Population Health and Its Integration into Advanced Nursing Practice

Edited by: Mary Bemker, PhD, PsyS, LADC, LPCC, CCFP, CCTP, CNE, RN, Full Time Faculty, Walden University, Minnesota and Christine Ralyea, DNP, MS-NP, MBA, NE-BC, CNL, OCN, CCRN, Assistant Vice President Patient Care Services—Atrium Health, Adjunct Faculty, Queens University Charlotte, NC

ISBN: 978-1-60595-392-2, February 2018, 528 pages, 6×9, Hard cover or e-book.

  • Presents key concepts in population health with a focus on advanced practice
  • Comprehensive chapters dedicated to essential topics such as obesity and substance use disorders
  • Provides theoretical foundation for transitioning from episodic health to population health principles
  • Includes contributions from topic experts in a variety of settings
  • Theory and concepts support the patient and client as well as the learner
  • Real-world case studies provide class discussion points and support learner-centered activities such as the flipped classroom.
  • Dedicated section provides techniques to address compassion fatigue, coaching, and social marketing
  • Toolkit and Resources provided for each chapter including websites, assignments, and discussion questions
  • Includes chapter dedicated to the role of the executive nurse in population health

This textbook provides essential population concepts in a comprehensive way to advanced practice students in population and public health. Focus is placed on the supports and practices used in the advanced practice role with chapters contributed by nationally known experts on their respective topics.

This text provides the reader with a strong foundation in current population health theory while also providing practical tools to implement the principles into practice.

The text is divided into three parts. The first part provides a global review of population health, and includes coverage of access to data, data analysis, and explores the various APN roles in population health; practitioner, nurse educator, nurse executive, and policy advocate. The second part addresses key issues and populations including the elderly, the military, the chronically ill, and the family roles and health impact of substance abusers. The third section addresses care providers and techniques that foster better care delivery, such as social marketing, coaching, and compassion fatigue. This textbook provides key population concepts in a comprehensive way to advanced practice students in population and public health.


“This textbook, Population Health and Its Integration into Advanced Nursing Practice, is a welcome and timely addition to the nursing literature. As advanced practice nurses, we have an opportunity for a more significant and far-reaching impact on healthcare by understanding the array of determinants that impact health and by intervening to utilize comprehensive and upstream strategies and solutions. The focus on population health, as offered by this textbook, supports this level of thinking. With a concentration in advanced nursing care, population health strives toward better health outcomes for the group. Population healthcare hinges on the belief that individuals will benefit when the focus is on improving communal healthcare. The contributors to this textbook have provided readers with information on population health, its fit with advanced practice nursing care, obtaining and using data to drive health, specific population foci across the lifespan, illustrative case studies, policy considerations, education, and social media strategies as sources of health advocacy. This is a one of a kind resource that will pave the way for advanced practice nurses and other healthcare providers to see greater possibilities of practice in advancing the health of all.”

EDILMA L. YEARWOOD, PhD, PMHCNS-BC, FAAN, Past-President International Society of Psychiatric Nurses,  Chair, Department of Professional Nursing Practice,
Georgetown University School of Nursing & Health Studies

From the Preface

 …As we are all aware, healthcare is not cut and dried. We nurses cannot claim a given group has issues because of X, and if Y is done, all will be well. Rather, as advanced practitioners and potential policy influencers, we must grasp the complexities of every case we encounter and address such in hypothetical and actual interventions.

For students, applying the information in this volume to real-life situations will support and reinforce their learning and career development. For those already in practice, this text is designed to increase understanding of the highly specific, often economic and cultural, influences on patients and clients in diverse communities. Being able to recognize the social dynamics allows for better comprehension, more effective intervention, and superior outcomes.



Contributing Authors


Section I—Population Health Overview and Engagement

Opportunities for Population Health


Chapter 1. Population Health Introduction


  • Population Health Overview
  • Defining Population Health
  • Food for Thought
  • Triple Aim
  • Application of Triple Aim in Practice
  • Expanding our Partners
  • Population Health Management
  • Framing the Issues
  • Business Imperatives for Population Health
  • Advance Practice Nurses Application
  • What is Next in the Book?
  • Tool Kit and Resources
  • References


Chapter 2. Integration of Population Health to

Advanced Nursing Care


  • Integration of Population Health to Advanced Nursing Care Changes in Advanced Nursing Practice to Accommodate the Patient Protection and Affordable Care Act and Steps to Accomplish this Goal
  • What APNs Need to Know About the ACA: History and Background of the Patient Protection and Affordable
  • Healthcare Act
  • Federal Policy Guidelines
  • Federal Mandates on Healthcare Insurance Coverage
  • Health Insurance Marketplace
  • The Affordable Care Act Impacts on Medicare and Medicaid
  • The Advanced Practice Nurse and the Affordable Healthcare Act
  • Increase Supply of Advanced Practice Nurses in Primary Care
  • Practice to the Full Extent of Education and Training
  • Changes in Payment Regulations and Policies for APN Practice
  • Increased Levels of Nursing Education
  • Increased APN/Physician Collaboration to Promote National Health Goals
  • Interprofessional Education
  • Benefits of APNs Including Population Health in Their Practices
  • Making a Difference through Nurse-Managed Health Centers
  • Leadership Opportunities for the DNP-Prepared APN to Utilize DNP Education
  • APNs Making Global and Population Health Changes Through Actions on a Local Level
  • Definitions of Global Health and Global Nursing
  • Including Population and Global Health Content in Nursing Education
  • Glocal: Think Global-Act Local
  • STTI Involvement in Glocal Health
  • IHI Open School Change Agent Network (I-CAN)
  • Global Strategic Directions for Strengthening Nursing and Midwifery
  • Transcultural Nursing Practice
  • Health Disparities, Healthcare Disparities and Health Equity
  • Culturally Competent Transcultural Nursing Practice
  • National Standards for Culturally and Linguistically Appropriate Services (CLAS)
  • Connection Between CLAS and Health Equity
  • Providing Culturally Competent Nursing Assessment and Care
  • Cultural Awareness
  • Culturagram
  • Conclusion
  • Tool Kit and Resources
  • References


Chapter 3. Population Health and Data Analysis


  • Population Health and Data Analysis
  • The Evolution of Clinical Informatics and Big Data in Healthcare
  • Case Study 1—National Cancer Institute, Cancer Moon Shot: Building an IT Structure
  • How Does Data Drive Population Health?
  • How Do We Obtain and Apply the Data?
  • Case Study 2—Millennium Cohort Study 2013—A DoD Research Project (DoD, 2013)
  • Sleep and Health Resilience Metrics in a Large Military Cohort Study (DoD, 2013)
  • Tool Kit and Resources
  • References


Chapter 4. Population Health: Making a Difference in Policy


Population Health: Making a Difference in Policy

  • Political Advocacy
  • Nurses in Political Roles
  • Developing Political Confidence and Clout
  • Getting Started—Nurse Political Awareness
  • Taking the First Steps
  • Advocating for Healthcare Policy Changes
  • Meeting with a Policymaker
  • Time for Reflection
  • Summary
  • Tool Kit and Resources
  • References


Chapter 5. The Nurse Executive Role in Population Health


  • Nurse Executive Role in Population Health Overview
  • Nurse Executives
  • Department of Veterans’ Affairs
  • Geisinger Health System
  • Informatics and Technology
  • Nursing Education
  • Process Improvement and Lean Management Systems
  • Change Management
  • Challenges Faced by Nurse Executives in Population Health
  • Additional Barriers
  • Substance Abuse and Drug Dependency in the Nursing Population
  • Summary
  • Tool Kit and Resources
  • References


Chapter 6. Nursing Education for Population Health


  • Nursing Education for Population Health
  • The APN as Nurse Educator in Population Health
  • History of the APN Evolution
  • Standards for APN Education
  • Board Certification/National Recognition
  • From Practice to Academia
  • Educating Nursing Students on Population Health
  • Strategies for Teaching Population and Community Health
  • High-Fidelity Simulation
  • Technology in the Learning Environment
  • Summary
  • Tool Kit and Resources
  • References


Section II—Populations/Considerations/Specific Areas


Chapter 7. Pediatric Issues


  • Pediatrics Overview
  • Specific Dynamics for Advanced Practice Nurses
  • Community Factors
  • Traditional Factors
  • Tools for Implementation and Quality
  • References


Chapter 8. Gerontology and the Aging American


  • Aging Within the U.S. Population
  • Generational Differences in Geriatrics
  • Causes of Mortality Within the United States
  • Theoretical Concepts of Aging
  • Physiological Processes of Aging
  • Geriatric Challenges
  • Advance Care Planning
  • Major Insurance Carriers
  • Disease Prevention and Health Promotion
  • Charity Meal Distribution Organizations
  • Resources for the Geriatric Population
  • Tool Kit and Resources
  • References


Chapter 9. Military and Care for Veterans


  • Introduction: Why We Serve
  • Understanding the Military System
  • Have You Served?
  • Watch Your Six
  • Shut Up and Color
  • Slick Sleeve
  • Medical Readiness
  • Physical Limitations: A Culture of Denial
  • I’m Being Deployed
  • I’m Coming Home
  • Adrenaline Junkie
  • Mental Health Considerations
  • Post-Traumatic Stress
  • Traumatic Brain Injury
  • Substance Abuse
  • Sexual Assault
  • Suicide
  • Separation from Service
  • Additional Considerations
  • Take Care of Yourself!
  • Tool Kit and Resources
  • References


Chapter 10. Chronic Disease


Chronic Disease

  • The Facts about Chronic Disease in the United States
  • The Impact of Chronic Conditions in the United States
  • Chronic Care Management and the Continuum of Care
  • Preventive Care in Chronic Conditions
  • The Chronic Care Model
  • Chronic Care and the DNP-Prepared Advanced Practice Nurse
  • Care Coordination and Care Management
  • Nursing Leadership in Chronic Care
  • Issues in Chronic Disease Management
  • Health Literacy
  • Innovations in Chronic Care Management
  • Summary
  • Tool Kit and Resources
  • References


Chapter 11. Obesity—Opportunities Across the Continuum


  • Obesity Opportunities Across the Continuum
  • The Stigma of Obesity
  • Obesity—A Crisis
  • Obesity Impact on the Population in the United States
  • Scope of the Obesity Issue
  • Best Practice with Congruency
  • Multifaceted Intervention
  • Clinical Prevention and Population Health
  • Familiar Factors for Obesity
  • Cultural Sensitivity
  • Ethical Considerations
  • Obesity and Quality of Life
  • Additional Treatment/Management
  • APN as an Advocate for Reducing Obesity
  • Summary
  • Tool Kit and Resources
  • References


Chapter 12. Population Health in Trauma and Mental Health


  • Population Health in Trauma and Mental Health
  • Survivor Populations
  • Mental Health Populations
  • Population Needs
  • Trauma Populations and Advanced Practice Nursing
  • Mental Health Populations and Advanced Practice Nursing
  • Overlapping Issues Between the Populations
  • Financial Impact of Trauma and Mental Illness
  • Summary
  • Tool Kit and Resources
  • References


Chapter 13. Substance Use Disorders


  • Substance Abuse and Addiction
  • Substance Use Disorders
  • Genetic Implications
  • Brain Chemistry
  • Impaired Control
  • Social Impairment
  • Risky Use
  • Pharmacological Criteria
  • Alcohol Impact and Related Disorders
  • Caffeine Disorders
  • Tobacco
  • Cannabis
  • Hallucinogens
  • Inhalant Use Disorders
  • Opioid Use Disorders
  • Sedative Use Disorders
  • Stimulants
  • Eating Disorders
  • Steroid Abuse
  • Addiction to Activities
  • Gambling
  • A Family Disease
  • Tool Kit and Resources
  • References


Chapter 14. Infectious Diseases as a Population Health Issue


  • Infectious Diseases as a Population Health Issue
  • Governmental Influence
  • Prevention
  • Incidence Versus Prevalence Rates
  • Surveillance
  • Basic Principles for Infection Prevention
  • Hepatitis
  • Hepatitis A
  • Hepatitis B
  • Incidence of Hepatitis B
  • Symptomatology
  • Hepatitis C
  • Vaccinations
  • Risk Factors
  • Etiology
  • Probability of Transmission
  • HIV/AIDS Progression
  • Acute/Early HIV infection
  • Clinical Latency/Asymptomatic
  • Classification System
  • HIV1 and HIV2
  • Sexually Transmitted Diseases
  • Respiratory Infections
  • Hospital Acquired Infections
  • Conclusion
  • Tool Kit and Resources
  • References


Section III—Tools for Managing Population Health Issues


Chapter 15. Health Coaching


  • Health Coaching
  • Background
  • What Is a Health Coach?
  • Benefits to Integrating Health Coaching into Advanced Nursing Practice
  • Health and Wellness Coaching Utilizing Motivational Interviewing
  • Theories and Theoretical Model for Change
  • Becoming a Health Coach
  • Health Coach Using Motivational Interviewing in Practice
  • The Future of Health Coaching
  • Conclusion
  • Tool Kit and Resources
  • References


Chapter 16. Care for Self: Compassion Fatigue and Burnout


  • Care for Self: Compassion Fatigue and Burnout
  • Compassion Fatigue and Burnout
  • Compassion Fatigue
  • Signs and Symptoms of Compassion Fatigue
  • Neuman’s Healthcare Systems Model
  • Framework
  • Compassion Fatigue versus Burnout
  • Signs and Symptoms of Burnout
  • How are Compassion Fatigue and Burnout Similar?
  • Occupational Hazards
  • Compassion Satisfaction
  • Interventions to Decrease Compassion Fatigue
  • Interventions from the Advanced Practice Nurse to Decrease
  • Compassion Fatigue
  • Tool Kit and Resource
  • References


Chapter 17. The Use of Social Marketing in Population Health Nursing


  • The Use of Social Marketing in Population Health Nursing
  • Social Media
  • Social Marketing (SOCMRKT)
  • Concepts of Population, Community, Subpopulation, Aggregate, and Stakeholders
  • Benefits of SOCMRKT in Population Health
  • Limitations of SOCMRKT in Population Health
  • Theoretical Foundations of SOCMRKT
  • Key Differences Between Marketing and Social Marketing
  • Transtheoretical Model
  • Behavioral Modification
  • Purposes of SOCMRKT
  • Ethical Considerations with SOCMRKT
  • The Ps of Social Marketing (SOCMRKT)
  • Examples of SOCMRKT Projects
  • Outcomes of SOCMRKT
  • Specific Dynamics for the Advanced Practice Nurse: Think 8 Ps
  • Conclusion
  • Tool Kit—SOCMRKT Quality Improvement Resources
  • References


  1. :

    The book is a new publication that examines population health in nursing practice. This is important, given that the medical community’s focus is often on pre-clinical interventions and preventive measures in certain patient subsets. The book is divided into two parts. The first examines the global aspect of population health, and the second delves into population health in relation to vulnerable populations. Further, the book provides an overview of how nursing has shifted its focus from supporting practitioners to promoting well-being and group-specific care to patients.
    As a frame to the book, the Foreword, written by Edilma L. Yearwood, the past president of the International Society of Psychiatric Nurses and Chair of the Department of Professional Nursing Practice at Georgetown University School of Nursing and Health Studies, offers a clear and detailed rationale of how the treatment of the subject here is vital to nursing practice.
    One of the main strengths of this text is to expand the notion of population health by including its effects on health policy and nursing education. Discussion questions are outlined at the end of each chapter and toolkit resources are furnished that invite readers to explore concepts in greater depth. This book has a chapter devoted to advanced nursing practice and another to nursing executives, which are important to population health and implementation for patients. The book takes a step further than other volumes by including a chapter on health coaching and its integration into advanced nursing practice.
    Finally, by giving voice to a diverse range of nursing practitioners, the book does a service to the field by encouraging different approaches to population health, while cultivating an honest and open enthusiasm for how population health will change and enhance the profession. The writers are to be commended for identifying numerous at-risk populations, e.g., veterans, and explaining health conditions unique to them. This book should be a staple for any nursing population health course that analyzes and fosters the connection between health education and nursing practice.
    –Luis Enrique Espinoza, PhD, MPH, CHES®, CPH, Assistant Professor, College of Health Sciences, Texas Woman’s University, Denton, Texas

ISBN: 978-1-60595-392-2, February 2018, 528 pages, 6×9, Hard cover or e-book.