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Making the modern army public health nurse: establishing essential service skills.

As times change, the defined roles for some military occupations must also change. One field where this has become evident is in the field of Army Public Health Nursing, Area of Concentration (AOC) designation 66B. The need for transformation is apparent from the recent name change for the 66B (Public Health Nurse), previously Community Health Nurse. Traditionally, the role of the Army Public Health Nurse (APHN) has been defined in terms of program management sets. The AOC was originally created in 1949 to run a planned program geared to assist new parents adjust to family life, with the overall goal of decreasing emergency room utilization. The scope of practice quickly widened to programs focusing on family-centered services and communicable disease case management. (1) Over time, the AOC 66B incorporated many more programs, including the identification or labeling as the Latent TB Infection (LTBI) program manager, the Sexually Transmitted Infection (STI) clinic director, the HIV/AIDS program administrator, the health consultant to the Child and Youth Services, or the Health Promotion Center manager. Other more local program titles might be In-Out Processing Center manager, Pregnant Soldier Physical Training Program director, or the Smallpox Vaccination coordinator. Sometimes one might wonder if the APHN is being asked to function as a specialty practicing nurse or as a nurse program administrator.

The incorporation of the previously mentioned programs as responsibilities of the AOC is not really the issue. The APHN can certainly function in those areas, and should maintain those duties. However, they have found themselves pigeon-holed into those program roles. Many of those responsibilities are not required during deployment, or at the least in a full time capacity. The APHN could be deployed being completely unsure of what will be expected. This uncertainty is understandable since much of the previous training and job descriptions have been geared towards running those programs.

A medical command group will naturally attempt to optimize use of their assets in a deployed setting. In the case of the Army Public Health Nurse, they must consider any value that is realized when this resource is assigned those traditional programs of the APHN in garrison. They know there is no need for a child and youth health consultant because there are no Child Development Centers. They are not interested in the establishment of an HIV/AIDS program. They probably do not see the need for in and out processing of Soldiers through the medical treatment facility. STI and LTBI can be followed in the acute care setting in a combat support hospital or a battalion aid station under established standard operating procedures. The environment of deployment probably explains why the deployed APHN is often tasked to function within the scope of the general medical-surgical nurse AOC on the intermediate or the minimal care ward. The command often sees that task as the most appropriate use of a nurse in a deployed environment. However, in making such assignments, commanders fail to fully exploit the valuable skills of the Public Health Nurse.

The role of the APHN in the increasing involvement of the Army in humanitarian efforts and civil-military operations is another factor to consider in Army Public Health Nurse training. The AOC 66B has been proposed to fill two slots within a civil affairs (CA) section of the Medical Deployment Support Command. Under the responsibilities expected of the CA section, there is little need for the APHN to function within the traditional roles or programs of that AOC. Instead, the Army Public Health Nurses will be expected to apply their skills as public health officials.

It is within this evolving environment that the APHN basic skill set must change to meet the changing needs of the Army, but at the same time maintain familiarization with the traditional programs still expected of the APHN in garrison. To accomplish this, it is important that we start looking at the APHN profession, not as program managers, but as skilled professionals that have much to bring to Preventive Medicine, Force Health Protection, and military operations. Recently, leadership in the APHN field has identified the direction to take regarding the APHN future practice. (2) They have established a vision of ready and fit Soldiers prospering in healthy military communities. The overall goal is to realize this vision and to align the 66B AOC with the American Nursing Association's (ANA) understanding of the skill sets required by a public health nurse to accomplish the job. For the APHN, this skill set should be used under any number of situations, including garrison, deployed settings, civil-military operations, and even local emergency response conditions.

The knowledge-based skill set recognized as the base foundation to practice as an Army Public Health Nurse has come to be known as the APHN-Public Health Essential Services. The 10 services are built directly around the work of the National Public Health Performance Standards Program. (3) It supports the 3 core public health functions (assessment, policy development, and assurance) modeled by the Association of State and Territorial Directors of Nursing Public Health Nursing Practice Model, (4) with the intent to standardize practice according to the ANA. The essential services, listed below, are those that the APHN is expected to perform under any situation requiring community-based health interventions and public health nursing efforts:

1. Monitor health status to identify community health problems.

2. Diagnose and investigate health problems and health hazards in the community.

3. Inform educate and empower people about health issues.

4. Mobilize community partnerships to identify and solve health problems.

5. Develop policies and plans that support individual and community health efforts.

6. Enforce laws and regulations that protect health and ensure safety.

7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

8. Assure a competent public and personal health care workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

10. Research new insights and innovative solutions to health problems.

To implement these skills, it is imperative that the initial training for the Army Public Health Nurse includes fundamental development and understanding of these essential service expectations. Presently, to become an Army Public Health Nurse, a Registered Nurse is required to attend the Principles of Military Preventive Medicine (6A-F5) course within the Army Medical Department (AMEDD) Center and School. Adjustments have been and continue to be made to the skill sets training in the 6A-F5 course, especially the nurse track phase, to accommodate this paradigm shift in Army Public Health Nursing.

The greatest change came in 2003, when a number of hours in the HIV/AIDS certification material were removed from the program. Though the topic is relevant to the 66B AOC, the depth was much greater than necessary when viewed in light of practical expectation of future application as an APHN. Though 6 hours of HIV/AIDS material are still provided, elimination of this and some other material freed up nearly 30 hours for additional course work.

The available time is used to focus on the essential skill sets and projected roles of the APHN in a deployed setting. Along with introduction to some other programs, classes that focused on developing skills applicable to public health nursing were incorporated into the curriculum. Training in many skills was expanded. Classes on the Planned Approach To Community Health and the PRECEDE/PROCEED Models (5) were introduced as tools for community assessments and setting health objectives for the community. Conducting a community health assessment is the primary skill that the APHN will need. The skill set includes collection of data, analysis of information, and determining risks and resources within the population. The assessment establishes the foundation of all the other APHN responsibilities. The assessment must not only consider the health of the population, but also recreation, education, safety, and economics. The professional skills background in nursing and the ability of nurses to build partnerships and mobilize the community make the APHN assessment different from other Preventive Medicine assessments.

Additional courses on etiology and epidemiology on many of the newer diseases of military importance are now included to improve competence in this critical area. A sample of these useful topics includes emerging infectious diseases, such as West Nile virus, avian influenza, and leishmaniasis. Another contemporary issue is exposure to biological agents and environmental hazards during deployment. It is important that the APHN is able to discuss these issues in the military context, and also have an awareness of the concerns of individuals who face potential exposure, as well as those of family members worried about their Soldiers.

To facilitate the changing role of the APHN, completely new material was introduced into the curriculum. The APHN now receives 12 hours in civil affairs, rapid health assessments, nutritional considerations in disaster relief, preventive medicine support in contingency operations, and PM operations with detainees. This course material was added to help the APHN incorporate the essential services and public health core functions into military operations other then war, in particular humanitarian assistance and disaster relief. The material is there to stimulate student thinking about the APHN role in a deployed setting. The student must understand that although the responsibilities during deployments are different in many ways from those in garrison, basic skills are applied the same way. The APHN must assess the deployment setting for risk and potential health concerns, and identify resources. Interventions, programs, and policies must then be instituted to decrease the risks and to link specific populations with the proper programs and resources in the area of concern. Lastly, the setting must be evaluated for the effectiveness of efforts and changes in the community. The population might be different, but the essential service skill set does not change.

Good presentation skills are necessary for the APHN to inform, educate, and empower people. Public speaking is vital to informing commanders of current issues, instructing personnel to insure a competent public health system, and supporting regulations. The presentations of medical threat briefs and aggregate health promotion education are the principal means for the prevention of disease and nonbattle injury in the Army. The APHN exposure to public speaking skill development has nearly doubled with recent changes in the nurse track of the 6A-F5 course.

Another increasing role for preventive medicine is in homeland security and local disaster response plans. The APHN is now given exposure to the issue and made aware of the potential need for public health nurse involvement in response plan development and postevent action. They are taught this with a special emphasis on biological threat responses, communicable disease outbreak responses, and preventive medicine support. Once again, in this environment, the APHN must be able to incorporate the essential service skills to manage the community under any of the potential situations.

There are, of course, many previous topics in the 6A-F5 course which are still integral parts of the training of the APHN. Some of these broad topics include epidemiology, outbreak investigations, occupational and radiological exposures, environmental quality, medical entomology, data management, and risk communication. No modifications have specifically been made to this material, but the nurses are challenged to see how this material is applicable within their scope of practice, and how it relates to the essential service skill set they are assimilating. The APHN also participates in a Preventive Medicine Operation and Field Training Exercise at the end of the course. They are immersed in a simulated deployed setting with other preventive medicine disciplines and are expected to incorporate their proficiency in issues that might occur in a field environment.

The modifications to update the role of the APHN also come at a critically vital time for the AMEDD. The capabilities of officers in other professional AOCs within Army Preventive Medicine are enhanced by the deployment of the skilled APHN in the operational setting. Whether at a combat support hospital or within a civil affairs unit, the assessment skills of the APHN can be invaluable to other nurses, physicians, physician assistants, and other AOCs, including Environmental Science Officers (ESOs), Environmental Engineers, Audiologists, Nuclear Medicine Science Officers, and Medical Entomologists. Greater numbers of ESOs are now assigned at the brigade level to enhance surveillance capabilities within a division. The APHN can now work hand in hand with ESOs at the brigade level and with preventive medicine physicians who are often assigned to the division surgeon section. This allows the APHN to act as an effective force multiplier for preventive medicine in this setting.

The changes in the program have been geared toward the modernization of the Army Public Health Nurse. The APHN brings educational expertise and professional nursing skills into the Army Preventive Medicine arena. Their background in the holistic nursing process helps fuse the environmental aspects with the individual factors associated with public health. They understand human responses to exposures and to the diseases that might occur. They can bridge the gap between data availability and practical utilization of these data. The public tends to trust the nurse in situations where they might be reluctant to accept words and messages from someone else. Therefore, the Army Public Health Nurses find themselves well placed in situations to bring public health education, compliance, and agreement on the focus of preventive medicine to benefit our most important asset--the Soldier.

REFERENCES

(1.) Field Manual 8-24: Community Health Nursing in the Army. Washington, DC: US Dept of the Army; 10 March 1980.

(2.) Hollandsworth JE, Hall TI, Hart CM. Community health nursing in the Army: past, present, and future. Army Med Dept J. 2005;PB 8-05-7/8/9:21-24.

(3.) The Public Workforce: An Agenda for the 21st Century. Washington, DC: US Dept of Health and Human Services, Public Health Service; 1997. Full report of the Public Health Function Project.

(4.) Association of State and Territorial Directors of Nursing: Public Health Nursing: A Partner for Healthy Populations. Washington, DC: American Nurses Publishing; 2003.

(5.) Green L, Kreuter M. Health Promotion Planning. 2nd ed. Mountain View, CA: Mayfield Publishing Co; 1991.

AUTHORS

MAJ Madson is the AOC 66B Program Director in the Department of Preventive Health Services, Academy of Health Sciences, AMEDD Center & Schools, Fort Sam Houston, Texas.

LTC Alsip is the 6A-F5 Course Director in the Department of Preventive Health Services, Academy of Health Sciences, AMEDD Center & Schools, Fort Sam Houston, Texas.

MAJ James A. Madson, MS, USA LTC Bryan J. Alsip, MC, USA
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Author:Madson, James A.; Alsip, Bryan J.
Publication:U.S. Army Medical Department Journal
Date:Apr 1, 2006
Words:2387
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