value and

health self-efficacy as variables in health-promoting life- styles among college students. Intervention programs that empower students to make positive health decisions and to engage in health-promoting behaviors may counter the influences to engage in health risk behaviors such as sub- stance abuse that are common in college environments.3,4

Health value and health self-efficacy significantly con- tributed to participants’ engagement in a health-promoting lifestyle. Participants who placed a higher value on health and on health self-efficacy tended to also have a greater involvement in a health-promoting lifestyle. This find- ing lends support for Pender’s Health Promotion Model

TABLE 2. Intercorrelations of Major Investigated Variables

Variable 1 2 3 4

1. Health value — 2. Family/friend social support .23 — 3. Health self-efficacy .29 .34 — 4. Health-promoting lifestyle .51 .35 .61 —

Note. All variables are significant at p < .01. N = 141.

TABLE 3. Analyses Predicting Health-Promoting Lifestyle, Controlling for Social Desirability

Variable B SE t p

Health value 2.32 .33 5.18 .00*

Perceived social support .52 .35 1.49 .14 Health self-efficacy .60 .09 7.03 .00*

Note. F(4,132) = 36.35, r2 adj

= .51, p < .01. *p < .01.

TABLE 4. Analyses of Significant Variables in Multivariate Analyses

Significant relationship B t p

Race and health-promoting lifestyle*

African American –13.72 –1.13 .26 Asian American –17.66 –1.39 .17 Caucasian 3.58 .32 .75 Latino/Hispanic black –11.97 –.81 .42 Latino/Hispanic white –8.89 –.71 .48 Age and family/friend social support† –.46 –2.54 .01

*F(5, 123) = 4.22, p < .01. †F(1, 123) = 6.46, p < .05.

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because it is consistent with the Pender’s tenet that engage- ment in health behavior is a function of the value attached to the outcome of good health and of personal beliefs, such as self-efficacy. However, family/friend social support was not a significant predictor of engagement in a health-promoting lifestyle. This unexpected finding suggests that, for this col- lege student sample, personal variables, such as health value and health self-efficacy, are stronger influences on engage- ment in a health-promoting lifestyle than are the external influence of general family/friend social support. Because college students typically spend more time away from home and their families, family support may be less influential in their engagement in health-promoting lifestyles. Indepen- dent exploration of family versus friend social support may provide clarity regarding the role of external social support in the health-promoting activities of college students.

Implications for College Student Personnel

Health professionals working on college campuses can facilitate the adoption and maintenance of health-promot- ing lifestyles among college students.13 By providing out- reach education on health issues, the self-efficacy beliefs of college students may be increased. As students are informed and instructed on how to perform certain posi- tive health behaviors, confidence in their ability to perform those actions may also be enhanced. Planners of outreach education programs can address breast self-examining, constructing healthy meal plans, balancing salt and sugar intake, proper exercise techniques, stress management, and relaxation. Administrators can also address these self-care practices at campus health fairs or in health classes.

Health professionals can also develop and implement programs aimed at increasing the health value of college students. Furthermore, they can offer seminars address- ing self-management strategies for engaging in health behaviors that decrease the likelihood of cancer, diabetes, hypertension, obesity, arthritis, substance addiction, and unplanned pregnancy. By explicitly describing the link between current health behavior and long-term health qual- ity of life, students’ value of health may be enhanced. At the same time, college students may desire healthier lifestyles and, therefore, increase levels of engagement in health-pro- moting behaviors. In addition, changing perceived social norms about health behaviors is an established way to alter health value valences.4 For instance, most students who engage in harmful behaviors, such as smoking or excessive alcohol use, significantly overestimate the percentage of their peers that engage in the same behaviors. Measuring social norms on campus and then advertising them can significantly alter student health value beliefs.

College and university administrators must aid college students in the adoption and maintenance of health-promot- ing lifestyles. By creating campuses in which students feel empowered to make healthy choices, college students can adopt healthy lifestyles as they enter the workforce. Health researchers, health educators, and mental health providers can facilitate this empowerment.

Our findings that 2 self variables, health self-efficacy and health value, were significant predictors of engagement in a health-promoting lifestyle among college students provides support for health-promoting interventions that empower college students to make positive health decisions. College health professionals possess the necessary skills to promote this empowerment of college students through teaching self-management strategies and using cognitive interven- tions designed for the adoption and maintenance of health- promoting lifestyles.

Implications for Future Research

Our study has several implications for advancing research. First, researchers should explore the health- promoting lifestyles of college students of different eth- nic backgrounds. Different ethnic populations must be researched independently to better grasp the motivating factors for each population. Possible contributing vari- ables include family value of health, family and close friend support for positive health behavior, family health practices, locus of control, and perceived barriers to health-promoting lifestyles.

Second, future studies are needed in which researchers further examine the role of health value in the health- promoting lifestyles of college students. It would also be beneficial to conduct this research with larger samples that include a representative number of male college students.

Third, researchers also should investigate the roles of family support and friend support separately as external social support influences on health-promoting lifestyles among college students. Because college students have limited interaction with their families during the college years, the support of friends may have been what accounted for the weak association between family/friend support and engagement in a health-promoting lifestyle in the present study.

Fourth, future research in which investigators explore the role of health self-efficacy in health-promoting lifestyles is clearly indicated. Such research would benefit from the inclusion of a general self-efficacy measure so that the relative influence of general self-efficacy and health self- efficacy can be assessed within the same study.

Limitations

Although our findings generally supported the hypotheses, some limitations must be considered when interpreting the results. The first major limitation of this study concerns the small sample size; 162 students participated in the study, and 68% were Caucasian Americans. Furthermore, the sample was predominantly female (70%). Because the sample was drawn from 2 classes on a single university, it is not known how well the findings generalize to students in other schools in other parts of the country or even to students at the same school. Additional research is needed to augment the present findings.

A second limitation of the study is the use of a cross- sectional design. This design does not allow for the infer-

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ence of causality. Therefore, research using longitudinal data may assist in determining a specific relationship between the investigated factors and engagement in a health-promoting lifestyle among college students.

Conclusion

Colleges and universities are environments where health professionals can establish intervention programs to pro- mote the adoption and maintenance of healthy lifestyles among college students. These programs are particularly meaningful, given that college students are challenged with the responsibility for their personal health.1 New life experiences in college may lead college students to engage in unhealthy behaviors, such as unprotected sex, substance abuse, or smoking. Research in which investigators aim to identify factors that contribute to health-promoting life- styles among college students can provide information that would aid in establishing effective health-promotion pro- grams on college campuses.

NOTE For comments and further information, address corre-

spondence to Dr Keith C. Herman, Johns Hopkins Univer- sity, 600 N. Wolfe St., CMSC 394, Baltimore, MD 21287 (e-mail: kherman6@jhmi.edu).

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Epidemiology in Community Health Care

NUR4636 – Community Health Nursing

Case Study

Chapter 7

Epidemiology in Community Health Care

The community health nurse is reviewing several epidemiologic research studies

with student nurses that are beginning a 6-month community health rotation.

Epidemiology offers community health nurses a specific methodology for assessing

the health of aggregates. The nurse has requested that the student participate in a

semester long epidemiologic research study

1. Why is it important that community health nurses review epidemiologic

research?

2. What are the seven steps that student nurses must consider when

participating with the community health nurse in the epidemiologic research

study?

3. The goals of epidemiologic investigation are to identify the causal

mechanisms of health and illness states and to develop measures for

preventing illness and promoting health. Epidemiologists employ an

investigative process that involves a sequence of three approaches that build

on one another. What are the three investigate approaches?

4. The community health nurse has been requested to figure out the prevalence

rate and the incidence rate of influenza for a 1-month period of time. There

were 1,000 students who reported flu-like symptoms during 1 month in a

population of 5,000 students at the local community college, and during the

same month, 500 individuals developed influenza. What is the prevalence

rate and incidence rate?

 

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Structure and Economics of Community Health Services

NUR4636 – Community Health Nursing

Case Study

Chapter 6

Structure and Economics of Community Health Services

Many factors and events have influenced the current structure, function, and

financing of community health services. Understanding this background gives the

community health nurse a stronger base for planning for the health of the

population. A group of student nurses have been requested to present a 1 hour in

service to the local health department on the structure and economics of

community health services as part of the community health nursing course

requirements. The presentation has to include information about a variety of topics.

1. What are the key historical events and philosophical developments that have

led to today’s health services delivery systems?

2. What are the differences between the functions of public versus private

sector health care agencies?

3. What are the three core functions of public health as they apply to health

service delivery?

4. There are several trends and issues that have influenced community health

care financing and delivery that are important in understanding health care

economics and helping to improve community health. What are some of

these trends and issues?

5. In what important ways has the changing nature of health care financing

adversely affected community health nursing and its practice?

 

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Global Public Health Nursing: Population Health Around the Globe

NUR4636 – Community Health Nursing

Case Study

Chapter 16

Global Public Health Nursing: Population Health Around the

Globe

Community health nurses work with populations that vary from country to country,

and to serve them appropriately requires an understanding of the ways in which the

context in which they are located interacts with their health status and health

histories. Student nurses are spending a month in Africa reviewing global health

and international community health nursing.

1. The student nurses are required to examine the population in Africa to assess

the kinds of health conditions the population experiences. What is the

context and framework for delivering community-based nursing within the

context of international community health nursing?

2. The student nurses are examining the population to assess the kinds of

health conditions the African population experience. The international

community health nurses suggest using the three eras and the three P’s as

helpful guides in this assessment. What are the three eras and the three P’s

that the student nurses need to consider?

3. What major international, national, regional, and local organizational

structures and organizations affect the ways in which community health

nursing is practiced?

 

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Adult Women and Men

NUR4636 – Community Health Nursing

Case Study

Chapter 23

Adult Women and Men

The school nurse is preparing for a week long community health nurse rotation. The

preparation includes reviewing and preparing a brief summary about common

issues affecting adult women and men. The community health nurse is going to ask

the student key questions to ensure that proper preparation for the rotation has

been completed.

1. The 20th century saw a shift in the leading causes of death from

communicable diseases to noncommunicable diseases. Currently, what are

the five leading causes of death in adults?

2. Chronic illness is an issue of increasing concern for both men and women as

life expectancies increase. What are the three levels of prevention and

activities that community health nurses should consider in order to promote

health across the adult women and men life span?

3. The student nurse visits a woman’s home with the community health nurse.

What are some important facts that the community health nurse and student

nurse can share with this woman to help raise awareness regarding heart

disease?

4. The community health nurse has to do a short program in the local senior

center on mortality from unintentional injuries in the United States. The

student nurse shares some key facts about mortality from unintentional

injuries in the United States based on age. What is the top unintentional

injuries mortality among adult groups?

 

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