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Nurs Outlook 63 (2015) 288e298
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A proposed conceptual model of nursing and population health Jacqueline Fawcett, PhD, RN, FAAN*, Carol Hall Ellenbecker, PhD, RN Department of Nursing, University of Massachusetts Boston, Boston, MA
article info
abstract
Article history: Received 29 August 2014 Revised 17 December 2014 Accepted 5 January 2015 Available online 19 February 2015
Objective: To describe a Conceptual Model of Nursing and Population Health about
Keywords: Population health Nursing Conceptual model
the intersection of nursing and population health. Methods: Review of literature and derivation of a new conceptual model. Results: The conceptual model concepts are upstream factors, population factors,
health care system factors, nursing activities, and population health outcomes. Nursing activities mediate the indirect relations of upstream, population, and health care system factors with population health outcomes; in addition, health care system factors and nursing activities are directly related to population health outcomes. Implications for research methods, revisions in all levels of nursing education, and population-focused advances in nursing practice are identified. Conclusion: The strength of the model is its emphasis on attainment of the highest possible quality of life for populations, by means of nursing activities directed to promote or restore and maintain wellness across the life course and to prevent disease. Cite this article: Fawcett, J., & Ellenbecker, C. H. (2015, JUNE). A proposed conceptual model of nursing and population health. Nursing Outlook, 63(3), 288-298. http://dx.doi.org/10.1016/j.outlook.2015.01.009.
The increasing global recognition of many common disease conditions requires population-level rather than individual-level solutions. The purpose of this article was to challenge nurses to shift their thinking from individual health to the health of populations by providing a comprehensive understanding of what population health is; discussing the role nursing plays in improving the health of populations; describing the Conceptual Model of Nursing and Population Health (CMNPH); and identifying implications for population health research methods, nursing education, and nursing practice. The conceptual model is based on our understanding of the meaning and methods of population health and is intended to advance contributions of the discipline of nursing to population health.
Rationale for a CMNPH Conceptual models are made up of a set of abstract and general concepts and propositions that describe the concepts and explain relations among concepts. Their value lies in offering a systematic way of understanding phenomena, guiding action, and providing a framework for derivation of the relatively specific and concrete concepts and propositions of middle-range and situation-specific theories (Bigbee & Issel, 2012; Fawcett & DeSanto-Madeya, 2013). The particular value of a CMNPH is its guidance for nursing research and nursing practice that comes from an enhanced understanding of population health phenomena.
* Corresponding author: Jacqueline Fawcett, Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA 02125-3393. E-mail address: [email protected] (J. Fawcett). 0029-6554/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.01.009
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In recent years, many health care experts have called for a shift in thinking about health care from an emphasis on individual disease conditions to population-level disease prevention and wellness promotion. This paradigm shift is caused by the widely recognized failure of the U.S. health care system, which spends approximately 75% of its health care resources on curing disease and expensive hospitalizations and very little on disease prevention (American Public Health Association, 2012). Although the U.S. spends more on health care than any other nation, the outcomes are not as good as those of most highincome nations. A comparison of health indicators from the U.S. with those from 16 other peer countries revealed that Americans on average have shorter lives and have higher rates of disease and injury than people in other high-income countries (Institute of Medicine [IOM], 2013). Specifically, people of all age groups and socioeconomic levels residing in the U.S. fare worse than people residing in other peer countries in rates of infant mortality, infants of low birth weight for gestational age, injuries, homicides, adolescent pregnancy, sexually transmitted infections including but not limited to HIV and AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disabilities. In 2013, the U.S. ranked 17th in life expectancy at birth among 17 other high-income nations (IOM, 2013). According to the IOM (2013), “the U.S. health disadvantage has multiple causes and involves some combination of inadequate health care, unhealthy behaviors, adverse economic and social conditions, and environmental factors, as well as public policies and social values that shape those conditions” (p. 3). Improving the health of the nation’s population by addressing system failures and factors that lead to these failures requires a shift in thinking from individually based disease care to population health care. Nurses, who comprise the largest group of health care providers in the U.S. health care system (American Association of Colleges of Nursing, 2011), are partially responsible for the poor health of the population because of a traditionally narrow focus on individuals and diseases. As Bekemeier (2008) pointed out, nurses’ participation in the current individual-centered health care system is a tacit agreement to improve “the health of the few” people they serve while at the same time participate, albeit with the best intentions, in “the illness and death of many” (p. 51). However, with a history of population-focused community and public health nursing practice (Buhler-Wilkerson, 1989; Dock & Stewart, 1938; Radzyminski, 2007; Skretkowicz, 2010), nurses are in an ideal position to shift thinking and participate in and lead teams of health care providers, policy makers, and the lay public committed to a strong focus on population health. Furthermore, although the basic idea of population health is part of nursing’s history, attention to population heath is especially important as health issues become more obviously global.
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The contemporary interest in the population level of nursing care was the catalyst for the addition of a population health track in the PhD nursing program at the University of Massachusetts Boston. Since its inception, faculty and students have been continuously challenged to better understand the meaning of population health, to identify appropriate research methods for the study of population health phenomena, and to differentiate population health nursing research from clinical nursing research. The proposed CMNPH is one way to begin to overcome these challenges.
Population Health Defined “Population health,” according to Radzyminski (2007), “has been a framework for providing health care since the time of Hippocrates” (p. 37). The term population health entered the modern policy and health care vocabulary during the past 2 or 3 decades (Batchelor, 2012) with an increase in citations in the mid-1990s (Tricco, Runnels, Sampson, & Bouchard, 2008). Although population health is a widely used term across many disciplines, there is considerable confusion about what the term actually means and how the discipline of nursing uses the term. Young (1998) pointed out that the literal meaning of population health is the health of populations. Some other definitions of population health focus on what it is not and how it is distinguished from epidemiology, public health, and community health rather than what it is. Other definitions are more specific to what population health is. Other elements of definitions of what population health is found in the literature are populations defined by geography or common characteristics, a focus on health outcomes for entire groups rather than individuals, and determinants of health.
Population Health Defined by Distinctions Batchelor (2012) linked population health with the evolution of epidemiology. He contended “that the concept of population health and its use in helping understand health and disease is simply part of the natural evolution of the science of epidemiology” (p. 12). Baisch (2009) also linked population health with epidemiology, explaining that population health is typically used within the context of epidemiology and addresses “broad determinants of health for populations” (p. 2469). Kindig and Stoddart (2003) asserted that the focus of epidemiology is not sufficiently broad and does not account for the various interactions between determinants of health outcomes. Stoto (2013) drew distinctions between public health and population health by contrasting the involvement of governmental agencies, as did Radzyminski (2007). Stoto (2013) explained, “First, [population health] is less directly tied to governmental health departments [than
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public health]. Second, [population health] explicitly includes the health care delivery system, which is sometimes seen as separate from or even in opposition to governmental public health” (p. 2). Radzyminski (2007) noted that public health focuses on “the relationship between the state and the health and welfare of its citizens” (p. 40). Issel and Bekemeier (2010) placed public health nursing within the context of organizations and governmental agency departments. Kindig and Stoddart (2003) maintained that at least some determinants of health outcomes, such as income, education, and medical care, are beyond the scope of the authority and responsibility of public health. Baisch (2009) pointed out that the attributes of population health overlap with the attributes of community health. Radzyminski (2007) acknowledged overlaps but commented that although community health focuses within the boundaries of a relatively broad view of the community, population health is boundaryless other than the boundaries of a specific aggregate of interest. Perhaps a major distinction between population health and public health and community health is the focus of public health on the development and implementation of governmental policies, whereas community health focuses on specific communities at the grass roots level and population health is a broader focus on the population of a nation- or worldwide population experiencing a particular health condition, such as cardiovascular disease or tuberculosis.
Population Health Defined by Geography or Common Characteristics Populations typically are geopolitical nations, communities, and other geographic regions. Populations also may be groups of employees, ethnic groups, persons with disabilities, groups of persons with particular disease characteristics, prisoners, or other groups (Adler, Bachrach, Daley, & Frisco, 2013; Kindig & Stoddart, 2003; Mason, 2014). Members of health care systems, especially, may think of populations as groups of patients (Adler et al., 2013).
Population Heath Defined by Outcomes Kindig and Stoddart (2003) defined population health as outcomes. Stoto (2013) pointed out that the use of the term outcomes emphasizes “the implicit goal of improving health outcomes” (p. 2). Sen (2002) used the term health achievements, which emphasizes comparisons of what populations are able to be and do to determine equity in achievement and distribution of health gains rather than outcomes.
Population Health Defined by Determinants A hallmark of population health, according to Kindig and Stoddart (2003), is the patterns of determinants
of health outcomes and the interactions between these determinants. They identified several determinants, including “medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and of the physical environment (urban design, clean air and water), genetics, and individual behavior” (p. 381). Bekemeier (2008) noted that many experts across disciplines are calling for a focus on upstream conditions (i.e., a root cause approach that emphasizes the causes of disease and disability in a population). The upstream approach includes understanding of socioeconomic determinants of wellness and illness as well as barriers to attaining high-level wellness and access to health care services.
The Conceptual Model Young (1998) maintained that population health, especially in Canada and the United Kingdom, connotes a “conceptual framework for thinking about why some populations are healthier than others as well as policy development, research agenda, and resource allocation” (p. 4). The CMNPH emphasizes the intersection of nursing and population health. The CMNPH draws primarily from the Institute for Health Care Improvement (IHI) Population Health Model (Stiefel & Nolan, 2012; Stoto, 2013), which was based on earlier work by Evans and Stoddart (1990). Although those models emphasized medicine as the driving force for population health outcomes, the CMNPH underscores the centrality of nursing while viewing medicine and other health care providers as important but not central in this model. The primary focus of the CMNPH is attainment of the highest possible quality of life for aggregates of people by means of nursing activities directed to promote or restore and maintain wellness and to prevent disease, thus making it relevant to both the improvement of population health and the practice of nursing. For the purposes of the CMNPH, population health is defined as life span wellness and disease experiences of aggregate groups of people residing in local, state, national, or international geographic regions or those populations with common characteristics. Population health includes aspects of public health, health care delivery systems, and determinants of wellness and illness, emphasizing promotion, restoration, and maintenance of wellness and prevention of disease.
Conceptual Model Concepts The concepts of population health are “more than the sum of individual parts of a cross-sectional perspective . [and inclusion of] a broader array of the [social] determinants of health than is typical in either health care or public health” (Stoto, 2013, p. 2-3). The CMNPH concepts encompass four social determinants of
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population health outcomesdupstream factors, population factors, health care system factors, and nursing activitiesdas well as the concept of population health outcomes. Each of these concepts is multidimensional. The dimensions of upstream factors are socioeconomic factors and physical environment. The dimensions of population factors are genetic factors, behavioral factors, physiologic factors, resilience, and health state. The CMNPH views the dimensions of genetic factors, behavioral factors, physiologic factors, resilience, and health state at the population level, whereas the IHI model (Stiefel & Nolan, 2012; Stoto, 2013) and the Evans and Stoddart (1990) model view these dimensions at the level of the individual, which obviously loses the population-level focus. The dimensions of health care system factors are providers, organizations and institutions, payers, and policies. The dimensions of nursing activities are population-based nursing practice processes and culturally appropriate wellness promotion, restoration, maintenance, and disease prevention. The dimensions of population health outcomes are population-level wellness, population-level disease burden, populationlevel functional status, population-level life expectancy, population-level mortality, and population-level quality of life.
Conceptual Model Propositions The nonrelational propositions of the CMNPH, which are the definitions for each concept and its dimensions, are provided in Table 1. The relational propositions of the CMNPH, which link the concepts, are as follows and are illustrated in Figure 1: 1. Upstream factors, population health factors, and health care system factors are interrelated. 2. Upstream factors, population factors, and health care system factors are related to nursing activities. 3. Health care system factors are related to population health outcomes. 4. Nursing activities mediate the relations of upstream factors, population factors, and health care system factors to population health outcomes. 5. Nursing activities are related to population health outcomes.
Discussion Limitations of the CMNPH The CMNPH, like all conceptual models, is made up of abstract and general concepts and propositions that are too abstract and general to be directly tested. Instead, a conceptual model is a guide or basis for generating new theories and testing existing theories
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by means of empirical research (Bigbee & Issel, 2012; Fawcett & DeSanto-Madeya, 2013). Furthermore, the development of the CMNPH is based on literature primarily from the U.S. and Canada. The extent to which the model is relevant for use in other countries remains to be determined.
Implications for Nursing Research The primary purpose of nursing research is to expand knowledge through generation and testing of theories that provide the evidence for effective nursing activities including assessments and interventions as well as measurement of outcomes (Fawcett & Garity, 2009). The purpose of CMNPH-guided nursing research is to advance knowledge of population health phenomena by linking concepts and propositions of the model with more specific and concrete concepts (research variables) and propositions (hypotheses) of descriptive, explanatory, and predictive theories (Bigbee & Issel, 2012; Fawcett & Garity, 2009). The trajectory of population-based nursing research begins with baseline descriptions of theory concepts representing upstream factors, population factors, health care system factors, and current population health outcomes. (See Table 1 for nonrelational propositions of these CMNPH concepts and their dimensions.) The research can be conducted with various qualitative, quantitative, and mixed methods research designs (Stoto, 2013). Concept analysis techniques can be used to articulate a more comprehensive definition of each concept of the CMNPH (Table 1). Qualitative descriptive research designs can be used to enhance understanding of the meaning of each concept to a particular population. Quantitative descriptive research designs, including instrument development studies and status surveys, can be used to develop or refine instruments to measure theory concepts representing each CMNPH concept and its dimensions. Realist reviews of literature, which focus on the feasibility of implementing specific nursing activities in real-life settings, also are needed (Pawson, Greenhalgh, Harvey, & Walshe, 2005). Research progresses to the examination of relations among theory concepts that are linked with upstream factors, population factors, and health care system factors (CMNPH relational proposition 1) and the root causes of population health outcomes (CMNPH relational propositions 2, 3, 4, and 5) using correlational and mixed methods designs that may be conducted by means of secondary analyses of large data sets (Patterson, 2014; Zeni & Kogan, 2007) using structural equation modeling statistics. Correlational designs using regression methods, such as path analysis, can be used to test the mediating role of specific nursing activities (CMNPH relational proposition 4; Kenny, 2012). Research then progresses to tests of the effectiveness of theory concepts linked with health care system factors and specific nursing activities (CMNPH
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Table 1 e Concepts of the Conceptual Model of Nursing and Population Health and Their Definitions Concepts and Concept Dimensions Upstream factors
Socioeconomic environment Physical environment
Population factors
Genetic factors Behavioral factors
Physiological factors Resilience Health state
Health care system factors
Providers
Organizations and institutions
Departments of public health Hospitals Inpatient and outpatient clinics
Community health centers Home health care agencies Payers Policies
Nursing activities
Definitions Social determinants of health encompassing socioeconomic environment and physical environment, which directly influence nursing activities and indirectly influence population health outcomes The circumstances of a population, including income, education, employment, social support, and culture (Kindig & Stoddart, 2003) The surroundings of the population, including the atmosphere of the earth, gaseous composition of air, solid and gaseous pollutants, smoke, weather conditions, geologic stability of the earth’s crust, water, urban and rural design and resources, housing, ultraviolet radiation, bacteria, viruses, and the built environment (Kindig & Stoddart, 2003; Orem, 2001; Stoto, 2013) Determinants of health encompassing population-based genetic factors, behavioral factors, physiological factors, resilience, and health state, all of which directly influence nursing activities and indirectly influence population health outcomes Inherited characteristics of a population Lifestyle variables of a population, such as smoking, alcohol consumption, substance abuse, sexual behaviors, physical activity, and diet (Stiefel & Nolan, 2012) Biological variables of a population, such as vital signs, body mass index, and cholesterol and blood glucose levels (Stiefel & Nolan, 2012) A population’s “ability to bounce back or recover from adversity” (Garcia-Dia, DiNapoli, Garcia-Ona, Jakubowski, & O’Flaherty, 2013, p. 267) “A state of the [population] that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning” (Orem, 2001, p. 186) Determinants of health encompassing providers, organizations, institutions, payers, and policies that directly influence nursing activities and population health outcomes and indirectly influence population health outcomes Nurses, physicians, therapists, pharmacists, technicians, and others who provide health-related services to populations Nurses may provide direct nursing care for populations, teach students and other nurses, and/or conduct and report results of studies of phenomena of interest to the discipline of nursing and population health Relevant health care system organizations and institutions include departments of public health, hospitals, inpatient and outpatient clinics, community health centers, and home health care agencies Local, state, or federally funded government entities responsible for the public’s health Institutions, large and small, that provide nursing and medical care that serve populations experiencing acute disease conditions Institutions that provide health-related services to populations who need adjuvant therapy for acute and chronic illness and populations recovering from acute disease conditions Centers that provide nursing and medical care to community-based populations Agencies that provide home-based health care for populations of patients Health insurance companies and other sources of reimbursement for healthrelated services Policies include those addressing access to and use of health care by populations Policies about access address availability and compatibility of health care for an entire population (Norris & Aiken, 2006) Policies about utilization address actual use of health care by an entire population Actions performed by nurses directed to populations within the context of multidisciplinary collaboration and coordination that directly influence population health outcomes and that mediate the relations of upstream factors, population factors, and health care system factors to population health outcomes (continued on next page)
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Table 1 e (Continued ) Concepts and Concept Dimensions Population-based nursing practice processes
Culturally appropriate wellness promotion, restoration, and maintenance
Culturally appropriate disease prevention
Population health outcomes
Population-level wellness
Population-level disease burden
Population-level functional status Population-level life expectancy Population-level mortality Population-level quality of life
Definitions Provision of population-based nursing practice processes as formalized in the practice methodologies of various nursing conceptual models and theories (Fawcett & DeSanto-Madeya, 2013) directed to actions that create environments for populations that promote, restore, and maintain wellness, and prevent disease. Nursing practice processes include all phases of the nursing process (assessment, planning, intervention, evaluation) with special emphasis on data collection, tracking, and analysis, and health care team coordination and collaboration Provision of nursing practice processes directed to enhancing the optimal level of the population’s collective “growth, integration of experience, and meaningful connection with others, reflecting [population] valued goals and strengths, and resulting in being well and living values” (p. 48) within the context of the culture of the population (McMahon & Fleury, 2012) Provision of nursing practice processes directed to preventing the occurrence of objective and tangible clinical signs and symptoms of a health problem (Venes, 2013) The status of the health of a population encompassing population-level wellness, disease burden, functional status, life expectancy, mortality, and quality of life, resulting directly from health care system factors and provision of nursing activities and indirectly from upstream, population, and health care system factors mediated by nursing activities The population’s collective level of “growth, integration of experience, and meaningful connection with others, reflecting [population] valued goals and strengths, and resulting in being well and living values” (McMahon & Fleury, 2012, p. 48) Incidence and/or prevalence of major chronic health conditions in a population (Stiefel & Nolan, 2012); “the total effect of a disease” (p. 699) on a population (Venes, 2013) A population’s optimal level of performing usual activities of daily living A population’s overall “expected years of remaining life at any age” (Stiefel & Nolan, 2012, p. 13) “Years of potential life lost” (p. 4) for a population (Stiefel & Nolan, 2012) A population’s “physical, psychological, social, economic, and environmental” (p. E5) well-being (Fulton, Miller, & Otte, 2012)
relational propositions 3 and 5) by means of natural experiments and quasi-experimental and true experimental designs, with randomization at the level of the population. Cost-benefit and cost-effective analyses of specific nursing activities and specific policies linked with the policy dimension of health care system factors also are important topics for CMNPH-guided nursing research. Inasmuch as the policies dimension of health care system factors addresses access to and use of health care by populations, the availability and compatibility of health care for an entire population, and the actual use of health care by an entire population, the CMNPH is an excellent guide for studying health disparities and social justice. For example, studies could be designed to examine the extent to which a population experiences disparities in health outcomes because of limited access to and use of available health care, taking into account the socioeconomic environment dimension of upstream factors. Other studies could focus on social justice using correlational research designs to examine the relations of pollution or toxic waste dumping in the
physical environment (a dimension of upstream factors) to the dimensions of population factors (genetic, behavioral, and physiological factors; resilience; and health state). A crucial area of population-based nursing research is the analysis and evaluation of health policies, which is needed to enhance the understanding of their impact on certain populations. These analyses and evaluations should be done using rigorous evaluation methods and mixed methods research designs (Creswell, 2015). The results of such studies should expand knowledge of the many determinants of population health and population health outcomes; provide the data on which to base more effective assessments and interventions; and, most importantly, provide the data needed for the consideration of policy alternatives when policies are being formulated (Munger, 2000). Ultimately, the results of CMNPH-based health policy research will provide direction for the transformation of the health care system that is needed to improve the health of populations.
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Figure 1 e Diagram of the CMNPH.
CMNPH-based nursing research may be a singlediscipline endeavor but is best conducted as a multidisciplinary endeavor. The study of theory concepts and propositions linked with the content of the CMNPH requires teams of nurses working with scientists and clinicians from many other disciplines, drawing on knowledge from other health-related sciences and from social, behavioral, and natural sciences. Populationbased nursing research also requires collaboration and coordination with various populations and communities, schools, organizations, public health departments, governmental and nongovernmental agencies, other community-based agencies, health care organizations, and providers. An example of research guided by the CMNPH is a hypothetical study of the effects of a culturally appropriate medication management educational program for a national population of Hispanic older adults with a medical diagnosis of cardiac disease (Figure 2). All CMNPH concepts are used to guide selection of the variables for the hypothetical study. The study variables linked with upstream factors are level of education, transportation, number of pharmacies, number of pharmacies with delivery service, and physical safety. The study variables linked with population factors are culturally specific genetic and cultural factors pertaining to cardiac disease, health behaviors, and level of health literacy. The study variables linked with health care system factors are the availability of bilingual/bicultural health care providers and health insurance. Nursing activities are linked to population-
level assessment of the study variables linked to upstream, population, and health care system factors; collaboration among providers and pharmacies; and design and implementation of a culturally appropriate medication management educational program. Population health outcomes are linked to three study variables: appropriate medication refills, reduced cardiac disease burden, and population-level physiologic variables. For the purposes of the hypothetical study, Hispanic (or Latino) is defined as “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race” (United States Office of Management and Budget, 2013). The focus on medication management by Hispanic older adults is in keeping with self-management needs imposed by the complexity of chronic diseases experienced by older adults (Hewner, Seo, Gothard, & Johnson, 2014) and the growing Hispanic population in the U.S. (United States Census Bureau, 2010, 2011). The focus on cardiac disease is in keeping with diseases of the heart as the leading cause of death for the Hispanic population in the U.S. from 1980 to 2010 (National Center for Health Statistics, 2014), with a disease burden of 20.8% in 2010 (Heron, 2013). Inclusion of health literacy as a study variable is in keeping with the National Action Plan to Improve Health Literacy initiative of the U.S. Department of Health and Human Services (Galletly, Neaves, Burton, Liu, & Denson, 2012). The study variables may be measured by population-level data obtained from reports issued by
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Figure 2 e Diagram for an example of a CMNPH-guided hypothetical study of the effect of a medication management educational program on medication management by a population of Hispanic older adults with a medical diagnosis of cardiac disease.
relevant governmental agencies and pharmacy and provider populationelevel databases. The culturally appropriate medication management educational program could be disseminated to the population via linguistically appropriate radio and television public service announcements, social media, and brochures distributed at community centers, shopping centers, and other relevant community locations.
Implications for Nursing Education The content of the CMNPH and the research methods used to study population health phenomena need to be included in all levels of nursing education (American Association of Colleges of Nursing, 2014). Traditional community health nursing courses may be a logical place to include this content and these methods. However, relevant content and methods should be included in all nursing education courses. For example, although individuals are the primary focus in many didactic and clinical nursing courses, students need to be encouraged to look beyond individual patients to all determinants of the health of the particular population of which each patient is a member. In the future, all nursing students will need to be aware of the key role and responsibility they have in improving the health of the populations they serve.
They need to refine their skills in assessing aggregates; developing and delivering evidence-based educational programs targeted to wellness promotion and disease prevention; collecting, tracking, and interpreting data; and delivering culturally appropriate care. In addition, all nursing students need to learn to function effectively as members of multidisciplinary teams and to work with community-based institutions, schools, public health departments, faith-based groups, and other organizations by enhancing their communication, collaboration, and coordination skills. They also need to know much more than most currently know about health care systems and political processes. Nursing doctoral students will need increased preparation in population health nursing research, especially research that will influence changes in health policies that affect populations. They will need to learn ever more sophisticated ways to measure the theory concepts that are linked to the CMNPH concepts, such as disease burden, and to test connections between the theory concepts using ever more sophisticated data analysis techniques, such as generalized estimating equations, as well as logistic regression and other categorical data analysis techniques. These students also will need to develop political intelligence (i.e., an understanding of the
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political process emphasizing how to inform and when to participate in the formulation of policies or advocate for the improvement of population health). Perhaps the CMNPH will catalyze the development of doctor of nursing practice programs that focus on the preparation of advanced practice nurses who are experts in the intersection of advanced nursing practice and population health. The CMNPH emphasis on the intersection of nursing and population health may resolve the more than a century-old debate about distinctions between public health nursing and community health nursing and concerns about the continued survival of both specialties (Canales & Drevdahl, 2014).
Implications for Nursing Practice Overcoming the challenge of a focus on populations rather than individuals requires an upstream approach, which within the context of the CMNPH includes not only upstream factors but also population factors and health care system factors. As Bekemeier (2008) explained, “our experiences with patients or populations, and the communities in which they live, ought to be the impetus for making our primary responsibility be practice and research that enables healthy policy change and identifies innovative strategies for addressing the social determinants of [population] health” (p. 51). Shifting the focus to populations requires overcoming many nurses’ tolerance of a perceived culture of oppression (Anderson, 2000). Perceived sources of oppression include mandated government and insurance policy regulations, opposition from other provider groups, and employers and institutional requirements, which tend to limit some nurses’ willingness to seek solutions to the very difficult problems of the health care system. Political challenges will arise as nurses adopt an upstream approach and participate in health policy decisions that address population health (Bekemeier, 2008). The influence of politics is especially evident in the scope of practice and licensing regulations, government reimbursement structures, and the historically poor funding for disease prevention and wellness promotion. The shift to population health does not mean that nurses will no longer be concerned with caring for individuals and families experiencing acute and chronic illness. It is anticipated that a large proportion of practicing nurses will continue to work with individuals as they transition from wellness to illness to recovery. Instead, a balance between individualfocused and population-focused practice is needed, along with a better understanding of individual experiences of illness and disease within a larger population context. For example, nurses working in emergency departments will continue to focus on saving individuals’ lives, but they also will begin to
think about what upstream, population, and health care system factors bring people to emergency departments. Clearly, nurses must consider indicators and root causes of disease conditions to better meet the health care needs of populations (Patterson, 2014).
Dissemination of Population-based Practice and Research All nurses and nursing students should take responsibility for disseminating their population-based work at professional association and other meetings and conferences and through publications in peerreviewed journals and in the lay literature. Given the need to reach all stakeholders for particular health policies, the results of population-based policy research should be published not only in peerreviewed nursing and multidisciplinary journals but also in nonepeer-reviewed government publications, reports, newsletters, fact sheets, working papers, technical reports, conference proceedings, and policy documents.
Conclusion The culture of health care in the U.S. emphasizes individuals, holding sacred the physician-patient and nurse-patient relationships and perpetuating faith in the individual’s view of benefits of care only for his- or herself. Many nurses, along with many physicians and other members of the health care team, have not yet shifted from the individual as the patient to the population as the patient. If nurses are to continue to be committed to improving the well-being and quality of life of all members of society, they must be part of the solution to improving the health of populations. Shifting nurses’ focus from individually based care to population-based care may not be easy. It will require revisions in educational programs and the acquisition of new ways of thinking, practicing, and conducting research. The CMNPH provides population-level guidance for research, educational program revisions, and practice. Stoto (2013) maintained that “responsibility for population health outcomes is shared but that accountability is diffuse” (p. 3). The CMNPH emphasizes the responsibility for population health outcomes that nurses share with other members of the health care team and especially with populations. Widespread adoption by nurses of the CMNPH should facilitate the much needed shift in thinking to multiple determinants of the health of aggregates, aggregatebased wellness promotion and disease prevention interventions, and aggregate-based outcomes that are needed to decrease rates of disease and increase wellness indicators and, ultimately, to enhance the quality of life of populations worldwide.
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Acknowledgments We gratefully acknowledge the contributions to our thinking of our colleagues Dr. Teri Aronowitz, Dr. Mary Cooley, Dr. Laura Hayman, Dr. Lisa Kennedy Sheldon, and Dr. Courtenay Sprague, all from the University of Massachusetts Boston, as well as the contributions of anonymous peer reviewers.
references
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Garcia-Dia, M. J., DiNapoli, J. M., Garcia-Ona, L., Jakubowski, R., & O’Flaherty, D. (2013). Concept analysis: Resilience. Archives of Psychiatric Nursing, 27, 264e270. Heron, M. (2013). Deaths: Leading causes for 2010. National Vital Statistics Report, 62(6), 1e96. Hewner, S., Seo, J. Y., Gothard, S. E., & Johnson, B. J. (2014). Aligning population-based care management with chronic disease complexity. Nursing Outook, 62, 250e258. Institute of Medicine (IOM). (2013). Report brief: U.S. health in international perspective: Shorter lives, poorer health. Retrieved from ww.iom.edu/w/media/Files/Report Files/2013/USHealth-International-Perspective/USHealth_Intl_ PerspectiveRB.pdf. Issel, L. M., & Bekemeier, B. (2010). Safe practice of populationfocused nursing care: Development of a public health nursing concept. Nursing Outlook, 58, 226e232. Kenny, D. A. (2012). Mediation. Retrieved from http://davidakenny. net/cm/mediate.htm. Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93, 380e383. Mason, D. J. (2014). Where and how is health created? Nursing Outlook, 62, 162e163. McMahon, S., & Fleury, J. (2012). Wellness in older adults: A concept analysis. Nursing Forum, 47, 39e51. Munger, M. C. (2000). Analyzing policy: Choice conflicts and practices. New York: W. W. Norton. National Center for Health Statistics. (2014). Health, United States, 2013: With special feature on prescription drugs. Hyattsville, MD: Author. Retrieved from http://www.cdc.gov/nchs/data/hus/ hus13.pdf. Norris, T. L., & Aiken, M. (2006). Personal access to health care: A concept analysis. Public Health Nursing, 23, 59e66. Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.) St. Louis: Mosby. Patterson, M. (2014). Taking nursing doctoral research upstream. Paper presented at the meeting of the American Association of Colleges of Nursing Doctoral Education Conference: Incorporating Population Health in Nursing Doctoral Education, Naples, FL. Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2005). Realist reviewdA new method of systematic review designed for complex policy interventions. Journal of Health Services Research & Policy, 10(Suppl 1), 21e34. Radzyminski, S. (2007). The concept of population health within the nursing profession. Journal of Professional Nursing, 23, 37e46. Sen, A. (2002). Why health equity? Health Economics, 11, 659e666. Skretkowicz, V. (Ed.). (2010). Florence Nightingale’s notes on nursing and notes on nursing for the laboring classes (Commemorative ed. with historical commentary). New York: Springer. Stiefel, M., & Nolan, K. (2012). A guide to measuring the triple aim: Population health, experience of care, and per capita cost. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/ resources/Pages/IHIWhitePapers/AGuidetoMeasuring TripleAim.aspx. Stoto, M. A. (2013). Population Health in the Affordable Care Act Era. Retrieved from http://www.academyhealth.org/files/ AH2013pophealth.pdf. Tricco, A. C., Runnels, V., Sampson, M., & Bouchard, L. (2008). Shifts in the use of population health, health promotion, and public health: A bibliometric analysis. Canadian Journal of Public Health, 99, 466e471. United States Census Bureau. (2010). Current population survey, annual social and economic supplement. Retrieved from http:// www.census.gov/population/hispanic/data/2010.html. United States Census Bureau. (2011). Current population survey, annual social and economic supplement. Retrieved from http:// www.census.gov/population/hispanic/data/2011.html.
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Young, T. K. (1998). Population health: Concepts and methods. New York: Oxford University Press. Zeni, M. B., & Kogan, M. D. (2007). Existing population-based health databases: Useful resources for nursing research. Nursing Outlook, 55, 20e30.
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www.nursingoutlook.org
A proposed conceptual model of nursing and population health Jacqueline Fawcett, PhD, RN, FAAN*, Carol Hall Ellenbecker, PhD, RN Department of Nursing, University of Massachusetts Boston, Boston, MA
article info
abstract
Article history: Received 29 August 2014 Revised 17 December 2014 Accepted 5 January 2015 Available online 19 February 2015
Objective: To describe a Conceptual Model of Nursing and Population Health about
Keywords: Population health Nursing Conceptual model
the intersection of nursing and population health. Methods: Review of literature and derivation of a new conceptual model. Results: The conceptual model concepts are upstream factors, population factors,
health care system factors, nursing activities, and population health outcomes. Nursing activities mediate the indirect relations of upstream, population, and health care system factors with population health outcomes; in addition, health care system factors and nursing activities are directly related to population health outcomes. Implications for research methods, revisions in all levels of nursing education, and population-focused advances in nursing practice are identified. Conclusion: The strength of the model is its emphasis on attainment of the highest possible quality of life for populations, by means of nursing activities directed to promote or restore and maintain wellness across the life course and to prevent disease. Cite this article: Fawcett, J., & Ellenbecker, C. H. (2015, JUNE). A proposed conceptual model of nursing and population health. Nursing Outlook, 63(3), 288-298. http://dx.doi.org/10.1016/j.outlook.2015.01.009.
The increasing global recognition of many common disease conditions requires population-level rather than individual-level solutions. The purpose of this article was to challenge nurses to shift their thinking from individual health to the health of populations by providing a comprehensive understanding of what population health is; discussing the role nursing plays in improving the health of populations; describing the Conceptual Model of Nursing and Population Health (CMNPH); and identifying implications for population health research methods, nursing education, and nursing practice. The conceptual model is based on our understanding of the meaning and methods of population health and is intended to advance contributions of the discipline of nursing to population health.
Rationale for a CMNPH Conceptual models are made up of a set of abstract and general concepts and propositions that describe the concepts and explain relations among concepts. Their value lies in offering a systematic way of understanding phenomena, guiding action, and providing a framework for derivation of the relatively specific and concrete concepts and propositions of middle-range and situation-specific theories (Bigbee & Issel, 2012; Fawcett & DeSanto-Madeya, 2013). The particular value of a CMNPH is its guidance for nursing research and nursing practice that comes from an enhanced understanding of population health phenomena.
* Corresponding author: Jacqueline Fawcett, Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA 02125-3393. E-mail address: [email protected] (J. Fawcett). 0029-6554/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.01.009
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In recent years, many health care experts have called for a shift in thinking about health care from an emphasis on individual disease conditions to population-level disease prevention and wellness promotion. This paradigm shift is caused by the widely recognized failure of the U.S. health care system, which spends approximately 75% of its health care resources on curing disease and expensive hospitalizations and very little on disease prevention (American Public Health Association, 2012). Although the U.S. spends more on health care than any other nation, the outcomes are not as good as those of most highincome nations. A comparison of health indicators from the U.S. with those from 16 other peer countries revealed that Americans on average have shorter lives and have higher rates of disease and injury than people in other high-income countries (Institute of Medicine [IOM], 2013). Specifically, people of all age groups and socioeconomic levels residing in the U.S. fare worse than people residing in other peer countries in rates of infant mortality, infants of low birth weight for gestational age, injuries, homicides, adolescent pregnancy, sexually transmitted infections including but not limited to HIV and AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disabilities. In 2013, the U.S. ranked 17th in life expectancy at birth among 17 other high-income nations (IOM, 2013). According to the IOM (2013), “the U.S. health disadvantage has multiple causes and involves some combination of inadequate health care, unhealthy behaviors, adverse economic and social conditions, and environmental factors, as well as public policies and social values that shape those conditions” (p. 3). Improving the health of the nation’s population by addressing system failures and factors that lead to these failures requires a shift in thinking from individually based disease care to population health care. Nurses, who comprise the largest group of health care providers in the U.S. health care system (American Association of Colleges of Nursing, 2011), are partially responsible for the poor health of the population because of a traditionally narrow focus on individuals and diseases. As Bekemeier (2008) pointed out, nurses’ participation in the current individual-centered health care system is a tacit agreement to improve “the health of the few” people they serve while at the same time participate, albeit with the best intentions, in “the illness and death of many” (p. 51). However, with a history of population-focused community and public health nursing practice (Buhler-Wilkerson, 1989; Dock & Stewart, 1938; Radzyminski, 2007; Skretkowicz, 2010), nurses are in an ideal position to shift thinking and participate in and lead teams of health care providers, policy makers, and the lay public committed to a strong focus on population health. Furthermore, although the basic idea of population health is part of nursing’s history, attention to population heath is especially important as health issues become more obviously global.
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The contemporary interest in the population level of nursing care was the catalyst for the addition of a population health track in the PhD nursing program at the University of Massachusetts Boston. Since its inception, faculty and students have been continuously challenged to better understand the meaning of population health, to identify appropriate research methods for the study of population health phenomena, and to differentiate population health nursing research from clinical nursing research. The proposed CMNPH is one way to begin to overcome these challenges.
Population Health Defined “Population health,” according to Radzyminski (2007), “has been a framework for providing health care since the time of Hippocrates” (p. 37). The term population health entered the modern policy and health care vocabulary during the past 2 or 3 decades (Batchelor, 2012) with an increase in citations in the mid-1990s (Tricco, Runnels, Sampson, & Bouchard, 2008). Although population health is a widely used term across many disciplines, there is considerable confusion about what the term actually means and how the discipline of nursing uses the term. Young (1998) pointed out that the literal meaning of population health is the health of populations. Some other definitions of population health focus on what it is not and how it is distinguished from epidemiology, public health, and community health rather than what it is. Other definitions are more specific to what population health is. Other elements of definitions of what population health is found in the literature are populations defined by geography or common characteristics, a focus on health outcomes for entire groups rather than individuals, and determinants of health.
Population Health Defined by Distinctions Batchelor (2012) linked population health with the evolution of epidemiology. He contended “that the concept of population health and its use in helping understand health and disease is simply part of the natural evolution of the science of epidemiology” (p. 12). Baisch (2009) also linked population health with epidemiology, explaining that population health is typically used within the context of epidemiology and addresses “broad determinants of health for populations” (p. 2469). Kindig and Stoddart (2003) asserted that the focus of epidemiology is not sufficiently broad and does not account for the various interactions between determinants of health outcomes. Stoto (2013) drew distinctions between public health and population health by contrasting the involvement of governmental agencies, as did Radzyminski (2007). Stoto (2013) explained, “First, [population health] is less directly tied to governmental health departments [than
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public health]. Second, [population health] explicitly includes the health care delivery system, which is sometimes seen as separate from or even in opposition to governmental public health” (p. 2). Radzyminski (2007) noted that public health focuses on “the relationship between the state and the health and welfare of its citizens” (p. 40). Issel and Bekemeier (2010) placed public health nursing within the context of organizations and governmental agency departments. Kindig and Stoddart (2003) maintained that at least some determinants of health outcomes, such as income, education, and medical care, are beyond the scope of the authority and responsibility of public health. Baisch (2009) pointed out that the attributes of population health overlap with the attributes of community health. Radzyminski (2007) acknowledged overlaps but commented that although community health focuses within the boundaries of a relatively broad view of the community, population health is boundaryless other than the boundaries of a specific aggregate of interest. Perhaps a major distinction between population health and public health and community health is the focus of public health on the development and implementation of governmental policies, whereas community health focuses on specific communities at the grass roots level and population health is a broader focus on the population of a nation- or worldwide population experiencing a particular health condition, such as cardiovascular disease or tuberculosis.
Population Health Defined by Geography or Common Characteristics Populations typically are geopolitical nations, communities, and other geographic regions. Populations also may be groups of employees, ethnic groups, persons with disabilities, groups of persons with particular disease characteristics, prisoners, or other groups (Adler, Bachrach, Daley, & Frisco, 2013; Kindig & Stoddart, 2003; Mason, 2014). Members of health care systems, especially, may think of populations as groups of patients (Adler et al., 2013).
Population Heath Defined by Outcomes Kindig and Stoddart (2003) defined population health as outcomes. Stoto (2013) pointed out that the use of the term outcomes emphasizes “the implicit goal of improving health outcomes” (p. 2). Sen (2002) used the term health achievements, which emphasizes comparisons of what populations are able to be and do to determine equity in achievement and distribution of health gains rather than outcomes.
Population Health Defined by Determinants A hallmark of population health, according to Kindig and Stoddart (2003), is the patterns of determinants
of health outcomes and the interactions between these determinants. They identified several determinants, including “medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and of the physical environment (urban design, clean air and water), genetics, and individual behavior” (p. 381). Bekemeier (2008) noted that many experts across disciplines are calling for a focus on upstream conditions (i.e., a root cause approach that emphasizes the causes of disease and disability in a population). The upstream approach includes understanding of socioeconomic determinants of wellness and illness as well as barriers to attaining high-level wellness and access to health care services.
The Conceptual Model Young (1998) maintained that population health, especially in Canada and the United Kingdom, connotes a “conceptual framework for thinking about why some populations are healthier than others as well as policy development, research agenda, and resource allocation” (p. 4). The CMNPH emphasizes the intersection of nursing and population health. The CMNPH draws primarily from the Institute for Health Care Improvement (IHI) Population Health Model (Stiefel & Nolan, 2012; Stoto, 2013), which was based on earlier work by Evans and Stoddart (1990). Although those models emphasized medicine as the driving force for population health outcomes, the CMNPH underscores the centrality of nursing while viewing medicine and other health care providers as important but not central in this model. The primary focus of the CMNPH is attainment of the highest possible quality of life for aggregates of people by means of nursing activities directed to promote or restore and maintain wellness and to prevent disease, thus making it relevant to both the improvement of population health and the practice of nursing. For the purposes of the CMNPH, population health is defined as life span wellness and disease experiences of aggregate groups of people residing in local, state, national, or international geographic regions or those populations with common characteristics. Population health includes aspects of public health, health care delivery systems, and determinants of wellness and illness, emphasizing promotion, restoration, and maintenance of wellness and prevention of disease.
Conceptual Model Concepts The concepts of population health are “more than the sum of individual parts of a cross-sectional perspective . [and inclusion of] a broader array of the [social] determinants of health than is typical in either health care or public health” (Stoto, 2013, p. 2-3). The CMNPH concepts encompass four social determinants of
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population health outcomesdupstream factors, population factors, health care system factors, and nursing activitiesdas well as the concept of population health outcomes. Each of these concepts is multidimensional. The dimensions of upstream factors are socioeconomic factors and physical environment. The dimensions of population factors are genetic factors, behavioral factors, physiologic factors, resilience, and health state. The CMNPH views the dimensions of genetic factors, behavioral factors, physiologic factors, resilience, and health state at the population level, whereas the IHI model (Stiefel & Nolan, 2012; Stoto, 2013) and the Evans and Stoddart (1990) model view these dimensions at the level of the individual, which obviously loses the population-level focus. The dimensions of health care system factors are providers, organizations and institutions, payers, and policies. The dimensions of nursing activities are population-based nursing practice processes and culturally appropriate wellness promotion, restoration, maintenance, and disease prevention. The dimensions of population health outcomes are population-level wellness, population-level disease burden, populationlevel functional status, population-level life expectancy, population-level mortality, and population-level quality of life.
Conceptual Model Propositions The nonrelational propositions of the CMNPH, which are the definitions for each concept and its dimensions, are provided in Table 1. The relational propositions of the CMNPH, which link the concepts, are as follows and are illustrated in Figure 1: 1. Upstream factors, population health factors, and health care system factors are interrelated. 2. Upstream factors, population factors, and health care system factors are related to nursing activities. 3. Health care system factors are related to population health outcomes. 4. Nursing activities mediate the relations of upstream factors, population factors, and health care system factors to population health outcomes. 5. Nursing activities are related to population health outcomes.
Discussion Limitations of the CMNPH The CMNPH, like all conceptual models, is made up of abstract and general concepts and propositions that are too abstract and general to be directly tested. Instead, a conceptual model is a guide or basis for generating new theories and testing existing theories
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by means of empirical research (Bigbee & Issel, 2012; Fawcett & DeSanto-Madeya, 2013). Furthermore, the development of the CMNPH is based on literature primarily from the U.S. and Canada. The extent to which the model is relevant for use in other countries remains to be determined.
Implications for Nursing Research The primary purpose of nursing research is to expand knowledge through generation and testing of theories that provide the evidence for effective nursing activities including assessments and interventions as well as measurement of outcomes (Fawcett & Garity, 2009). The purpose of CMNPH-guided nursing research is to advance knowledge of population health phenomena by linking concepts and propositions of the model with more specific and concrete concepts (research variables) and propositions (hypotheses) of descriptive, explanatory, and predictive theories (Bigbee & Issel, 2012; Fawcett & Garity, 2009). The trajectory of population-based nursing research begins with baseline descriptions of theory concepts representing upstream factors, population factors, health care system factors, and current population health outcomes. (See Table 1 for nonrelational propositions of these CMNPH concepts and their dimensions.) The research can be conducted with various qualitative, quantitative, and mixed methods research designs (Stoto, 2013). Concept analysis techniques can be used to articulate a more comprehensive definition of each concept of the CMNPH (Table 1). Qualitative descriptive research designs can be used to enhance understanding of the meaning of each concept to a particular population. Quantitative descriptive research designs, including instrument development studies and status surveys, can be used to develop or refine instruments to measure theory concepts representing each CMNPH concept and its dimensions. Realist reviews of literature, which focus on the feasibility of implementing specific nursing activities in real-life settings, also are needed (Pawson, Greenhalgh, Harvey, & Walshe, 2005). Research progresses to the examination of relations among theory concepts that are linked with upstream factors, population factors, and health care system factors (CMNPH relational proposition 1) and the root causes of population health outcomes (CMNPH relational propositions 2, 3, 4, and 5) using correlational and mixed methods designs that may be conducted by means of secondary analyses of large data sets (Patterson, 2014; Zeni & Kogan, 2007) using structural equation modeling statistics. Correlational designs using regression methods, such as path analysis, can be used to test the mediating role of specific nursing activities (CMNPH relational proposition 4; Kenny, 2012). Research then progresses to tests of the effectiveness of theory concepts linked with health care system factors and specific nursing activities (CMNPH
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Table 1 e Concepts of the Conceptual Model of Nursing and Population Health and Their Definitions Concepts and Concept Dimensions Upstream factors
Socioeconomic environment Physical environment
Population factors
Genetic factors Behavioral factors
Physiological factors Resilience Health state
Health care system factors
Providers
Organizations and institutions
Departments of public health Hospitals Inpatient and outpatient clinics
Community health centers Home health care agencies Payers Policies
Nursing activities
Definitions Social determinants of health encompassing socioeconomic environment and physical environment, which directly influence nursing activities and indirectly influence population health outcomes The circumstances of a population, including income, education, employment, social support, and culture (Kindig & Stoddart, 2003) The surroundings of the population, including the atmosphere of the earth, gaseous composition of air, solid and gaseous pollutants, smoke, weather conditions, geologic stability of the earth’s crust, water, urban and rural design and resources, housing, ultraviolet radiation, bacteria, viruses, and the built environment (Kindig & Stoddart, 2003; Orem, 2001; Stoto, 2013) Determinants of health encompassing population-based genetic factors, behavioral factors, physiological factors, resilience, and health state, all of which directly influence nursing activities and indirectly influence population health outcomes Inherited characteristics of a population Lifestyle variables of a population, such as smoking, alcohol consumption, substance abuse, sexual behaviors, physical activity, and diet (Stiefel & Nolan, 2012) Biological variables of a population, such as vital signs, body mass index, and cholesterol and blood glucose levels (Stiefel & Nolan, 2012) A population’s “ability to bounce back or recover from adversity” (Garcia-Dia, DiNapoli, Garcia-Ona, Jakubowski, & O’Flaherty, 2013, p. 267) “A state of the [population] that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning” (Orem, 2001, p. 186) Determinants of health encompassing providers, organizations, institutions, payers, and policies that directly influence nursing activities and population health outcomes and indirectly influence population health outcomes Nurses, physicians, therapists, pharmacists, technicians, and others who provide health-related services to populations Nurses may provide direct nursing care for populations, teach students and other nurses, and/or conduct and report results of studies of phenomena of interest to the discipline of nursing and population health Relevant health care system organizations and institutions include departments of public health, hospitals, inpatient and outpatient clinics, community health centers, and home health care agencies Local, state, or federally funded government entities responsible for the public’s health Institutions, large and small, that provide nursing and medical care that serve populations experiencing acute disease conditions Institutions that provide health-related services to populations who need adjuvant therapy for acute and chronic illness and populations recovering from acute disease conditions Centers that provide nursing and medical care to community-based populations Agencies that provide home-based health care for populations of patients Health insurance companies and other sources of reimbursement for healthrelated services Policies include those addressing access to and use of health care by populations Policies about access address availability and compatibility of health care for an entire population (Norris & Aiken, 2006) Policies about utilization address actual use of health care by an entire population Actions performed by nurses directed to populations within the context of multidisciplinary collaboration and coordination that directly influence population health outcomes and that mediate the relations of upstream factors, population factors, and health care system factors to population health outcomes (continued on next page)
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Table 1 e (Continued ) Concepts and Concept Dimensions Population-based nursing practice processes
Culturally appropriate wellness promotion, restoration, and maintenance
Culturally appropriate disease prevention
Population health outcomes
Population-level wellness
Population-level disease burden
Population-level functional status Population-level life expectancy Population-level mortality Population-level quality of life
Definitions Provision of population-based nursing practice processes as formalized in the practice methodologies of various nursing conceptual models and theories (Fawcett & DeSanto-Madeya, 2013) directed to actions that create environments for populations that promote, restore, and maintain wellness, and prevent disease. Nursing practice processes include all phases of the nursing process (assessment, planning, intervention, evaluation) with special emphasis on data collection, tracking, and analysis, and health care team coordination and collaboration Provision of nursing practice processes directed to enhancing the optimal level of the population’s collective “growth, integration of experience, and meaningful connection with others, reflecting [population] valued goals and strengths, and resulting in being well and living values” (p. 48) within the context of the culture of the population (McMahon & Fleury, 2012) Provision of nursing practice processes directed to preventing the occurrence of objective and tangible clinical signs and symptoms of a health problem (Venes, 2013) The status of the health of a population encompassing population-level wellness, disease burden, functional status, life expectancy, mortality, and quality of life, resulting directly from health care system factors and provision of nursing activities and indirectly from upstream, population, and health care system factors mediated by nursing activities The population’s collective level of “growth, integration of experience, and meaningful connection with others, reflecting [population] valued goals and strengths, and resulting in being well and living values” (McMahon & Fleury, 2012, p. 48) Incidence and/or prevalence of major chronic health conditions in a population (Stiefel & Nolan, 2012); “the total effect of a disease” (p. 699) on a population (Venes, 2013) A population’s optimal level of performing usual activities of daily living A population’s overall “expected years of remaining life at any age” (Stiefel & Nolan, 2012, p. 13) “Years of potential life lost” (p. 4) for a population (Stiefel & Nolan, 2012) A population’s “physical, psychological, social, economic, and environmental” (p. E5) well-being (Fulton, Miller, & Otte, 2012)
relational propositions 3 and 5) by means of natural experiments and quasi-experimental and true experimental designs, with randomization at the level of the population. Cost-benefit and cost-effective analyses of specific nursing activities and specific policies linked with the policy dimension of health care system factors also are important topics for CMNPH-guided nursing research. Inasmuch as the policies dimension of health care system factors addresses access to and use of health care by populations, the availability and compatibility of health care for an entire population, and the actual use of health care by an entire population, the CMNPH is an excellent guide for studying health disparities and social justice. For example, studies could be designed to examine the extent to which a population experiences disparities in health outcomes because of limited access to and use of available health care, taking into account the socioeconomic environment dimension of upstream factors. Other studies could focus on social justice using correlational research designs to examine the relations of pollution or toxic waste dumping in the
physical environment (a dimension of upstream factors) to the dimensions of population factors (genetic, behavioral, and physiological factors; resilience; and health state). A crucial area of population-based nursing research is the analysis and evaluation of health policies, which is needed to enhance the understanding of their impact on certain populations. These analyses and evaluations should be done using rigorous evaluation methods and mixed methods research designs (Creswell, 2015). The results of such studies should expand knowledge of the many determinants of population health and population health outcomes; provide the data on which to base more effective assessments and interventions; and, most importantly, provide the data needed for the consideration of policy alternatives when policies are being formulated (Munger, 2000). Ultimately, the results of CMNPH-based health policy research will provide direction for the transformation of the health care system that is needed to improve the health of populations.
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Figure 1 e Diagram of the CMNPH.
CMNPH-based nursing research may be a singlediscipline endeavor but is best conducted as a multidisciplinary endeavor. The study of theory concepts and propositions linked with the content of the CMNPH requires teams of nurses working with scientists and clinicians from many other disciplines, drawing on knowledge from other health-related sciences and from social, behavioral, and natural sciences. Populationbased nursing research also requires collaboration and coordination with various populations and communities, schools, organizations, public health departments, governmental and nongovernmental agencies, other community-based agencies, health care organizations, and providers. An example of research guided by the CMNPH is a hypothetical study of the effects of a culturally appropriate medication management educational program for a national population of Hispanic older adults with a medical diagnosis of cardiac disease (Figure 2). All CMNPH concepts are used to guide selection of the variables for the hypothetical study. The study variables linked with upstream factors are level of education, transportation, number of pharmacies, number of pharmacies with delivery service, and physical safety. The study variables linked with population factors are culturally specific genetic and cultural factors pertaining to cardiac disease, health behaviors, and level of health literacy. The study variables linked with health care system factors are the availability of bilingual/bicultural health care providers and health insurance. Nursing activities are linked to population-
level assessment of the study variables linked to upstream, population, and health care system factors; collaboration among providers and pharmacies; and design and implementation of a culturally appropriate medication management educational program. Population health outcomes are linked to three study variables: appropriate medication refills, reduced cardiac disease burden, and population-level physiologic variables. For the purposes of the hypothetical study, Hispanic (or Latino) is defined as “a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race” (United States Office of Management and Budget, 2013). The focus on medication management by Hispanic older adults is in keeping with self-management needs imposed by the complexity of chronic diseases experienced by older adults (Hewner, Seo, Gothard, & Johnson, 2014) and the growing Hispanic population in the U.S. (United States Census Bureau, 2010, 2011). The focus on cardiac disease is in keeping with diseases of the heart as the leading cause of death for the Hispanic population in the U.S. from 1980 to 2010 (National Center for Health Statistics, 2014), with a disease burden of 20.8% in 2010 (Heron, 2013). Inclusion of health literacy as a study variable is in keeping with the National Action Plan to Improve Health Literacy initiative of the U.S. Department of Health and Human Services (Galletly, Neaves, Burton, Liu, & Denson, 2012). The study variables may be measured by population-level data obtained from reports issued by
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Figure 2 e Diagram for an example of a CMNPH-guided hypothetical study of the effect of a medication management educational program on medication management by a population of Hispanic older adults with a medical diagnosis of cardiac disease.
relevant governmental agencies and pharmacy and provider populationelevel databases. The culturally appropriate medication management educational program could be disseminated to the population via linguistically appropriate radio and television public service announcements, social media, and brochures distributed at community centers, shopping centers, and other relevant community locations.
Implications for Nursing Education The content of the CMNPH and the research methods used to study population health phenomena need to be included in all levels of nursing education (American Association of Colleges of Nursing, 2014). Traditional community health nursing courses may be a logical place to include this content and these methods. However, relevant content and methods should be included in all nursing education courses. For example, although individuals are the primary focus in many didactic and clinical nursing courses, students need to be encouraged to look beyond individual patients to all determinants of the health of the particular population of which each patient is a member. In the future, all nursing students will need to be aware of the key role and responsibility they have in improving the health of the populations they serve.
They need to refine their skills in assessing aggregates; developing and delivering evidence-based educational programs targeted to wellness promotion and disease prevention; collecting, tracking, and interpreting data; and delivering culturally appropriate care. In addition, all nursing students need to learn to function effectively as members of multidisciplinary teams and to work with community-based institutions, schools, public health departments, faith-based groups, and other organizations by enhancing their communication, collaboration, and coordination skills. They also need to know much more than most currently know about health care systems and political processes. Nursing doctoral students will need increased preparation in population health nursing research, especially research that will influence changes in health policies that affect populations. They will need to learn ever more sophisticated ways to measure the theory concepts that are linked to the CMNPH concepts, such as disease burden, and to test connections between the theory concepts using ever more sophisticated data analysis techniques, such as generalized estimating equations, as well as logistic regression and other categorical data analysis techniques. These students also will need to develop political intelligence (i.e., an understanding of the
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political process emphasizing how to inform and when to participate in the formulation of policies or advocate for the improvement of population health). Perhaps the CMNPH will catalyze the development of doctor of nursing practice programs that focus on the preparation of advanced practice nurses who are experts in the intersection of advanced nursing practice and population health. The CMNPH emphasis on the intersection of nursing and population health may resolve the more than a century-old debate about distinctions between public health nursing and community health nursing and concerns about the continued survival of both specialties (Canales & Drevdahl, 2014).
Implications for Nursing Practice Overcoming the challenge of a focus on populations rather than individuals requires an upstream approach, which within the context of the CMNPH includes not only upstream factors but also population factors and health care system factors. As Bekemeier (2008) explained, “our experiences with patients or populations, and the communities in which they live, ought to be the impetus for making our primary responsibility be practice and research that enables healthy policy change and identifies innovative strategies for addressing the social determinants of [population] health” (p. 51). Shifting the focus to populations requires overcoming many nurses’ tolerance of a perceived culture of oppression (Anderson, 2000). Perceived sources of oppression include mandated government and insurance policy regulations, opposition from other provider groups, and employers and institutional requirements, which tend to limit some nurses’ willingness to seek solutions to the very difficult problems of the health care system. Political challenges will arise as nurses adopt an upstream approach and participate in health policy decisions that address population health (Bekemeier, 2008). The influence of politics is especially evident in the scope of practice and licensing regulations, government reimbursement structures, and the historically poor funding for disease prevention and wellness promotion. The shift to population health does not mean that nurses will no longer be concerned with caring for individuals and families experiencing acute and chronic illness. It is anticipated that a large proportion of practicing nurses will continue to work with individuals as they transition from wellness to illness to recovery. Instead, a balance between individualfocused and population-focused practice is needed, along with a better understanding of individual experiences of illness and disease within a larger population context. For example, nurses working in emergency departments will continue to focus on saving individuals’ lives, but they also will begin to
think about what upstream, population, and health care system factors bring people to emergency departments. Clearly, nurses must consider indicators and root causes of disease conditions to better meet the health care needs of populations (Patterson, 2014).
Dissemination of Population-based Practice and Research All nurses and nursing students should take responsibility for disseminating their population-based work at professional association and other meetings and conferences and through publications in peerreviewed journals and in the lay literature. Given the need to reach all stakeholders for particular health policies, the results of population-based policy research should be published not only in peerreviewed nursing and multidisciplinary journals but also in nonepeer-reviewed government publications, reports, newsletters, fact sheets, working papers, technical reports, conference proceedings, and policy documents.
Conclusion The culture of health care in the U.S. emphasizes individuals, holding sacred the physician-patient and nurse-patient relationships and perpetuating faith in the individual’s view of benefits of care only for his- or herself. Many nurses, along with many physicians and other members of the health care team, have not yet shifted from the individual as the patient to the population as the patient. If nurses are to continue to be committed to improving the well-being and quality of life of all members of society, they must be part of the solution to improving the health of populations. Shifting nurses’ focus from individually based care to population-based care may not be easy. It will require revisions in educational programs and the acquisition of new ways of thinking, practicing, and conducting research. The CMNPH provides population-level guidance for research, educational program revisions, and practice. Stoto (2013) maintained that “responsibility for population health outcomes is shared but that accountability is diffuse” (p. 3). The CMNPH emphasizes the responsibility for population health outcomes that nurses share with other members of the health care team and especially with populations. Widespread adoption by nurses of the CMNPH should facilitate the much needed shift in thinking to multiple determinants of the health of aggregates, aggregatebased wellness promotion and disease prevention interventions, and aggregate-based outcomes that are needed to decrease rates of disease and increase wellness indicators and, ultimately, to enhance the quality of life of populations worldwide.
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Acknowledgments We gratefully acknowledge the contributions to our thinking of our colleagues Dr. Teri Aronowitz, Dr. Mary Cooley, Dr. Laura Hayman, Dr. Lisa Kennedy Sheldon, and Dr. Courtenay Sprague, all from the University of Massachusetts Boston, as well as the contributions of anonymous peer reviewers.
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