Community and Public Health Nursing
PRACTICUM
Theme: INJURY PREVENTION.
OBJECTIVES:
1.
Types of childhood injuries:
a.
Unintentional injuries;
b.
Intentional injuries;
c.
Dominating injuries in different age groups.
2.
Safety promotion and injury
prevention.
3.
Strategies to prevent childhood injuries.
Injury is defined as damage or harm
to an individual resulting in destruction of health, disability, or death (Deal, Gomby,
Zippiroli, & Behrman, 2000). An injury is
classified as intentional or unintentional, denoting whether or not it was
meant to harm the victim. Box 1-3 shows those typically included in each
category.
Among children aged 1-19,
unintentional injuries are responsible for more deaths each year than homicide,
suicide, congenital anomalies, cancer, heart disease, respiratory illness, and
HIV combined (CDC, National Center for Injury Prevention and Control, 1999).
Although unintentional injuries are the leading cause of death for all
children over 1 year of age, the incidence varies by age. More than one-half of
all unintentional injury-related deaths occur in the 15-19-year-old group due
to motor vehicle-related injuries. Common subcategories of motor vehicle
injuries include (1) occupant (drivers and passengers), (2) bicycle-related,
(3) motorcycle, and (4) pedestrian injuries.
There is considerable
variation in injury rates among children depending on their age group. Among
children under 1 year of age, suffocation is the leading cause of unintentional
injury-related death, followed by motor vehicle occupant injury, choking,
drowning, and fires or burns. Some suffocation deaths in infants are due to
entrapment of the head and neck in cribs. Another cause is choking on food or
an object, leading to airway obstruction. For children aged 1—4 years, drowning
is the leading cause of injury death, followed by motor vehicle occupant
injury, fires or burns, and airway obstruction. Infants often drown in
bathtubs, usually as a result of poor supervision or neglect, whereas toddlers
and young children fall into a body of water such as a swimming pool, lake, or
river, usually while unsupervised. Among children aged 5-14, motor vehicle
occupant-related injury is the leading cause of death, followed by drowning,
pedestrian injury (i.e., motor vehicle collisions with the child), bicycle
injury, and fires or burns (National SAFE KIDS Campaign, 1998). Pedestrian
injury often occurs when a child darts out between parked cars or into the
street to get a ball or another object. During adolescence (14-19 years), motor
vehicle occupant injuries are the primary cause of injury-related
deaths. Driver inexperience and alcohol use are key contributors to the high
rate of fatal crashes in adolescents
(Grossman, 2000).
Rates of unintentional injury
deaths among children have declined by 43% over the past several decades.
Decreases in injury deaths have been observed for every age group and for
nearly all causes. Reductions have been most evident among adolescents and for
poisoning deaths (CDC, National Center for Injury Prevention and Control, 1999b). Additionally, most
unintentional injury deaths to children can be prevented. Simple
proven interventions such as using child car seats and bicycle helmets,
requiring that prescription medications have child-resistant caps, installing
smoke detectors in homes, requiring that children's sleep wear be flame
retardant, and enclosing swimming pools with fences have saved the lives of
thousands of children each year.
The key approaches to injury
prevention are education, changes in the environment and in products, and legislation or regulation.
Education to promote changes in individual's behaviors has reduced the risk of
childhood injuries. Education by health care professionals has increased
individual safety behaviors, including seat belt and car seat use, smoke
detector ownership, and safe hot water temperature. Nurses and other health
care providers should incorporate education about safety practices into routine
health visits. Pediatric nurses can play an important educational role by
teaching caregivers about expected behaviors for their child's upcoming
developmental stage. This alerts them to the types of injuries common to that
age group and to potential environmental hazards. Nurses can initiate safety
programs in schools, neighborhoods, and cities (Figure 1-8).
Changes in the environment and
in products can make children's physical surroundings, toys, and clothing
safer. Strategies that make children's environments safer such as traffic
calming to reduce or slow the speed
of traffic in neighborhoods and fencing to enclose swimming pools on all sides should
be implemented in all communities and be mandated by law. Legislation and
regulation are among the most effective tools to reduce injuries, and most
environment and product modifications require legal action. However, some laws
have not been adopted in every state, e.g., 35 states lack bicycle helmet laws
(Bicycle Helmet Safety Institute, 2000), and most states do not require appropriate
protection in automobiles for children between the ages of 4 and 8. For maximum
effectiveness, laws, regulations, and policies must be supported by the public
and enforced at the community level.
A major challenge is to coordinate all groups involved in unintentional injury
prevention to create a
critical mass for action (Schieber, Gilchrist, &
Sleet, 2000).
Injury prevention is an effort
to prevent or reduce the severity of bodily injuries caused by external
mechanisms, such as accidents, before they occur. Injury prevention is a
component of safety and public health, and its goal is to improve the health of
the population by preventing injuries and hence improving quality of life.
Among laypersons, the term "accidental injury" is often used.
However, "accidental" implies the causes of injuries are random in
nature.[citation needed]. Researchers use the term
"unintentional injury" to refer to injuries that are nonvolitional but preventable. Within the field of public
health, efforts are also made to prevent or reduce "intentional
injury." Data from the U.S. Centers for Disease Control, for example, show
unintentional injuries are the leading cause of death from early childhood
until middle adulthood. During these years, unintentional injuries account for
more deaths than the next nine leading causes of death combined.
Injury prevention strategies
cover a variety of approaches, many of which are classified as falling under
the “3 E’s” of injury prevention: education, engineering modifications, and
enforcement/enactment. Some organizations, such as Safe Kids Worldwide, have
expanded the list to six E’s adding: evaluation, economic incentives and
empowerment.
Measuring effectiveness
Research in is challenging,
because the usual outcome of interest is deaths or injuries prevented, and it
is nearly impossible to measure how many people did
not get hurt who otherwise would have. Education efforts can be measured by
changes in knowledge, attitudes, beliefs and behaviors, before and after the
intervention, however tying these changes back into reductions in morbidity and
mortality is often problematic.
Examining trends in morbidity and mortality in the
population is usually not difficult and may provide some indication of the effectiveness
of injury prevention interventions. However, this approach suffers from the
potential of ecological fallacy, where the data shows an association between an
intervention and a change in the outcome, but there is actually no causal
relationship.
Access to Health
Care
For a growing number of
children, access to health care is hampered by lack of health insurance. The
number of uninsured children has been growing at an alarming rate. In 1999,
approximately 11.9 million children (one in seven) under the age of 19 lacked health
insurance (U.S. Census Bureau, 1999). Ethnic minority children are overrepre-sented among the uninsured. They account for more
than half of uninsured children. Three-quarters of uninsured children are
among the working poor, that is, in families in which the head of the household
is employed full time for all or part of the year (Office of the Assistant
Secretary for Planning and Evaluation [OASPE], 1998).
Socioeconomic status largely
dictates the source of children's health insurance. Those from higher income
families are more likely to have private health insurance (90%) than are
children from lower income families (40%) (Brennan, Holahan, & Kenney, 1999). Uninsured children in
low-income families experience substantial difficulties in accessing health
care. They tend to lack (1) the usual sources of routine and sick care, (2) a
primary care provider, and (3) recent visits to health care providers.
Uninsured children are more likely to be underimmunized
and to go without needed medical services due to the costs of care (Newacheck, Halfon, & Inkelas, 2000).
Despite high employment and a
robust economy during the previous 8 years, the number of uninsured children
continued to grow. Several factors have contributed to this situation,
predominately welfare reform. Between 1995 and 1997, 1.25 million individuals
lost Medicaid coverage due to welfare-to-work initiatives (Families USA, 1999).
Many families who left the welfare roles obtained
low-paying jobs for which their employer did not offer health insurance coverage
or could not afford to pay the contributions toward the insurance premiums.
Although many adult members of families were no longer eligible for Medicaid
due to reforms, most of the children in these families were and are still eligible
for its benefits; however, many of these families are unaware that their
children continue to be eligible. Additionally, some children lost their
coverage because welfare administrators failed to inform families of their
continuing eligibility. Other families lost coverage because of state
administrative errors, barriers, and misunderstandings. Finally, in some
states, efforts were made to deter individuals from applying for Medicaid (Sochalski & Villarruel,
1999).
In response to the growing
problem of uninsured children and to expand health insurance coverage for
them, Congress enacted the State Children's Health Insurance Program (SCHIP) as
part of the Balanced Budget Act of 1997. SCHIP was established as Title XXI of
the Social Security Act. Not since the enactment of Medicaid in 1965 has there
been greater funding for children's health insurance coverage. The purpose of
SCHIP is to provide health insurance coverage for children through 18 years of
age who are uninsured or ineligible for Medicaid. More than $40 billion in
federal grants will be allocated to states over a 10-year period. States must
contribute a defined share of funds to obtain federal matching grants (American
Academy of Pediatrics Committee on Child Health Financing, 2001). By October
2000, 3.3 million children were enrolled in SCHIP programs (Health Care
Financing Administration, 2001).
The success of SCHIP will
depend heavily on getting caregivers to enroll their children in the program.
Nurses must assume responsibility for helping to facilitate access to health
care for families with children. First, they need to be aware of their state
health insurance coverage's eligibility requirements and procedures for
enrollment. Nurses should work with community agencies in developing mechanisms
for identifying children eligible for federal and state programs. Then, they
must refer families to available resources and intervene if necessary to help
them navigate through the system.
Beyond the barriers created by
lack of health insurance, there are other factors involved in access to and use
of care. Demographic factors such as family income, race/ethnicity, place of
residence, and type of insurance have been identified as barriers to access of
care (Sochalski & Villarruel,
1999). Institutional factors such as gate keeping by health plans, distance
from families' homes to health site, availability of transportation, and
waiting times are other factors. Nurses need to assess barriers for families in
accessing health care beyond their insurance status in order to ensure that
children will receive needed health care.
PERSPECTIVES ON
PEDIATRIC NURSING
Family-Centered
Care
All health care professionals
recognize that quality health care of children must extend to the entire
family. Thus, the focus of pediatric nursing must be on the child as well as
the family. The term family-centered care describes a philosophy of care that
recognizes the centrality of the family in the child's life and inclusion of
the family's contribution and involvement in the plan for care and its
delivery. It is a health care delivery model that seeks to fully involve
families in the care of children. Family-centered care evolved in response to
the critical need to maintain the relationship between hospitalized children and
their families. Previously this relationship had been neglected or disrupted
because of forced separation by the health care system.
In 1987, a revolutionary
document that defined the elements of family-centered care was published by
the Association for the Care of Children's Health (ACCH). Family-centered care
was defined by this group as including eight equally important elements (Box
1-4). Meeting the ever-changing needs of all family members, not just
those of the child, is paramount to the concept of family-centered care. When
families are incorporated into the care of their children, the physical and
psychosocial health of the child improves and accelerated rates of progress have
been seen. Additionally, these families have demonstrated enhanced learning,
less stress, and more satisfaction with
care (Heller & McKlindon,1996).
The elements of
family-centered care are based on principles that are designed to promote
greater family self-determination, decision-making capabilities, control, and self-efficacy.
Collectively, these attributes are said to reflect a sense of empowerment.
In contrast, the medical model directs health care professionals to assume the
roles of evaluator and
controller of treatment interventions. This approach results in child and
caregiver dependence on the health care providers (Dunst
& Trivette, 1996). This position is in direct
conflict with the conditions necessary for more active involvement of caregivers
in the care of their health-impaired children.
Many health care providers
respect and support the idea of family-centered care; however, the practice of
this type of care has not been fully actualized (Ahmann,
1994). This discrepancy between their support and actual practice of
family-centered care may be attributed in part to the model they employ (family
empowerment versus medical approach). Additionally, professionals often
inadvertently foster family dependency, alienation, and helplessness by taking
control and administering care without family input for the convenience and
expediency of the staff and the institution. However, in order to facilitate
family-centered care, health care providers must seek caregiver input,
suggestions, and advice; incorporate this information into the plan of care; and teach the
family the appropriate health care interventions. By providing education and knowledge to the family, caregivers
can be empowered to make informed decisions about their child's care (Dunst & Trivette, 1996).
Other strategies that enhance family-centered care include no limits on the
ages or number of visitors (unless directed otherwise by the family); adequate
sleeping facilities for caregivers in the child's room; meals or discounts in
cafeterias for caregivers; free parking or a discount for caregivers; and
family attendance at interdisciplinary conferences regarding the child's care.
Atraumatic Care
Atraumatic care is a philosophy of providing care that minimizes or
eliminates physical and psychological distress for children and their families
in the health care environment. In pediatric care, many interventions are
traumatic, stressful, and painful; therefore, it is important for nurses to be
cognizant of these situations and provide care that minimizes distress. Three
principles provide the basis for atraumatic care:
(1) identifying stressors for the child and family, (2) minimizing separation of the child from caregivers,
and (3) minimizing or preventing pain (Furdon, Pfell,& Snow,
1998). Examples of atraumatic interventions include:
• Preparing
the child prior to every procedure using age-appropriate explanations
• For the
child scheduled for surgery, preparing her or him prior to hospital admission
(encourage child and caregivers to visit the hospital, allow the child to play
with equipment and items such as a stethoscope, blood pressure cuff, IV
equipment, masks and gowns)
• Allowing
caregivers to be involved and physically present as much as possible to provide
support and comfort for the child
• Controlling
pain by administering analgesics freely
• Using a euteric mixture of local anesthetics (EMLA) cream at least
1 hour prior to blood draws, insertion of IV needles, and injections
STANDARDS OF CARE
AND STANDARDS OF PROFESSIONAL PERFORMANCE
Professional nurses, as well
as all health care professionals, are being held more accountable for their
actions. This change is translating into more emphasis on adherence to
standards of care. The standard of care is the accepted action expected
of an individual of a certain skill or knowledge level. It is considered the
minimal level of functioning and what a reasonable and prudent person would do
in a similar situation. Standards are a tool for determining if the litigation
as a legal yardstick to determine if care can be considered acceptable nursing
practice.
Specific standards of care and
professional performance have been developed for pediatric clinical nursing
practice by the American Nurses Association (ANA) and the Society of Pediatric
Nurses (SPN) (Box 1-6). Other standards of practice have been developed
by pediatric nursing specialty groups, such as oncology and emergency nursing.
|
BOX 1-6 ANA-SPN standards of
care and standards of professional performance for pediatric nurses Standards of care for the
pediatric nurse: · Collects health data · Analyzes the assessment data
in determining · Identifies expected outcomes
individualized to the · Develops a plan of care that
prescribes interven · Implements the interventions
identified in the plan · Evaluates the child's and
family's progress toward Standards of professional
performance for the pediatric nurse: · Systematically evaluates the
quality and effective · Evaluates her or his own
nursing practice in relation to professional practice standards and relevant
statutes and regulations · Acquires and maintains
current knowledge in pediatric nursing practice · Contributes to the
professional development of · Makes decisions and takes
actions on behalf of children and their families that are determined in an
ethical manner · Collaborates with the child,
family, and health care providers in providing client care · Uses research findings in
practice · Considers factors related to
safety, effectiveness, and cost in planning and delivering care American Nurses Association
and the Society of Pediatric Nurses. (1996). Statement on the scope and
standards of pediatric clinical practice. Washington, DC: American Nurses
Publishing. |
Professional standards are
derived from regulatory agencies, nursing practice acts, professional nursing
organizations, and state or federal laws. Additionally, they come from
scientific literature, which is typically research-based or
evidence-based, and from health care institutions' policies and procedures.
Standards are used not only to evaluate the effectiveness of nursing care
provided, but also are used in litigation as a legal yardstick to determine if
care can be considered acceptable nursing practice.
Specific standards of care and
professional performance have been developed for pediatric clinical nursing
practice by the American Nurses Association (ANA) and the Society of Pediatric
Nurses (SPN) (Box 1-6). Other standards of practice have been developed
by pediatric nursing specialty groups, such as oncology and emergency nursing.
STANDARDS AND GUIDELINES FOR
PRELICENSURE AND EARLY PROFESSIONAL EDUCATION
Caring for children and their
families has always been challenging, but has become increasingly more complex
as technology advances. This complexity has resulted in challenges for nursing
educators, one of which is an expanded and more complex amount of knowledge in
pediatric nursing. Also, with increased attention to family-centered and
community-based care, all nurses will care for children and their families at
some point during their nursing career. Thus, the Standards and Guidelines for Prelicensure and Professional Education for the Nursing
Care of Children and Their Families were developed to support the education of prelicensure students and the professional development of
new graduates for the nursing of children and their families (Box 1-7).
These standards and guidelines are based on (1) child, family, and societal
factors, (2) clinical problems or areas, and (3) care delivery.
The intent is that the goals
will be implemented across all settings where prelicense
and early professional education occur. Resources and
circumstances unique to each education situation will influence how the goals
are implemented, how teaching-learning processes are chosen and applied, and
the outcomes that are selected as the main aims of the education. Additionally,
it is expected that the standards and guidelines will be integrated throughout
the entire curriculum rather than only
in one course.
MEETING THE CHALLENGES OF THE 21ST CENTURY
Child health care has changed
considerably over the past 20 years. Health care systems were previously
focused on the treatment of disease. Health care personnel placed a greater
emphasis on treating disease while neglecting early detection and treatment of
illness as well as health promotion and maintenance. Disease treatment usually
involved invasive procedures through medical technology in acute care settings,
a costly approach.
Financing and reorganization of services has changed to a managed care system.
With managed care, the traditional physician-oriented focus has shifted to a
payer-oriented focus emphasizing health promotion, disease prevention, and cost
containment. Cost cutting in health care institutions is currently pervasive in
the market-driven system of the United States, resulting in a move from inpatient acute care or more
ambulatory and community-based care. Health promotion has always been an area
of strength for nursing practice. Nurses are in an excellent position to be
leaders in today’s health care market. Additional major shifts have occurred in
providing health care, including:
• Children in inpatient
facilities having conditions that
are more acute
• Shorter length of stay in
these facilities
• Increased incidence of
chronic illnesses
• Constraints on delivery of
care, including reduced
human and material resources
• Advances in
telecommunications and information
technology
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BOX 1-7 Standards and guidelines for prelicensure and early professional education for the
nursing care of children and their families I. Child, family, and societal factors 1. Concept: Anatomic structures and physiologic and psychologic processes in neonates, infants, children, and
adolescents Goal The nurse will integrate
knowledge of the unique anatomic structures, physiologic and psychologic processes of children from birth through
adolescence to make assessments, plan, implement, and evaluate care. 2. Concept: Health behaviors Goal: The nurse will use
opportunities to positively influence the health behaviors of children and
their families. 3. Concept: Separation, loss, and bereavement Goal: The nurse will provide
supportive care for children and families experiencing separation, loss,
and/or death. 4. Concept: Economic, social, and political influences Goal: The nurse will use knowledge
of how the larger environment influences the child's health and development
and the family's care to (a) make assessments, plan strategies, and implement
approaches that are in accord with the family's economic and social situation
and available resources, and (b) work with others in the community to make
and implement plans for the health care needs of children. II. Clinical problems or areas: 1. Concept: Safety and injury prevention Goal: The nurse will provide
and promote safety in order to prevent injuries and support the development
of the child. 2. Concept: Children with chronic conditions or
disabilities and their families Goal: The nurse will make
assessments, plan strategies of care, and intervene in ways that promote the
growth and development of the child with a chronic condition or disability.
Additionally, the nurse will support the child's and family's management of
care and promote a healthy family lifestyle. Evaluation of nursing care is a
part of this process. 3. Concept: Children with acute illness or injuries and
their families Goal: When providing care to
children with acute illness or injuries and their families, the nurse will
make assessments, plan strategies of care, and intervene in ways that promote
the growth, development, and safety of the child. Evaluation of nursing care
is a part of this process. III. Care delivery 1. Concept: Family-centered care Goal: A The nurse will use the
family-centered approach to: (a) assess needs, plan and implement
interventions, and evaluate outcomes relevant to the health care needs of
children in partnership with them and their families; (b) work with other
health care providers and the family to promote coordinated service delivery;
and (c) advocate for family-centered care of children. Goal: B The nurse will participate
in developing and working within service delivery systems to support practice
that is consistent with principles of a family-centered approach. 2. Concept: Cultural competence Goal: The nurse will acknowledge
and integrate into health care the beliefs, practices, and values of cultural
groups defined by geography, race, ethnicity, religion, or socioeconomic
status. 3. Concept: Communication Goal: The nurse will communicate
effectively with the child, family, and others who participate in the care
and education of the child and family. 4. Concept: Values
and moral and ethical reasoning Goal: The nurse will respond
to ethical, moral, or legal health-related dilemmas in ways that promote the
development of families and children, assist them in making decisions, and
support them in implementing the decisions. Pridham, K., Broome, M., Woodring, B., & Baroni, M. (1996). Education for the nursing of children
and their families. Standards and guidelines for pre-licensure and early
professional education. Journal of Pediatric Nursing, 11, 273-280. |
These changes in the health
care delivery system have resulted in unprecedented challenges for nurses who
care for children and their families.
Telecommunications and the
Internet have made available vast amounts of health information for health
care providers as well as the consumer. The public is becoming so well informed
about their health problems that the mystique, and therefore, the power of
medical providers are disappearing.
Clients are challenging
clinicians with information obtained on the Internet, and the increasing
available health information is changing nurses' role from health expert to
information broker (Clark, 2000). Yet, this information is of variable quality.
Nurses caring for children will need to be able to use critical appraisal
skills to evaluate health information and to help caregivers interpret it. They
can direct families to valid websites, identify reliable sources of
information, and teach them evaluation skills.