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Doi:10.1016/j.dmr.2005.07.004

The Role of Public Health Nurses inBioterrorism PreparednessRalitsa B. Akins, MD, PhD, Josie R. Williams, MD, MMM, RN, Rasa Silenas, MD, FACS,and Janine C. Edwards, PhD Background: Public health nurses have a central Conclusions: The study’s findings could have function in the public health system. Nurses implications for public policy and nursing conduct disease surveillance, which is an leadership. Defining the structure of the public important first step in recognizing diseases health system and the scope of public health caused by bioterrorist agents. Unfortunately, the nurses’ responsibilities will serve as the cornerstone for improvement of bioterrorism expectations for public health nurses are not clearly defined and therefore pose seriousdifficulties for conducting disease surveillance.
Increased surveillance activities for bioterrorismpreparedness add more responsibilities to the issue for public health systems across theUnited States.The US public health system relies on primary health care providers to recognize unusual cases or activity levels and notify officials of surveillance was conducted with public health their observations. In turn, local, state, and federal officials at regional and local levels, working in public health agencies have proscribed roles designed a variety of urban and rural settings in one large to help limit the spread of a potentially lethal or public health region in Texas. Data analysis was disabling agent. Central to this planning are public supported by qualitative research software, health nurses, who are expected to provide any number of essential services. Planners often assumethat a system is adequately staffed to allow for new or Results: The study found that the nurses workingat the local level were extremely dedicated toserving their communities, had formed informal partnerships that are essential for diseasesurveillance, and effectively used informal communication channels to obtain critical surveillance information. The study revealed thatnurses had unmet needs and experienced expanded roles. Unfortunately, insufficient numbers of specific types of staff, or insufficient staff prepara- tion, may impede the success of such plans. The Ralitsa B. Akins is Associate Research Scientist at The Texas Quality Program, Cooperative Agreement No. 1 U18 A&M University System, Health Science Center, Rural and Community Health Institute, Quality and Patient Safety Reprint requests: Ralitsa B. Akins, MD, PhD, The Texas Initiatives, College Station, Texas. Josie R. Williams is A&M University System Health Science Center, Rural Director at the Rural and Community Health Institute, and Community Health Institute, Quality and Patient The Texas A&M University System Health Science Center, Safety Initiatives, 301 Tarrow, 7th Floor, College Station, College Station, Texas. Rasa Silenas is Medical Director at TX 77840; E-mail: ralitsa_akins@yahoo.com.
The Texas A&M University System Health Science Center,Office of Homeland Security, College Station, Texas.
Disaster Manage Response 2005;3:98-105.
Janine C. Edwards is Research Professor at The Texas A&M University System, Health Science Center, Rural Copyright Ó 2005 by the Emergency Nurses Association.
and Community Health Institute, College Station, Texas.
This research was sponsored by the Agency forHealthcare Research and Quality, Partnerships for 98 Disaster Management & Response/Akins et al Table 1. Study sites and characteristics of the study interviewees Epidemiologist, Metropolitan Health District Emergency Management Coordinator (retired) Surveillance Director and Senior Staff Scientist DSHS, Department of State Health Services.
human factor is a necessary and critical asset for health The interviewed public health officials represented services functioning and is often missing from national local and regional public health levels and had diverse backgrounds including nursing, medicine, epidemiol- The human factor (eg, staff numbers, availability, ogy, and emergency management. The characteristics training, and networking) as it relates to professional public health nursing demands further exploration. It Settings. The interviews were conducted at 9 sites is important to explore the role of public health nurses within Texas Department of State Health Services in bioterrorism preparedness and their readiness to (DSHS) Region 8, which includes 1 large metropolitan assume that role and to define their new responsi- area, San Antonio, and 21 surrounding counties, the bilities in bioterrorism preparedness and disease majority of which are rural. Texas DSHS Region 8 has a population of 2,146,154 people and is spread over32,429 square miles. DSHS 8 is larger (both inpopulation numbers and square miles) than the states of West Virginia, Rhode Island, Delaware, Vermont, orNew Hampshire.The research sites included the We report the results from a qualitative study on headquarters of the Texas DSHS, San Antonio disease surveillance that revealed the importance of Metropolitan Health District (nationally recognized monitoring the ability of public health nurses to for its high bioterrorism preparedness), 5 rural participate in bioterrorism preparedness and disease counties with county-based public health departments surveillance. This study was sponsored by the Agency (2 of which were testing new surveillance systems), for Healthcare Research and Quality and was ap- 1 military installation, and 2 border cities (1 in the proved by the Institutional Review BoarddHuman United States and 1 in Mexico) with a border crossing Subjects in Research at Texas A&M University (pro- A comprehensive set of questions about existing Interviewees. The interview sample was selected and emerging disease surveillance systems in the to present a multifaceted picture of the current public region was developed by 2 researchers in the study health system and existing surveillance approaches.
team (RS and JCE). A pilot interview with the staff of Disaster Management & Response/Akins et al 99 Table 2. Questionnaire for semi-structured inter What kinds of disease surveillance are practiced in your community? (syndrome and disease reporting, environmental monitoring, vector monitoring, electronic data mining, etc) For each surveillance method, please describe who reports, who initiates the reporting, and what happens to the information after it is reported.
How satisfied are you with each of the surveillance methods in terms of costs and limitations? (timeliness, accuracy, sensitivity, specificity, personnel, space, infrastructure, etc) What surveillance information do you receive and what do you do with it? Please describe the internal use and external reporting of disease surveillance information.
How well does available surveillance information support the needs of senior officials in your community? What would improve your ability to communicate risk to senior officials? What method or capability for disease surveillance would you like to add? What kind of information would What else would you like to say about disease surveillance? (free comments) )Detailed questionnaire is available upon request.
a county public health office was conducted to test the could affect a public health department’s ability to validity of the questionnaire. The questions proved prepare for bioterrorist events and to conduct disease satisfactory, and one change to the interview pro- cedure was made as a result of our experience in thepilot test. presents the major interviewquestions that were used in this study.
Lack of a Standard Education for PublicHealth Providers Providers enter a public health career through The study data were collected during the period a variety of different venues and at several different of March through August 2004 by our research educational levels. This factor makes it difficult to team. Using a qualitative research approach,semi- quantify the public health workforce and standardize structured interviews were conducted with 19 public the position requirements, a process that is even more health officials at 9 interview sites at regional and local difficult for rural areas. Officials with graduate degrees levels (see The interviews were 1½ to 3 hours in public health were found only at the regional level; no officials with public health academic degrees werefound at the local agency sample sites. Many nurses and officials interviewed in this study had found their The audiotapes were transcribed and entered into way to public health service without formal education research software (The Ethnograph, 5.08, distributed by Qualis Research Associates) that is designed tofacilitate the analysis of qualitative data. Researchers Many nurses and officials interviewed in this coded all segments of the text and compiled themesby code. A code book and a code family tree were study had found their way to public health used to ensure consistency and objectivity in working service without formal education or training in with text segments across the interviews. The inter-views iterated a primary theme regarding the diverse roles that public health nurses have in general and indisease surveillance in particular. This theme also was The public health nurses came from a variety of present across a variety of initially defined codes.
previous types of practice. Only a few had taken In the process of data analysis, the thoughts of courses in public health, and local public health separate interviewees on different public health nurses’ nurses trained each other. Many nurses expressed roles were reconstructed into a meaningful category by frustration at the difficulty of finding additional the processes of data reduction, combining same or training or taking time to study when they did not similar themes, and induction, identifying new mean- have adequate coverage for their absence.
ingful ideas emerging from the gathered data.
Many of the local health departments in Texas This study of the public health system in Texas DSHS Region 8 consisted of one nurse and perhaps an DSHS Region 8 demonstrated a number of themes that administrative assistant. Two public health nurses 100 Disaster Management & Response/Akins et al described being on call around the clock, year-round,even taking calls when on vacation, sometimes out ona boat in the middle of a lake. When one person ina department leaves, others may try to ‘‘keep the placefrom falling apart,’’ but often the traveler is the onlyone who is fully capable of some functions.
We found a well-established network of formal reporting pathways, coupled with very importantinformal networks of information sharing and feed-back. shows the complicated informationflow from various reporters to the public healthagencies.
Our study showed that regular reporting of in- fectious diseases at a county level was dependent onthe working relationships between the public healthnurse and all other reporters (eg, the doctors, infectioncontrol people at the hospital, clinics, laboratories, Figure 1: Disease surveillance reporters to public health school nurses, day care, and nursing homes). The agencies. Straight lines indicate formal networks; dashed public health nurses took the initiative, whether it was lines indicate informal networks and partnerships.
weekly or only several times a year, to talk with thevarious reporters about the importance of what theyare doing and the need for timeliness. Feedback about aggregated counts of cases from the public health department to all of the reporters also assisted in Funding for public health nurses has traditionally maintaining the awareness of the necessity of timely come through disease or service-specific programs (eg, tuberculosis screening, family planning, or treating All of the interviewees spontaneously expressed sexually transmitted diseases). Unlike hospital-based their belief that person-to-person working relation- nurses who theoretically could change positions and ships were the backbone of surveillance. In one roles based on the general needs of the institution, county, active surveillance began in 1998 when the public health nurses’ primary responsibilities are public health nurse became more aware of the closely tied to particular funding programs, which necessity for collecting information about communi- often are mandated through legislation. It becomes cable diseases in a timely manner. That nurse took the extremely difficult for a public health nurse who is initiative to call each of the possible reporters and funded through a specific program to be proactive in explain why they needed to make complete reports in bioterrorism preparedness and disease surveillance in a timely manner on infectious diseases. The nurse addition to the primary program activities.
explained that it took some time to educate all of the As one of our interviewees noted, ‘‘A lot of people reporters, but they all soon began to appreciate the have spent their entire public health careers watching regular weekly phone calls. Furthermore, the report- disease du jour funding. In fact, if you look across ers began to fax or telephone a suspicious report health departments in Texas, you can see evidence of immediately on their own initiative, without waiting this, because depending on when they established their health department, those are the program dollars that Another county public health nurse undertook they get. So you’ve got programs created in the 60’s that a very active campaign when she came into that have. a vast majority of their State funding is position to educate doctors, school and hospital tuberculosis. It has nothing to do with the disease nurses, and all other reporters. The nurse explained patterns now of TB, but it has to do with when they that with personal relationships and communications, raised their hand and said, ‘‘We want to have a local she was able to initiate more reporting and timelier health department’’ and the money available in the 60’s reports: ‘‘I made packets with the reporting guidelines was TB money. So, they still have it. Health departments from the State, and I went out and visited with every that sprang up in the 70’s have immunization money, physician and their office staff. I explained the and in the 80’s, the health departments started getting importance of and the legal need for, which they were disproportionately funded with HIV and STD money.
not aware of really, that these were laws that required And if you formed a health department right now, then you’ve got people on a bioterrorism budget.’’ Disaster Management & Response/Akins et al 101 The Texas DSHS Region 8 Director noted that although bioterrorism preparedness funds have been Local public health nurses are expected to in- available after September 11, 2001, few positions in vestigate disease outbreaks, assess community health, this region have been established with the grant provide a variety of health community services, money. This is because the bioterrorism grant funding execute prevention programs, interpret and apply was expected to go on for only several more years, analytic tools and methodologies, and build commu- and there was an obvious lack of a source to sustain the funding over time. The unreliable sources of Their duties include guiding the development of funding made it difficult to open positions for public bioterrorism response plans for their institutions and health nurses that also were needed for other essential communities, encompassing preventive measures, public health services. ‘‘Theoretically you would think infection control practices, postexposure manage- that we could look at the time of a public health nurse, ment, laboratory support, and public information and we could say, 2 days a week she spends doing bioterrorism, one day maternal and child health, one In general, the public health workforce includes all day TB, one day vaccine preventable diseases, and people educated and employed in public health or right there I’ve filled up a week in 20% increments.
related fields, and their professional skills can be And you would think that we would be able to broad and variable.In our study, the public health attribute her salary in 20% increments to those 4 nurses came from a variety of backgrounds, including different programs: bioterrorism, TB, family health well-child nursing, psychiatric nursing, communicable services, immunizations. But our accounting system diseases, hospital nursing, and school nursing. If can’t do that. It wants everybody, every full time public health professionals were to be defined solely on their education or certification, it would be almostimpossible to recruit enough nurses to fill the positions, because of a lack of public health focus innursing curricula and a competition for nurses who might be interested in other, more financially re- 2001, few positions in this region have been warding fields.Nurses who assume public healthroles have multiple educational needs, including how to connect with their community needs and publichealth priorities.
Although nurses are funded through a specific In a case study conducted in rural local health program, their scope of responsibilities can encom- departments of Wyoming and Idaho, the lack of pass both clinical and public health care in their local formal public health training of the workforce was communities. There is an explicit expectation by the identified as a major problem in reaching the public regional office that the nurses will know their health service objectives.It was concluded that the communities and local authorities and will need to lack of scientific and medically relevant curriculum establish relationships and networks. Public health materials for public health and medical professionals nurses were perceived to be the ‘‘bridge’’ connecting is contributing to the knowledge gap in bioterrorism clinical health care and public health at the local level.
This is an example of how a nurse’s practice can differ The need for specialized bioterrorism training has due to the constraints of programmatic funding.
led some agencies to create their own resources. TheUniversity of Connecticut utilizes a variety of ap-proaches to accommodate working public health practitioners by offering evening programs, distancelearning, interdisciplinary approach, maximum utili- In general, the US public health system structure zation of local resources (such as the regional office of has enormous variability across different states. Local the Federal Bureau of Investigation), guest speakers, public health offices comprise the safety network for communities in case of natural disaster or terroristattack and nurses play a pivotal role in ensuring thefunction of the public health system.The scope and extent of the services provided in each state depend Traditionally, when a public health nurse is needed, on infrastructure, workforce composition, educational a recruitment announcement for a nurse is placed.
preparedness, and funding sources. The only com- Persons with new clinical skills are put into the monality found across state public health organiza- community but are not necessarily public health–- tions is the great demand for nurses to fill public trained individuals. This practice leads to public health nurses getting knowledge and skills from on-the-job 102 Disaster Management & Response/Akins et al training. The general lack of available and accessible The active outreach activities carried on by the nurses education and training, the noncompetitiveness of we interviewed display remarkable commitment and public health position salaries, and the national nurse problem–solving ability in the face of persistent shortage are all problems for filling public health personnel and resource shortages. We perceive that positions with appropriately trained nurses. One study these partnerships have improved the timeliness of of the nursing workforce documented that an increase communicable disease reporting during recent years.
in nursing wages affected nurses’ supply, causing the Multiple communication systems required. Pub- number of employed nurses to increase when wages lic health nurses are expected to use complex commu- increased.Thus, increased funding for public health nication and information technology systems (including nurses may increase the number of persons interested work with E-mail, Internet, and the Public Health Information Network) to support important functions Interviewees indicated that they would be more of surveillance, such as disease outbreak detection and effective if they had additional public health nurse monitoring, data analysis, knowledge management, personnel. Employers may find it challenging to develop uniform public health job requirements based Although constrained by limited resources, the on job title, functions, and organizational base.
public health nurses in this study found creative Previous researcsuggests that many public health ways to improve reporting and keep information nurses, especially those in rural areas, are filling in for flowing. The nurses created formal and informal jobs and activities that would have been delegated to networking (partnerships) to conduct disease surveil- others if more staff were available in their public lance. The complexity of information pathways health departments. The inadequate number of reflects the widely diverse sources and users of this personnel available to perform day-to-day functions information. The formal and informal pathways forinformation flow are equally important and publichealth nurses play a pivotal role in data gathering and Because the personnel are stretched to the The informal pathways supplement the formal ones and ensure timely recognition of important problems.
the infrastructure for surge capacity for These informal pathways are created by the partner-ships established by public health nurses, which are catastrophic disasters is not developed.
characteristic of Region 8 surveillance. If only the for-mal pathways for information flow were used, part of can easily lead to ‘‘burnout.’’ Because the personnel the surveillance information would not be available.
are stretched to the breaking point with everyday Informal networks were considered extremely activities, the infrastructure for surge capacity for important for successful functioning of local public catastrophic disasters is not developed.
health departments. In one case of a school outbreakof Shigella infection, the public health nurses quickly informed neighboring counties to be on the lookout Active versus passive surveillance. The litera- for a secondary spread. Although this happened ture makes a distinction between active and passive through an informal reporting chain, it served the surveillance methodshowever, Region 8 county practicality of the issue very well; the public health public health nurses used both methods of collecting nurses of surrounding counties were notified even information. Active surveillance occurs when public before the medical doctors went to the school.
health officials request surveillance reports from Each organizational level of health departments in health care providers on a regular basis. Passive Region 8 has processes to relay information up and surveillance refers to public health officials expecting down the chain. The state health department operates the providers/reporters to send the information to a Health Alert Network of fax and E-mail notification them unprompted. In our study, we found no useful of important disease information to health depart- distinction between active and passive surveillance ments, public health nurses and practitioners. Most because the nurses created good working relation- local health departments also have means to relay ships (partnerships) among the public health officials local surveillance information to their reporters. All and the various types of reporters, so that both types public health officials believed that when an emerging situation required a public response, they were able to The partnerships developed with the providers/ get that response. They expressed confidence that reporters in their communities by the public health their elected officials trust them to provide appropriate nurses in this study (see ) give evidence of information and recommendations. A few interview- fulfilling the ‘‘extensive individual initiative’’ required ees mentioned the role of economic and political in the county public health nurse position description.
influences on action, but most believed that a true Disaster Management & Response/Akins et al 103 health emergency would receive appropriate atten- responsibilities, will serve as a cornerstone for tion, even if there were negative effects such as loss of improvement and national alignment of bioterrorism This case study is important because it clearly identified the multifaceted roles of public health nurses in bioterrorism preparedness and chartedsome of their needs and barriers to more proactive This study is limited to information acquired from surveillance. The role of the public health nursing literature and document review, and the perceptions, workforce merits clear definition and emphasis in the experiences, and expertise of the study participants, further development of the public health infrastructure who are public health officials at local and regional for bioterrorism preparedness. Focused attention from levels in a large public health region in Texas public health, political, and homeland security leaders including both urban and rural settings.
for support in the development of the public healthworkforce is well deserved.
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to carry a variety of responsibilities while continuing 3. Census 2000 [online, accessed 2005 Feb 3]. Available their community service. The nurses emerged as a fragily balanced, but critical and committed compo- 4. Emerson RM, Fretz RI, Shaw LL. Writing ethnographic nent of the public health system, and disease fieldnotes. Chicago: The University of Chicago Press; surveillance, in particular. Our data suggest that the 5. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park nurses created informal partnerships to augment and support the formal information flow pathways needed 6. Gebbie K, Merrill J, Tilson HH. The public health workforce. Health Affairs 2002;21:57-67.
Our study showed that the fragmentation of the 7. Latter S, Speller V, Westwood S, Latchem S. Education for public health system, the operational lines, expect- public health capacity in the nursing workforce: findingsfrom a review of education and practice issues. Nurs ations, and responsibilities for public health nurses are quite confusing. The lack of clearly set theoretical and 8. Dembek Z, Iton A, Hancen H. A model curriculum for public health bioterrorism education. Public Health Rep2005;120:11-8.
Public health nurses carry both public health 9. Richardson M, Casey S, Rosenblatt RA. Local health districts and the public health workforce: a case study of Wyoming and Idaho. J Public Health Manage Practice2001;7:37-48.
10. English JF, Cundiff MY, Malone JD, Pfeifer JA, Bell M, Steele L, et al. Bioterrorism readiness plan: a template for healthcare facilities [online; 1999 Apr 13; accessed 2005May 27]. Available from: URL: service boundaries makes it difficult even for nurses formally trained in public health to define public 11. Grant Makers in Health. Strengthening the public health health responsibilities and expectations at national or system for a healthier future (Issue Brief No.17, February2003) [online, accessed 2005 Feb 3]. Available from: URL: local levels. Thus, the lack of a systems design and the fragmented infrastructure become hindrances in the 12. Dumpe ML, Herman J, Young SW. Forecasting the execution of public health priorities. Furthermore, nursing workforce in a dynamic health care market. Nurs public health nurses carry both public health and community health functions, which, although over- 13. Hajat A, Stewart K, Hayes KL. The local public health workforce in rural communities. J Public Health Manage lapping, have different connotations. Defining the structure of the public health system, as well as the 14. Dicker R. Principles of epidemiology. 2nd ed. (CDC expectations for and the scope of public health nurses’ Self-Study Course 3030-G, 1992) [online, accessed 2005 104 Disaster Management & Response/Akins et al based approach to connecting public health and clinical medicine. In: Syndromic surveillance: reports from 15. Broome CV, Loonsk J. Public Health Information Net- a national conference, 2003. Morbid Mortal Weekly Rep work: improving early detection by using a standards- Disaster Management & Response/Akins et al 105

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