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CHAPTER  vii

C ONTR IB UTO RS

Charon Burda, MS, PMHNP-BC
Assistant Professor
University of Maryland School of Nursing
Department of Family & Community Health
Baltimore, Maryland
Chapter 25: Substance Use Disorders
Angeline Bushy, PhD, RN, FAAN,
PHCNS-BC
Professor & Bert Fish Chair
University of Central Florida, College of
Nursing
Orlando, Florida
Chapter 32: Rural Health
Verna Benner Carson, PhD, PMH/CNS-BC
Associate Professor
Towson University
Towson, Maryland
Chapter 33: Community Mental Health
Robin Fleming, PhD, MN, RN, NCSN
Nursing Practice and Education
Specialist
Washington State Nurses Association
Seattle, Washington
Chapter 30: School Health
Linda Haddad, PhD, RN, FAAN
Associate Professor
Virginia Commonwealth University
Richmond, Virginia
Chapter 10: Relevance of Culture and
­Values for Community/Public Health
Nursing
Sarah Hargrave, MS, BSN, RN, CPHQ
Regulatory Specialist
Bartlett Regional Hospital
Juneau, Alaska
Chapter 29: State and Local Health
­Departments
Gail Ann DeLuca Havens, PhD, RN
Owner and Principal
INSIGHT: Consultative Services in
­Healthcare Ethics
Bluffton, South Carolina
Ethics in Practice Boxes
Gail Heiss, MSN, RN
Nursing Education Specialist
VA Maryland Health Care System
Baltimore, Maryland
Chapter 18: Health Promotion and Risk
­Reduction in the Community
Chapter 19: Screening and Referral
Chapter 20: Health Teaching
Christina Hughes, BSN, MS, RN, NREMT-P,
CHEP
Director, Healthcare System Preparedness
MedStar Health ER One Institute
Emergency Preparedness Coordinator
EMS Liaison
MedStar Franklin Square Medical Center ED
Baltimore, Maryland
Chapter 22: Disaster Management: Caring for
Communities in an Emergency
Jennifer Maurer Kliphouse, BSN, RN, BA
Wound Specialist
Frederick Regional Health System
Frederick, Maryland
Table 8–3: Communicable Diseases, Community
Health Concerns, and Treatment
The Nursing Process in Practice boxes
Helen Kohler, PhD, MSPH, RN
Visiting Professor
University of Eastern Africa
Baraton, Kenya
Visiting Professor
Moravian College
Bethlehem, Pennsylvania
Chapter 5: Global Health
Cara J. Krulewitch, PhD, CNM, FACNM
Associate Clinical Professor
George Washington University
Washington, DC
Chapter 23: Violence: A Social and Family
Problem
Tina Marrelli, MSN, MA, RN, FAAN
Editor, Home Healthcare Nurse
Marrelli and Associates, Inc.
Healthcare Consultants
Boca Grande, Florida
Chapter 31: Home Health Care
Michelle McGlynn, BSN, RN
Assistant Master Technical Instructor
University of Texas and Brownsville
Texas Southmost College, College of Nursing
Brownsville, Texas
Chapter 27: Children in the Community
Leslie Neal-Boylan, PhD, CRRN, APRN-BC,
FNP
Professor, Graduate Program Director
Southern Connecticut State University
School of Nursing
New Haven, Connecticut
Chapter 26: Rehabilitation Clients in the
Community
Corrine Olson, MS, BSN
Retired Deputy Chief, Public Health
Nursing
State of Alaska
Viroqua, Wisconsin
Frankston, Texas
Chapter 29: State and Local Health
­Departments
Anne Rentfro, PhD, RN
Professor
College of Nursing
The University of Texas at Brownsville
Adjunct Faculty
University of Texas Health Science
Center - Houston
Brownsville, Texas
Chapter 27: Children in the Community
Sally Roach, MSN, RN, APHN-BC, CNE
Associate Professor
University of Texas at Brownsville
Brownsville, Texas
Chapter 28: Older Adults in the
Community
Gina C. Rowe, DNP, MPH, APRN, BC
Assistant Professor
University of Maryland School of Nursing
Baltimore, Maryland
Chapter 7: Epidemiology: Unraveling the
Mysteries of Disease and Health
Barbara Sattler, RN, DrPH, FAAN
Professor
School of Nursing and Health
Professions
University of San Francisco
San Francisco, California
Chapter 9: Environmental Health Risks
at Home, at Work, and in the Community
Susan M. Wozenski, JD, MPH
Assistant Professor and Vice Chair, Family
and Community Health
University of Maryland School
of Nursing
Dual Degree Director, MPH Program
Department of Epidemiology and Public
Health
University of Maryland School
of Medicine
Baltimore, Maryland
Chapter 6: Legal Context for Community/
Public Health Nursing Practice
vii
viii CONTRIBUTORS
ANCILLARY CONTRIBUTORS
Joanna E. Cain, BSN, RN
President and Founder
Auctorial Pursuits, Inc.
Austin, Texas
NCLEX Review Questions
TEACH for RN- Case Studies
Discussion of Focus Questions
R EVI EWERS
Laurel Boyd, MA, MEd, RN
Assistant Professor, Nursing
University of West Florida
Pensacola, Florida
Jo DeBruycker, MPH, RN
Adjunct Professor
St. Cloud State University
Department of Nursing Science
St. Cloud, Minnesota
Jennifer Maurer Kliphouse, BSN, RN, BA
Wound Specialist
Frederick Regional Health System
Frederick, Maryland
Care Plans
Stephanie Powelson, MPH, EdD, RN
Chair, Nursing Department
Truman State University
Kirksville, Missouri
PowerPoint Slides
Christine Crytzer Divens, MSN, RN, CPN
Clinical Nurse Specialist
Children's Hospital of Pittsburgh
of UPMC
Pittsburgh, Pennsylvania
Susan L. Fogarty, MSN, RN
Associate Professor, Nursing
Ferris State University School of Nursing
Big Rapids, Michigan
Anna K. Wehling Weepie, DNP, RN, CNE
Assistant Dean, Undergraduate Nursing
and Associate Professor
Allen College
Waterloo, Iowa
Test Bank
Stephanie Powelson, MPH, EdD, RN
Chair, Nursing Department
Truman State University
Kirksville, Missouri
Julie St. Clair, MSN, RN
Instructor, Nursing Program
University of Southern Indiana
College of Nursing and Health Professions
Evansville, Indiana

June 2012 marked the 100th anniversary of the term public health
nurse, adopted by the National Organization for Public Health
Nursing, the forerunner of the National League for Nursing.
Anniversaries and transitions offer time to reflect on the past
and present, as well as to clarify directions and strategies for
the future. When the first edition of this text was published, we
had just celebrated the 100th anniversary of modern commu-
nity/public health nursing in the United States. The second edi-
tion anticipated the arrival of the twenty-first century, which
brought both practical and symbolic implications for the future
of community/public health nursing. As the fifth edition is pub-
lished, we continue to confront global health issues including
climate change, food shortages and maldistribution, refugee
health, exposure to environmental chemicals, and disabilities
and deaths from conflicts and warfare. The United States health
care system is undergoing dramatic changes that will affect both
consumers and providers of health care services in critical ways.
Creative ways are called for to improve the health and well-
being of our citizens and communities.
This fifth edition explores our history and present prac-
tice, and contemplates our future. The title: Community/ Public
Health Nursing Practice: Health for Families and Populations
reflects the practice arena of community/public health, empha-
sizing the application of content to nursing practice, and shows
the broad scope of community-based and community-focused
practice.
Throughout this text, emphasis is placed on the core of "what
a community/public health nurse needs to know" to prac-
tice effectively in the context of a world, nation, society, and
health care system that are ever changing. This text is intended
for baccalaureate nursing students taking courses related to
­community/public health nursing, including registered nurses
returning for their baccalaureate degrees. The text is also suit-
able for entry-into-practice Clinical Nurse Leader students.
Beginning practitioners in community/public health nursing
will also find much useful information. The term community/
public health nursing is used in this text to remind the reader
that community-orientated nursing practice is broad based and
aimed at improving the health of families, groups, and popula-
tions. To save space in the text, the term community health nurse
may sometimes be used in place of community/public health
nurse. The term client is used to reflect individual, group, and
population recipients of nursing care, while the term patient is
used selectively to denote individuals under care in intense clin-
ical and hospital-based practice.
Changes in the delivery and financing of health care services
affect professional practice as well as individuals, families, pop-
ulations, and communities. Therefore in this edition we explore
past and present efforts at health service and funding reform,
critique progress toward stated reform goals, and identify cur-
rent and future areas of concern for health care providers and
communities.
Unlike 100 years ago, the major causes of death in the United
States today are not communicable diseases. Rather, the major
causes today are chronic diseases, such as heart disease, cancer,
PR EFAC E
stroke, pulmonary diseases, and diabetes, and, at all ages, unin-
tentional injury. Much of the premature death and disability
is preventable through control of environmental and personal
risk factors, such as smoking and obesity. Health promotion and
prevention have been historic aims of community/public health
nursing. Today, the National Health Objectives for the year 2020
identify measurable targets for reduction in death and disability.
Because community/public health nurses are in the forefront of
helping families and communities identify and reduce their risk
factors, the Healthy People 2020 objectives and progress toward
goal attainment are included in all appropriate chapters.
Reducing health disparities is a foremost national goal.
Health, illness, and health care are unevenly distributed among
people. The relevance of population-focused nursing emerges
when the unmet health needs of populations are recognized.
For example, numbers of injured veterans, the homeless, the
chronically mentally ill, and poor children are increasing. The
poor have higher rates of illness, disability, and premature
death. The cost of health care and absent or inadequate health
insurance coverage combine to also increase the numbers of
medically indigent, such as survivors of accidental head and spi-
nal trauma. This text explores the commitments and activities
of community/public health nursing in improving the health
of such vulnerable families, groups, and populations. Research
studies discussed throughout the text illustrate the success of
nursing interventions with vulnerable populations in commu-
nities and provide a basis for evidence-based practice.
To identify the health-related strengths and problems of a
community, it is necessary to assess the demographic and health
statistics of the community's population and to explore the
existing community structures, functions, and resources. In this
text, we stress the importance of developing partnerships with
community members. We present a community assessment tool
with several case studies showing its application to both geopo-
litical and phenomenological communities. We discuss varied
perspectives for planning and evaluating nursing care within
communities. Community/public health nurses recognize
that much of a person's attitude and behavior toward health is
learned initially in his or her own family. Family-focused health
promotion and prevention is an important community/public
health nursing strategy. As was true in previous centuries, some
families today experience multiple problems with unhealthy
environments, disabled or chronically ill members, develop-
mental issues, breakdowns in family communication, and weak
support systems.
The text reflects the increasing demand for community/
public health nursing in home health care for the ill. Hospital cost-
containment measures that began in the 1980s have resulted in a
decrease in the average length of stay of patients in hospitals. As
was true 100 years ago, families today are caring for ill members
at home and are requiring assistance from community health
nurses. In response to client needs, newer structures of nursing
care delivery also have emerged, including hospice and medical
daycare centers. A family focus and care for clients in their daily
settings—homes, schools, and worksites—are traditional aspects
ix
x PREFACE
of community/public health nursing. Community/public health
nursing acknowledges the importance of caring for the family
caregivers as well as for ill family members and of strengthening
community support services.
The community/public health nurse's involvement with
contemporary public health problems—substance abuse,
violence, and newly emerging or persistent communicable
diseases (including HIV/AIDS, MRSA, SARS, multi-drug
resistant tuberculosis, and West Nile Virus)—is thoroughly
covered. As a response to recent events, the disaster chapter
provides greater emphasis on disaster prevention and man-
agement. Adolescent sexuality and the health risks associated
with sexual activity for both adolescents and their infants are
explored. Chapters on vulnerable populations and community
mental health examine two areas of increasing concern for
community/public health nursing. Toxic substances in home,
work, and community environments are identified as special
health hazards.
Changes in the age composition of our country's residents
pose concerns related to the ratio of dependent persons. More
older adults and, in selected subpopulations, more children
make up the population. Special emphasis is given in the text to
a discussion of the support networks with which community/
public health nurses work as they provide nursing care with
elderly people, children, and persons with disabilities.
LEVEL OF LEARNER
This book is intended as a basic text for baccalaureate students
in community/public health nursing. It is appropriate for basic
baccalaureate students, registered nurses returning for bac-
calaureate degrees, and baccalaureate graduates and entry-­
into-practice Clinical Nurse Leader graduates who are new to
community/public health employment. It assists the learner in
the practical application of community/public health nursing
content.
The material covered in the text has been updated to be con-
sistent with the American Association of Colleges of Nursing
2008 report The essentials of baccalaureate education for pro-
fessional nursing practice and the Association of Community
Health Nursing Educators 2010 report Essentials of baccalau-
reate nursing education for entry-level community/public health
nursing.
Additionally, the text can benefit registered nurses without
baccalaureate degrees who are changing their practice settings
because of health care system changes. For example, in some
places, registered nurses with strong technological medical-­
surgical or pediatric skills are being employed in home care.
These nurses, their supervisors, and/or in-service education
directors can use this text to provide background information,
especially in relation to the context of practice, family-focused
care, home visiting, and scope of community resources.
The text has a descriptive focus, including both historical
changes in practice and the relative magnitude of community/
public health nursing problems and solutions today. The text
also is structured to promote further inquiry related to each
subject and to connect information with examples of practice.
Thus, the text includes abstractions and concepts, as well as
questions and examples, to promote critical thinking and appli-
cation of the information.
We are pleased with student comments about the strengths
of previous editions and have maintained these positive charac-
teristics in the fifth edition:
• The text is very readable.
• The writing style maintains interest.
• Tables are clear and useful.
• Explanations discuss the relevance of ideas to practice.
• Examples show practical application.
• Evidence-based practice examples are integrated throughout.
• Each chapter is self-contained, without the need to refer to
appendixes.
This text builds on prerequisite knowledge and skills related
to application of the nursing process, interpersonal relation-
ships, and nurse/client communication skills. Other prerequi-
sites are knowledge of human development, basic concepts of
stress and adaptation, and nursing care with individuals. While
a basic general systems language is used with family and com-
munity theory, terms are defined for those who have not had
formal instruction in these concepts.
ORGANIZATION OF TEXT
The text is organized into eight units. Unit One, Role and
Context of Community/Public Health Nursing Practice,
describes the ethical commitments underlying community/
public health nursing practice as well as the scope and context
of community/ public health nursing practice. We explore how
the structure and function of our complex health care system
and legal and economic factors influence communities and
community/public health nursing practice. A chapter on global
health provides a broader perspective of the concepts of health
and illness throughout the world.
Unit Two, Core Concepts for the Practice of Community/
Public Health Nursing, presents basic concepts necessary
for effective community/public health practice. An under-
standing of the process of epidemiology, including the
impact and control of communicable diseases, is essential
to community/ public health nursing practice. A chapter on
environmental issues at home, at worksites, and in geopolit-
ical communities identifies specific health risks. Culturally
competent nursing care depends on understanding the
impact of culture and values on health and health behaviors.
Culturally competent nursing care also requires an under-
standing of the impact that diversity in culture and values
among clients and health providers may have on the nurse-
client relationships.
Unit Three, Family as Client, presents a broad theory base
related to family development, structure, functioning, and
health. A family assessment tool is provided, and sources for
additional tools are identified. Specific case studies demonstrate
the application of the nursing process with families. Special
emphasis is given to working with families in crisis and "multi-
problem" families.
Nurses with baccalaureate degrees belong to one of a few
professions whose members learn to care for people at home
as a part of their educational experiences. Many nurses without
baccalaureate degrees who desire to transfer from hospital to
home care settings must learn on the job. Consequently a chap-
ter is devoted to home visiting, a continuing facet of ­community/
public health nursing.

Unit Four, Community as Client, presents the commu-
nity and population approach that is unique to community/­
public health nursing. Communities may be characterized as
­geopolitical or phenomenological (communities of b ­ elonging).
Assessment tools are presented for each type of community
and case examples provided to illustrate the application of the
nursing process with communities. Numerous measures for
evaluating the outcomes of community/public health nursing
programs are discussed. Additionally, process and management
evaluations are examined.
Unit Five, Tools for Practice, develops three strategies for
population-focused intervention used frequently by commu-
nity/ public health nurses:
• Health promotion and risk reduction
• Screening and referral
• Health teaching
Specific tools are included that can be used to help indi-
viduals identify risk factors for illness and identify more
healthful personal behavior. Detailed instructions are pro-
vided for conducting health screening. Also included are
the current recommended schedules for health screening
for males and females of various age groups. These specific
practice skills may be applied with individuals, families, and
populations.
Unit Six, Contemporary Problems in Community/Public
Health Nursing, focuses on contemporary problems encountered
in community/public health nursing practice. Demographic and
epidemiological data help identify populations most at risk for
specified health problems. A chapter is devoted to each of the
following:
• Vulnerable populations, including people in poverty, the
homeless, migrant populations, and prison populations
• Disaster management
• Family and community violence
• Adolescent sexual activity and teenage pregnancy
• Substance use disorders
The impact of poverty on health is explored in depth. The
health risks of vulnerable groups are explored. Societal and per-
sonal factors contributing to health problems are identified,
including psychological and family stress related to homeless-
ness, poverty, and a migrant lifestyle.
The disaster chapter emphasizes the importance of preplan-
ning and outlines the roles of both public and private organi-
zations in disaster relief. Common disaster scenarios for both
natural and manmade disasters are presented. Changes in
disaster preparation and management to improve commu-
nity response to terrorism are outlined, and potential terrorist
threats are identified.
Unit Seven, Support for Special Populations, discusses three
vulnerable populations: persons with disabilities, children, and
older adults. Prevalence of health problems, common nursing
interventions, and the importance of community support ser-
vices are discussed.
Unit Eight, Settings for Community/Public Health Nursing
Practice, describes settings for community/public health nurs-
ing practice, including state and local health departments,
schools, home health agencies, rural communities, and commu-
nity mental health sites. Each chapter includes a day or a week
in the life of a community/public health nurse or a case study to
help students experience the reality of working in that setting.
PREFACE xi
CHANGES TO THE FIFTH EDITION
The fifth edition updates and expands content from the fourth
edition, which was widely acclaimed. New content is also
included and listed below.
Throughout the Text We Have Updated the Following:
• Demographic statistics
• Descriptive epidemiology, incidence and prevalence data
• Standards for practice and quality
• Initiatives to improve access to health care
• Current evidence-based findings and best practices
• References and recommended readings
• Community resources for practice
New Content in this Edition:
• Healthy People 2020 objectives with Healthy People 2020
boxes
• The Patient Protection and Affordable Care Act of 2010
(ACA) and its impact on health care delivery systems, financ-
ing of health care services, specific populations, and health
disparities
• Shifting federal/state responsibilities in health care delivery
• State and federal efforts at universal health coverage
• Trends in employer-provided health insurance
• Community health centers
• Top ten public health accomplishments during the past
decade
• Global health disparities
• International health care delivery systems
• Impact of war, terrorism, and national disasters on health
and health care delivery
• Human trafficking and genital circumcision
• Evidence-based home visiting programs
• New health risk appraisal tools
• Newborn screening for genetic disorders
• Fatalities associated with weather-related disasters
• Bioterrorism and national and state planning responses,
including role of the United States Department of Homeland
Security
• Impact of sexting, sex education, and abstinence-only pro-
grams on teen behavior
• Addiction as a brain disorder
• Language stigma and substance use disorders
• Community re-integration and community living arrange-
ments for patients in with disabilities
• Bullying
Expanded Content in this Edition:
• Clinical examples that are related to the chapter content and are
common in the practice of community/public health nurses
• Internet resources for both faculty and students, including
additional links to Community Resources for Practice
• Distribution of community health nurses by worksites
• Social determinants of health
• Social justice
• Medicare Advantage and Medicare Part D – Prescription
Drug Plan
• Cost-sharing impacts on access to health care
• Core public health functions
xii PREFACE
• Third-party reimbursement for nurse practitioners and clin-
ical nurse specialists
• Emerging problems with communicable diseases
• Climate change and health
• Chemical policies
• Immigration trends
• Health disparities and health care disparities
• Household composition in United States
• Family case management in community/public health
• Informatics and electronic health systems
• Evidence-based practice examples of community planning
and intervention
• Evidence-based practice examples of community health pro-
gram evaluations
• Mobilization Action Through Partnerships and Planning
(MAPP)
• Geographic information systems (GIS)
• Examples of epidemiological studies and their application in
public health practice
• Guidelines for screenings
• Nursing interventions related to the Transtheoretical
Model—Stages of Change
• SMOG formula to determine readability of print materials
• Sample health education lesson plan
• Migrant and prison health problems
• Contemporary tools for addictions screening
• Disability prevalence by age
• Common health problems throughout the life span
• Environmental aspects of school health
• State and local health department services and use of public
private partnerships
• Major challenges for public health in the twenty-first century
• Trends in child, older adult, rural, and school health services
• National goals for the community mental health system
CHAPTER ORGANIZATION TO PROMOTE LEARNING
Each chapter has the following features:
Focus Questions
Outline
Key Terms (boldfaced in the text)
Chapter narrative
Key Ideas
Learning by Experience and Reflection
References
Suggested Readings
The majority of chapters also present one or more of the follow-
ing special features to aid learning:
Case Study
The Nursing Process in Practice
Community Resources for Practice
Ethics in Practice
Focus Questions at the beginning of each chapter and Key
Ideas at the end help the reader focus on the material presented.
The questions encourage the reader to approach learning from
the perspective of inquiry. Key Ideas summarize the important
ideas. Where appropriate, epidemiological data are presented to
describe the magnitude of the health problems and the popula-
tions in which they occur more frequently.
Case Studies and The Nursing Process in Practice encourage
application of the chapter material. Most chapters provide an
example of the nursing process applied with a family or commu-
nity or a case study in which the chapter concepts may be applied.
Learning by Experience and Reflection at the end of each
chapter is designed to foster student learning through inquiry
and a variety of ways of knowing. Ways of knowing include
empirical knowledge and logic, interpersonal learning expe-
riences, ethics, and greater awareness of personal preferences
(aesthetics). Guidelines may promote reflection and self-­
awareness, observation, analysis, and synthesis. Each chapter
includes guidelines for learning appropriate to most students
as well as suggestions for those who are interested in further
exploration and creativity.
Community Resources for Practice appears at the end of
each chapter. This list of resources provides the organization
names and websites.
Suggested Readings have been selected with the level of student
in mind. Some readings expand on concepts and tools of practice
mentioned in the chapter. Other readings provide descriptions
of community/public health nursing programs or descriptions of
nurses' experiences related to their professional practice.
Ethics in Practice is a special feature appearing predomi-
nantly in chapters in Units Five and Six. A situation involving a
community/public health nurse is used to identify ethical ques-
tions, related ethical principles, and the actions of the specific
nurse. These situations provide the opportunity for student/
faculty dialogue to explore one's own ethical decision-making.
Several of the situations demonstrate the tension between the
rights of individuals and the rights of the public at large; other
situations depict competing values.
ANCILLARY PACKAGE
A complete teaching and learning package is available on the
book's dedicated Evolve website at http://evolve.elsevier.com/
Maurer/community/. This website offers materials for both
­students and instructors.
Study Aids for Students
See previous Evolve page for more details on student resources.
For Instructors
TEACH for Nurses: NEW to this edition, detailed chapter Lesson
Plans containing references to curriculum standards such as
QSEN, BSN Essentials and Concepts; new and unique Case
Studies; as well as Teaching Strategies and Learning Activities.
PowerPoint Slides: Slides of bulleted information that high-
light key chapter concepts to assist with classroom presentation
and lecture.
Teaching Strategies for Learning by Experience and Reflection:
Detailed plans and suggested activities for implementing the
Learning by Experience and Reflection exercises in the book.
Test Bank: Over 800 NCLEX-style questions, with cognitive
level, topic, rationale, and text page reference provided. One
question in each chapter is presented in the newer innovative
item format.
Discussion of Focus Questions: Short answers to the questions
that introduce each chapter.
Image Collection: Contains illustrations selected from the
textbook.
Frances A. Maurer
Claudia M. Smith
 C ONTENTS IN B R I E F

UNIT 1 ROLE AND CONTEXT OF UNIT 5 TOOLS FOR PRACTICE

COMMUNITY/PUBLIC HEALTH
18 Health Promotion and Risk Reduction in the
NURSING PRACTICE Community, 466
1 Responsibilities for Care in Community/Public 19 Screening and Referral, 486
Health Nursing, 2 20 Health Teaching, 505
2 Origins and Future of Community/Public Health
Nursing, 31
UNIT 6 CONTEMPORARY PROBLEMS IN
3 The United States Health Care System, 54
4 Financing of Health Care: Context for Community/ COMMUNITY/PUBLIC HEALTH
Public Health Nursing, 86 NURSING
5 Global Health, 113
6 Legal Context for Community/Public Health 21 Vulnerable Populations, 527
Nursing Practice, 136 22 Disaster Management: Caring for Communities in
an Emergency, 552
23 Violence: A Social and Family Problem, 575
UNIT 2 CORE CONCEPTS FOR THE 24 Adolescent Sexual Activity and Teenage
PRACTICE OF COMMUNITY/ Pregnancy, 603
25 Substance Use Disorders, 631
PUBLIC HEALTH NURSING
7 Epidemiology: Unraveling the Mysteries of
Disease and Health, 161 UNIT 7 SUPPORT FOR SPECIAL
8 Communicable Diseases, 190 POPULATIONS
9 Environmental Health Risks: At Home, at Work,
and in the Community, 235 26 Rehabilitation Clients in the Community, 659
10 Relevance of Culture and Values for Community/ 27 Children in the Community, 679
Public Health Nursing, 266 28 Older Adults in the Community, 701

UNIT 3 FAMILY AS CLIENT UNIT 8 SETTINGS FOR COMMUNITY/

11 Home Visit: Opening the Doors for Family Health, 298 PUBLIC HEALTH NURSING
12 A Family Perspective in Community/Public Health PRACTICE
Nursing, 322
13 Family Case Management, 340 29 State and Local Health Departments, 726
14 Multiproblem Families, 372 30 School Health, 749
31 Home Health Care, 777
32 Rural Health, 799
UNIT 4 COMMUNITY AS CLIENT 33 Community Mental Health, 822
15 Community Assessment, 393 Index, 841
16 Community Diagnosis, Planning, and
Intervention, 427
17 Evaluation of Nursing Care with Communities, 449

xiii
C O N T ENTS
UNIT 1 ROLE AND CONTEXT OF
COMMUNITY/PUBLIC HEALTH
NURSING PRACTICE
1 Responsibilities for Care in Community/Public
Health Nursing, 2
Claudia M. Smith
Visions and Commitments, 4
Distinguishing Features of Community/Public
Health Nursing, 6
Theory and Community/Public
Health Nursing, 7
Goals for Community/Public
Health Nursing, 11
Nursing Ethics and Social Justice, 11
The Nursing Process in
Community/Public Health, 13
Responsibilities of Community/Public
Health Nurses, 14
Expected Competencies
of ­Baccalaureate-Prepared Community/
Public Health Nurses, 22
Leadership in Community/Public
Health Nursing, 24
2 Origins and Future of Community/Public Health
Nursing, 31
Claudia M. Smith
Roots of Community/Public
Health Nursing, 32
Definition of Public Health, 37
Nursing and Sanitary Reform, 38
Population-Focused Care and
Subspecialties, 38
Expansion into Rural America, 41
Government Employment of Public
Health Nurses, 42
Dichotomy in Public Health Nursing, 43
Educational Preparation for Public
Health Nurses, 44
Expanded Practice in Community Health
Nursing: 1965 to 1995, 44
Reclaiming Public Health Nursing:
1995 to 2010, 45
Community/Public Health Nursing: Creating
the Future, 45
Continuing Issues, 50
3 The United States Health Care System, 54
Frances A. Maurer
Our Traditional Health Care System, 56
Components of the U.S. Health Care System, 57
Direct and Indirect Services and Providers, 63
xiv
Public and Private Sectors, 63
Public Sector: Government's Authority and
Role in Health Care, 63
Private-Sector Role in Health Care Delivery, 68
Public and Private Health Care Sectors
Before 1965, 71
Public and Private Sectors, 1965 to 1992, 71
Public and Private Sectors Today, 73
A National Health Care System? 79
Challenges for the Future, 80
4 Financing of Health Care: Context for Community/
Public Health Nursing, 86
Frances A. Maurer
Relevance of Health Care Financing
to Community/Public Health
Nursing Practice, 87
Relative Magnitude of Health
Spending in the United States, 87
Reasons for the Increase in Health Care Costs, 89
Groups at Risk for Increased Costs and
Fewer Services, 90
Health Care Financing Mechanisms, 90
Publicly Funded Programs for Health
Care Services, 94
Trends in Reimbursement, 104
The Nurse's Role in Health Care Financing, 108
5 Global Health, 113
Helen R. Kohler and Frances A. Maurer
Health: A Global Issue, 113
Health Disparities Among Countries, 114
International Health Organizations, 116
Health and Disease Worldwide, 118
Health Care Delivery Systems, 124
New and Emerging Health Issues, 128
Role of Nursing in International Health, 131
6 Legal Context for Community/Public
Health Nursing Practice, 136
Susan Wozenski
Public Health Law, 137
Community/Public Health Nurses and
Public Health Law, 137
Sources of Law, 138
Classification of Laws and Penalties, 146
Purposes and Application of Public
Health Law, 147
Legal Responsibilities of Community/Public
Health Nurses, 148
How to Find Out About Laws, 153
Standards of Care, 154
Quality and Risk Management, 154
Ethics and Law, 156

UNIT 2 CORE CONCEPTS FOR THE
PRACTICE OF COMMUNITY/
PUBLIC HEALTH NURSING
7 Epidemiology: Unraveling the Mysteries of
Disease and Health, 161
Gina C. Rowe
Interests of Population-Based Data, 162
Types of Epidemiological Investigation, 164
Understanding Aggregate-Level Data, 165
Concepts Related to Prevention, Health
Promotion, and Disease, 166
Health Information Systems, 168
Demographic Data, 170
Department of Commerce Health-Related
Studies, 172
Major Causes of Death, 172
Health Profiles or Status and the Life Cycle, 178
Health Profiles or Status of Populations
at High Risk, 184
Continuing Issues, 186
8 Communicable Diseases, 190
Frances A. Maurer
Communicable Diseases and Control, 190
Contemporary Issues in Communicable
Disease, 192
Influences of Modern Lifestyle
and Technology, 201
Issues of Population Safety Versus
Individual Rights, 202
Role of the Nurse in Communicable
Disease Control, 202
Epidemiology Applied to Communicable
Disease Control, 204
Role of Boards of Health, 207
Nursing Care in the Control of
Communicable Diseases, 209
9 Environmental Health Risks: At Home, at Work,
and in the Community, 235
Barbara Sattler
Overview of Environmental Health, 236
Assessment of Environmental Health
Hazards, 241
Environmental Issues for the 21st Century, 257
Community/Public Health Nursing
Responsibilities, 259
The Nurse's Responsibilities in Primary,
Secondary, and Tertiary Prevention, 260
The Future of Environmental Health
Nursing, 262
10 Relevance of Culture and Values for Community/
Public Health Nursing, 266
Linda Haddad and Claudia M. Smith
Cultural Pluralism in the United States, 267
Culture: What It Is, 268
Values, 269
Race, 270
CONTENTS xv
Ethnicity, 271
Racial and Ethnic Health and Health Care
Disparities, 272
Role of Insurance in Health Disparities, 273
Strategies for Eliminating Health Disparities, 274
Understanding Cultural Differences, 274
Biological Variations, 280
Culture-Bound Syndromes, 280
Cultural Patterns of Care, 281
Community/Public Health Nurse's Role
in a Culturally Diverse Population, 284
Culturally Appropriate Strategies for the
Community/Public Health Nurse Working
with Diverse Communities, 289
Contemporary Issues and Trends, 290
UNIT 3 FAMILY AS CLIENT
11 Home Visit: Opening the Doors for Family
Health, 298
Claudia M. Smith
Home Visit, 300
Nurse–Family Relationships, 301
Increasing Nurse–Family Relatedness, 304
Reducing Potential Conflicts, 309
Promoting Nurse Safety, 311
Managing Time and Equipment, 312
Postvisit Activities, 315
The Future of Evidence-Based Home-Visiting
Programs, 317
12 A Family Perspective in Community/Public
Health Nursing, 322
Claudia M. Smith
A Family Perspective, 322
What is Family, 324
Historical Frameworks, 327
How Can These Approaches be Integrated? 334
Family Perspectives in Nursing, 335
13 Family Case Management, 340
Claudia M. Smith
Family Case Management, 341
Family Assessment, 342
Analyzing Family Data, 346
Developing a Plan, 354
Implementing the Plan, 355
Evaluation, 361
Terminating the Nurse–Family
Relationship, 363
Evaluation of Family Case Management
Programs, 363
14 Multiproblem Families, 372
Claudia M. Smith
Families Experiencing Crisis, 373
Families with Chronic Problems, 373
Resilience, 377
Responsibilities of the Community/Public
Health Nurse, 377
xvi CONTENTS
UNIT 4 COMMUNITY AS CLIENT
15 Community Assessment, 393
Frances A. Maurer and Claudia M. Smith
Community Assessment: Application to
Community/Public Health Nursing
Practice, 394
Community Defined, 394
Basic Community Frameworks, 396
Systems-Based Framework for Community
Assessment, 398
Tools for Data Collection, 408
Approaches to Community Assessment, 412
Analysis, 413
16 Community Diagnosis, Planning,
and Intervention, 427
Frances A. Maurer and Claudia M. Smith
Population-Focused Health Planning, 428
Planning for Community Change, 430
Steps of Program Planning, 432
Implementation, 439
17 Evaluation of Nursing Care with
Communities, 449
Claudia M. Smith and Frances A. Maurer
Responsibilities in Evaluation of Nursing Care
with Communities, 449
Steps in Evaluation, 451
Questions Answered by Evaluation, 451
Uniqueness in Evaluation of Nursing Care
with Communities, 457
Analyzing Evaluation Data, 459
Modification of Nursing Care with
Communities, 459
Evaluation Methods and Tools, 459
UNIT 5 TOOLS FOR PRACTICE
18 Health Promotion and Risk Reduction in the
Community, 466
Gail L. Heiss
Meaning of Health, 468
Determinants of Health, 468
National Policy, 469
Health Models, 470
Health-Promotion and Health-Protection
Programs, 473
Health Promotion and Nursing
Practice, 477
19 Screening and Referral, 486
Gail L. Heiss
Definition of Screening, 487
Criteria for Selecting Screening Tests: Validity
and Reliability, 488
Contexts for Screening, 489
Community/Public Health Nurse's Role
in Screening, 496
Screening and the Referral Process, 499
20 Health Teaching, 505
Gail L. Heiss
Health-Teaching Process, 506
Research Evidence: What Works in Client
Health Education? 507
Nursing Assessment of Health-Related
Learning Needs, 508
Construction of Health Education
Lesson Plans, 510
Health-Related Educational Materials, 516
Principles of Teaching, 521
UNIT 6 CONTEMPORARY PROBLEMS
IN COMMUNITY/PUBLIC
HEALTH NURSING
21 Vulnerable Populations, 527
Frances A. Maurer
Vulnerable Populations, 528
Poverty, 529
Race and Ethnicity and Their Relationship to
Income and Health Status, 531
The Uninsured, 533
Homelessness, 534
Migrant/Seasonal Workers, 538
The Prison Population, 539
Services Available for Vulnerable
Populations, 540
Nursing Considerations for Vulnerable
Populations, 543
22 Disaster Management: Caring for Communities in
an Emergency, 552
Christina Hughes and Frances A. Maurer
Definition of Disaster, 553
Factors Affecting the Scope and Severity
of Disasters, 554
Dimensions of a Disaster, 555
Phases of a Disaster, 556
Disaster Management: Responsibilities of
Agencies and Organizations, 557
Emergency Response Network, 560
Principles of Disaster Management, 561
Reconstruction and Recovery, 563
New Challenges for Disaster Planning
and Response, 564
Nursing's Responsibilities in Disaster
Management, 566
23 Violence: A Social and Family Problem, 575
Cara J. Krulewitch
Extent of the Problem, 576
National Health Priorities to Reduce
Violence, 576
Violence in the Community: Types and
Risk Factors, 577
Impact of Violence on the Community, 579
Violence Within the Family, 579

Child Abuse and Neglect, 580
Intimate Partner Violence, 583
Nursing Care in Abusive Situations:
Child Abuse or Partner Abuse, 587
Elder Abuse, 593
24 Adolescent Sexual Activity and Teenage
Pregnancy, 603
Frances A. Maurer
Teenage Sexual Activity, 604
Teenage Pregnancy, 608
Comparison of Pregnancy-Related Issues
in Other Countries, 611
Public Costs of Adolescent Pregnancy
and Childbearing, 612
Consequences of Early Pregnancy
for Teenagers and Infants, 612
Legal Issues and Teen Access to Reproductive
Health Services, 616
Nursing Role in Addressing Teenage
Sexual Activity and Pregnancy, 616
Primary Prevention, 617
Secondary Prevention: The Care
of Pregnant Teenagers, 620
Tertiary Prevention, 624
25 Substance Use Disorders, 631
Charon Burda
Background of Addiction, 632
Effects of Alcohol and Drugs on the Body, 636
Monitoring Incidence and Prevalence, 639
Stigma and Language, 642
Impact of Substance Use Disorders
on Individuals and Family Members, 643
Addictions and Communicable Diseases, 645
Responsibilities of the Community/Public
Health Nurse, 647
Community and Professional Resources, 652
Funding Issues and Access to Care, 652
UNIT 7 SUPPORT FOR SPECIAL
POPULATIONS
26 Rehabilitation Clients in the Community, 659
Leslie Neal-Boylan
Concept of Disability, 660
Concept of Rehabilitation, 660
Magnitude of Disability in the United States, 663
Legislation, 667
Needs of Persons with Disabilities, 669
Responsibilities of the Rehabilitation Nurse, 671
Community Reintegration Issues, 674
27 Children in the Community, 679
Anne Rath Rentfro and Michelle McGlynn
Children in the United States, 679
Families and Communities with Children, 682
Common Health Needs of Children, 685
Children at Risk, 689
CONTENTS xvii
Community Health Care for Children with
Special Needs, 693
Community/Public Health Nursing
Responsibilities, 694
Trends in Child Health Services, 695
28 Older Adults in the Community, 701
Sally C. Roach
Aging, 702
Role of Older Adults in the Family
and the Community, 703
Common Health Needs of Older Adults, 708
Impact of Poverty on Older Adults, 713
Development and Organization of Community
Resources, 714
Trends in Health Care Services for
Older Adults, 716
Responsibilities of the Nurse Working with
Older Adults in the Community, 718
UNIT 8 SETTINGS FOR COMMUNITY/
PUBLIC HEALTH NURSING
PRACTICE
29 State and Local Health Departments, 726
Sarah Hargrave , Corrine Olson and Frances A. Maurer
Core Functions and Essential Services
of Public Health, 726
Structure and Responsibilities of the State
Health Agency, 728
Structure and Responsibilities of Local Public
Health Agencies, 729
Services Provided by the State Health Agency
and the Local Health Department, 733
Evolution of Public Health Nursing
in Official Agencies, 738
External Influences on Public Health Nursing, 738
Public Health Nursing Practice, 738
Future Trends and Issues in Public
Health and Public Health Nursing, 744
30 School Health, 749
Robin Fleming
Historical Perspectives of School Nursing, 750
Components of Coordinated School
Health, 751
Organization and Administration
of School Health, 757
Responsibilities of the School Nurse, 759
Common Health Concerns of School-Aged
Children, 761
Future Trends and Issues in School
Health Programs, 768
31 Home Health Care, 777
Tina M. Marrelli
Definitions, 779
Standards and Credentialing, 779
Home Health Care Today, 780
xviii CONTENTS

Responsibilities of the Home Health 33 Community Mental Health, 822

Care Nurse, 786 Verna Benner Carson
Issues in Home Care, 788 Advent of Community Mental Health Care, 822
Hospice Home Care, 794 Philosophy of Community Mental Health
32 Rural Health, 799 Care, 826
Angeline Bushy Population Served by Community Mental
Definitions, 800 Health Care, 827
Status of Health in Rural Populations, 802 Services Provided in Community Mental
Factors Influencing Rural Health, 806 Health Care, 829
Rural Lifestyle and Belief Systems, 810 Role of the Nurse in Community Mental
Rural Community/Public Health Health Care, 830
Nursing Practice, 811 The Nursing Process in Practice, 831
Building Professional-Community Continuing Issues in Community Mental
Partnerships, 815 Health Care, 836
Trends and Issues, 817 Index, 841
 U N I T
1
Role and Context of Community/
Public Health Nursing Practice
1 Responsibilities for Care in Community/Public Health
Nursing
2 Origins and Future of Community/Public Health
Nursing
3 The United States Health Care System
4 Financing of Health Care: Context for Community/
Public Health Nursing
5 Global Health
6 Legal Context for Community Health Nursing Practice

1
CHAPTER

1
Responsibilities for Care in
Community/Public Health Nursing
Claudia M. Smith

FOCUS QUESTIONS
What is the nature of community/public health nursing practice?
What values underlie community/public health nursing?
How is empowerment important in community/public health
nursing?
What health-related goals are of concern to community/public
health nurses?
Who are the clients of community/public health nurses?
What are the basic concepts and assumptions of general
systems theory?
What is meant by the terms population-focused care and
aggregate-focused care?
What are the responsibilities of community/public health
nurses?
What competencies are expected of beginning community/
public health nurses?
How are community/public health nurse generalists and
specialists similar and different?

CHAPTER OUTLINE
Visions and Commitments Surveillance, Monitoring, and Evaluation
Distinguishing Features of Community/Public Health Policy Enforcement and Development
Nursing Environmental Management
Healthful Communities Case Management, Coordination of Care, and Delegation
Empowerment for Health Promotion Partnership/Collaboration
Theory and Community/Public Health Nursing Consultation
General Systems Theory Social, Political, and Economic Activities
Nursing Theory Empowerment for Creativity
Public Health Theory Self-Care and Development
Goals for Community/Public Health Nursing Expected Competencies of Baccalaureate-Prepared
Nursing Ethics and Social Justice Community/Public Health Nurses
Ethical Priorities Direct Care with Individuals
Distributive Justice Direct Care with Families
Social Justice Direct Care with Groups
The Nursing Process in Community/Public Health Direct Care with Aggregates/ Populations
Responsibilities of Community/Public Health Nurses Leadership in Community/Public Health Nursing
Direct Care of Clients with Illness, Infirmity, Suffering, and Professional Certification
Disability Quality Assurance
Referral and Advocacy Community/Public Health Nursing Research and
Teaching Evidence-Based Practice

KEY TERMS
Aggregate General systems theory Public health nursing
Commitments Group Risk
Community-based nursing Population Social justice
Community health nursing Population-focused Visions
Community/public health nurse Professional certification
Distributive justice Public health nurse

2
 CHAPTER 1 Responsibilities for Care in Community/Public Health Nursing
Imagine that you are knocking on the door of a residential trailer,
seeking the mother of an infant who has been hospitalized because
of low birth weight. You are interested in helping the mother
­prepare her home before the hospital discharge of the infant.
Or imagine that you are conducting a nursing clinic in a high-
rise residence for older adults. People have come to obtain blood
pressure screening, to inquire whether ­tiredness is a side effect of
their antihypertensive medications, or to validate whether their
recent food choices have reduced their sodium intake. Or picture
yourself sitting at an office desk. You are ­telephoning a physical
therapist to discuss the progress of a school-aged child who has
mobility problems secondary to cerebral palsy.
Now, imagine yourself at a school parent–teacher associa-
tion (PTA) meeting as a member of a panel discussion on the
prevention of human immunodeficiency virus (HIV) trans-
mission. Think about developing a blood pressure screening
and dietary education program for a group of predominantly
African American, male employees of a publishing company.
Picture yourself reviewing the statistics for patterns of death in
your community and contemplating with others the value of a
hospice program.
Who would you be to participate in all these activities, with
people of all ages and all levels of health, in such a variety of set-
tings—homes, clinics, schools, workplaces, and community meet-
ings? It is likely you would be a community health nurse, and you
would have specific knowledge and skills in public health nursing.
Note that we have used the terms community health n ­ ursing
and public health nursing. In the literature, and in ­practice,
there is often a lack of clarity in the use of these terms. Also,
the use of these terms changes with time (see Chapter 2).
Both the American Nurses Association (ANA, 1980) and the
Public Health Nurses Section of the American Public Health
Association (APHA, 1980, 1996) agree that the type of involve-
ment previously described is a synthesis of nursing practice and
public health practice. What the ANA called community health
nursing, the APHA called public health nursing (Box 1-1).
In 1984, the Division of Nursing, Bureau of Health Professions
of the Health Resources and Services Administration of the U.S.
Department of Health and Human Services (USDHHS), spon-
sored a national consensus conference. Participants were invited
from the APHA, the ANA, the Association of State and Territorial
Directors of Nursing, and the National League for Nursing. The
purpose was to clarify the educational preparation needed for
public health nursing and to discuss the future of public health
nursing. It was agreed that “the term ‘community health nurse’
is … an umbrella term used for all nurses who work in a com-
munity, including those who have formal p ­ reparation in pub-
lic health nursing (Box 1-2 and Figure 1-1). In essence, public
health nursing requires specific educational preparation, and
community health nursing denotes a setting for the practice of
nursing” (USDHHS, 1985, p. 4) (emphasis added). The consen-
sus conference further agreed that educational preparation for
beginning practitioners in public health nursing should include
the following: (1) epidemiology, s­ tatistics, and research; (2) ori-
entation to health care systems; (3) identification of high-risk
populations; (4) application of public health concepts to the
care of groups of culturally diverse persons; (5) interventions
with high-risk populations; and (6) orientation to regulations
affecting public health nursing practice (USDHHS, 1985). This
educational preparation is assumed to be complementary to a
basic education in nursing.
3
BOX 1-1  SELECTED DEFINITIONS
OF COMMUNITY/PUBLIC
HEALTH NURSING
American Nurses Association
Community health nursing is a synthesis of nursing practice and
­public health practice applied to promoting and preserving the health
of ­populations. The practice is general and comprehensive. It is not
­limited to a particular age group or diagnosis, and it is continuing,
not episodic. The dominant responsibility is to the population as a
whole; nursing directed to individuals, families, or groups contrib-
utes to the health of the total population. … The focus of community
health ­nursing is on the prevention of illness and the promotion and
­maintenance of health.
American Public Health Association
Public health nursing is the practice of promoting and protecting
the health of populations using knowledge from nursing, social, and
public health sciences. … Public health nursing practice includes
assessment and identification of subpopulations that are at high risk
for injury, ­disease, threat of disease, or poor recovery and focusing
resources so that services are available and accessible. … [Public
health nurses work] with and through relevant community leaders,
interest groups, employers, families, and individuals, and through
involvement in ­relevant social and political actions.
Quad Council of Public Health Nursing Organizations
Public health nursing is population-focused, community-oriented
­nursing practice. The goal of public health nursing is the prevention of
disease and disability for all people through the creation of conditions
in which people can be healthy.
Data from American Nurses Association. (1980). A conceptual model
of community health nursing (pp. 2, 11). Washington, DC: Author;
American Public Health Association, Public Health Nursing Section.
(1996). The definition and role of public health nursing: A statement
of APHA Public Health Nursing Section (pp. 1, 4). Washington, DC:
Author; and Quad Council of Public Health Nursing Organizations.
(1999). Scope and standards of public health nursing practice.
Washington, DC: American Nurses Association.
Following the logic of the consensus statements, a registered
nurse who works in a noninstitutional setting and has either
received a diploma or completed an associate-degree nursing
education program can be called a community health nurse and
practices community-based nursing because he or she works
outside of hospitals and nursing homes. However, this nurse
would not have had any formal education in public health
­nursing. Such a nurse may provide care directed at individuals
or families, rather than populations (ANA, 2007).
Public health nurses provide population-focused care.
Assessment, planning, and evaluation occur at the population
level. However, implementation of health care programs and
services may occur at the level of individuals, families, groups,
communities, and systems (ANA, 2007; Minnesota Department
of Health, 2001; Quad Council of Public Health Nursing
Organizations, 2004). The ultimate question is: Have the health
and well-being of the population(s) improved?
Large numbers of registered nurses are employed in home
health care agencies to provide home care for clients who are
ill. This text can assist those without formal preparation in
public health nursing to expand their thinking and practice to
­incorporate knowledge and skills from public health nursing.
4 CHAPTER 1 Responsibilities for Care in Community/Public Health Nursing
BOX 1-2  WHERE ARE COMMUNITY
HEALTH NURSES EMPLOYED?
1. More than 355,000 registered nurses are employed in community
health in the United States (see Figure 1-1), who constitute 14% of
all employed registered nurses.
2. Between 1980 and 2000, the numbers of nurses employed in
­community health nursing settings increased by 155% compared
with an increase of 55% in nurses working in hospitals.
3. Between 2004 and 2008, the numbers of nurses in community
health settings remained stable, with fewer working for state and
local health departments as a result of government budget cuts.
4. The largest percentage (47%) of community health nurses work in home
health and hospice agencies to provide nursing care to i­ndividuals with
illnesses, injuries, and disabilities and to their families.
5. Almost one in five community health nurses is employed by a local
or state health department or community health or rural health
­center. These nurses provide primary care services, promote health,
and prevent illnesses, injury, and premature death.
6. Other community health nurses work with populations associated
with a specific age group or type of organization: youth in public
and parochial schools, students in colleges and universities, indi-
viduals in correctional facilities, and adults at work sites.
7. It is not the place of employment that determines whether a nurse
is a community/public health nurse, however. Instead, community/
public health nurses are distinguished by their education and by the
community/population focus of their practice.
Data from U.S. Department of Health and Human Services. (2006).
The registered nurse population: Findings from the March 2004
National Sample Survey of Registered Nurses. Washington, DC:
Health Resources and Services Administration, Bureau of Health
Professions, Division of Nursing; and USDHHS. (2010). The registered
nurse population: Findings from the 2008 National Sample Survey of
Registered Nurses. Washington DC: Health Resources and Services
Administration, Bureau of Health Professions, Division of Nursing.
Community mental health
and substance abuse
(10,700)
Correctional
(nonhospital)
(14,200) Home health
Hospice (128,200)
(37,500)
Occupational
health
(18,800)
School health
(84,400)
State and local health departments
and community and rural health centers
(61,300)
FIGURE 1-1 Estimated community health nurses by work
sites—2008 (total community health nurses = 355,100). (Data
from U.S. Department of Health and Human Services. [2010]. The regis-
tered nurse population: Findings from the 2008 National Sample Survey
of Registered Nurses. Washington, DC: Health Resources and Services
Administration, Bureau of Health Professions, Division of Nursing.)
For those currently enrolled in a baccalaureate nursing
e­ducation program, this text can assist in integrating ­public
health practice with nursing practice as part of the formal
­educational preparation for community/public health nursing.
The terms community/public health nurse and public
health nurse are used in this text to denote a nurse who has
received formal public health nursing preparation. Community/
public health nursing is population-focused, community-ori-
ented nursing. Population focused means that care is aimed at
improving the health of one or more populations. To save space
in the narrative of this text, the term community health nurse is
sometimes used instead of community/public health nurse.
VISIONS AND COMMITMENTS
When describing an object, we often discuss what it looks like,
what its component parts are, how it works, and how it relates
to other things. Although knowledge of structure and function
is important, in interpersonal activities, the exact form is not as
important as the purpose of the exchange. And the quality of
our specific, purposeful relationships derives from our visions
of what might be as well as our commitments to work toward
these visions.
Visions are broad statements describing what we desire
something to be like. They derive from the ability of human
beings to imagine what does not currently exist. Commitments
are agreements we make with ourselves that pledge our energies
for or toward realizing our visions.
As a synthesis of nursing and public health practice, commu-
nity/public health nursing accepts the historical commitments
of both. By definition and practice, our caring for clients who
are ill is part of the essence of nursing. Likewise, we bring from
nursing our commitment to help the client take responsibility
for his or her well-being and wholeness through our genuine
interest and caring. We add, from public health practice, our
role as health teacher to provide individuals and groups the
opportunity to see their own responsibility in moving toward
health and wholeness.
Community/public health nurses are concerned with the devel-
opment of human beings, families, groups, and c­ommunities.
Nursing provides us our commitment to assist individuals
­developmentally, especially at the time of birth and death. Public
health expands our commitment beyond i­ndividuals to consider
the development and healthy ­functioning of families, groups,
and communities.
Public health practice makes its unique contribution to
­community/public health nursing by adding to our commit-
ments. These commitments include the following:
1. Ensuring an equitable distribution of health care
2. Ensuring a basic standard of living that supports the health
and well-being of all persons
3. Ensuring a healthful physical environment
These commitments require our involvement with the ­public
and private, political and economic environments.
Boxes 1-3 and 1-4 list the commitments of nursing and public
health, respectively, that are grounded in their h ­ istorical devel-
opments. These commitments are the foundations on which
specific professional practices, projects, goals, and ­activities can
be created.
Because our culture is biased toward “doing” (being active,
being busy, and producing), we often are not conscious of
 CHAPTER 1 Responsibilities for Care in Community/Public Health Nursing
BOX 1-3  COMMITMENTS OF NURSING
1. Patterning an environment of safety and asepsis that promotes
health and protects clients
2. Promoting health for individuals by caring for them when they are
not able to do so themselves because of age, illness, disability, or
dysfunction
3. Promoting health for individuals and support for families related to
developmental stages (pregnancy, labor and delivery, and care of
newborns; care of dependent family members; care of dependent
elderly; care of the dying)
4. Promoting wellness and integration during illness, disability,
and dying
5. Treating clients equitably without bias related to age, race, gender,
socioeconomic class, religion, sexual preferences, or culture
6. Calling forth the client's commitment to his or her own well-being
and wholeness
BOX 1-4  COMMITMENTS OF PUBLIC
HEALTH
1. Patterning of an environment that promotes health
2. Promotion of health for families and populations
3. Assurance of equitable, just distribution of health care to all
4. Creation of a just economic environment to support health and v­ itality
of individuals, families, groups, populations, and communities
5. Prevention of physical and mental illnesses as a support to the
wholeness and vitality of individuals, families, groups, populations,
and communities
6. Provision of the greatest good for the greatest number—thinking
collectively on behalf of human beings
7. Education of others to be aware of their own responsibility to move
toward health, wholeness, and vitality
our visions of what might be. We study, exercise, go out with
friends, cook, clean, play with children, invest money, and shop.
We can get bogged down in “doing” the activities and projects
appropriate to our commitments. For example, if you are com-
mitted to having relationships with friends, recall a time when
a meeting with friends felt like a duty and obligation. You were
going through the motions of being together, but you were
not ­genuinely relating to your friends. At that moment, you
were not c­reating the relationship from your commitment;
you probably felt burdened rather than enlivened.
Likewise, it is possible to get bogged down professionally
by doing the “right” things that public health nurses are sup-
posed to do, but not feeling satisfied. We are disappointed that
results do not show up quickly or that suffering persists. We
create too many professional projects and feel spread too thin.
We burn out.
Working on activities directed toward the commitments
underlying community/public health nursing does not guaran-
tee that we will achieve our visions. But not working toward our
visions and giving up on our commitments guarantees that we
are part of the problem rather than part of the solution in our
communities. Not working toward our visions also results in
dissatisfaction and disconnectedness.
Remaining in touch with the reasons we are doing some-
thing empowers us. Our vision of healthy, whole, vital individu-
als, ­families, and communities, as well as our related commitments,
can provide a renewing source of energy. And it is hope and energy
5
that we draw on to empower our professional practice and bring
vitality to our relationships with individuals, families, and groups.
Expressing our visions and commitments to others provides
them an opportunity to become partners in working for what
might be. By having partners, we gain support not only for our
visions but also for specific projects.
Janel, the mother in a young family consisting of a mother,
a father, and a 2-year-old son with cerebral palsy, called
the health department during her second pregnancy. She
requested that a nurse assist her in having a healthy sec-
ond child. No one could guarantee that vision, but Janel's
­willingness to seek a partner in the commitment provided
an ­opportunity for a nurse–client relationship that would
increase the likelihood of a healthy newborn. The nurse,
Shari, and Janel developed specific projects related to, among
other things, financial access to prenatal care, nutrition,
­prenatal monitoring, and anxiety management.
Community/public health nurses often have visions about
health that others do not know are possible. Nurses can educate
and speak about visions of health and specific commitments that
can increase the likelihood of particular health possibilities.
Amos and Joice, a married couple in their sixties, were
­committed to remaining self-sufficient. Both had diabetes,
and Joice had had a stroke that resulted in right hemipare-
sis and expressive aphasia. When Joice had to retire from
her job, their income declined dramatically. Amos worked
two jobs and was rarely home to be a companion to his
wife. The couple fought about money, and because Joice's
verbal ­
­ communication was very slow and unclear, for
the first time in their marriage, they resorted to express-
ing frustration and anger by hitting each other. Initially,
the family did not ask Cassandra, the community/public
health nursing student, for assistance. On one visit, recog-
nizing that the wife was angry, Cassandra began to explore
the family stressors. The student's vision that “families can
solve problems through communication” made it possible
for her to discuss the problem with the spouses and solicit
their commitment to explore alternatives with her. The
couple eventually agreed to turn to their extended family,
social service agencies, and a bank for additional sources of
revenue. In this situation, it was the nurse who i­ nitiated the
discussion of her vision and enlisted the family m ­ embers'
commitment to exploring possibilities.
We have discussed two examples of expressing a vision as a
basis for creating commitments in nurse–client relationships
and in relationships between the nurse and other service pro-
viders. It is helpful for each nurse to express his or her visions
and commitments to peers and supervisors. As nurses, we need
colleagues to encourage us, work with us, and coach us. Work
groups whose members can identify some visions common
to their individual practices and can agree on some common
­commitments have a vital source of energy. When we know
what we are for, we can assertively invite others to participate
with us. When others are working with us, more possibilities are
created for synergistic effects.
6 CHAPTER 1 Responsibilities for Care in Community/Public Health Nursing
DISTINGUISHING FEATURES OF COMMUNITY/
PUBLIC HEALTH NURSING
Community/public health nurses are expected to use the
nursing process in their relationships with individuals,
­families, groups, populations, and communities (ANA, 2007).
Community/public health nursing is the care provided by
educated nurses in a particular place and time and directed
toward promoting, restoring, and preserving the health of the
total population or community. Families are recognized as an
important social group in which values and knowledge are
learned and health-related behaviors are practiced.
Healthful Communities
What aspects of this definition are different from definitions of
nursing in general? The explicit naming of families, groups, and
populations as clients is a major focus. Community-based health
nurses care for individuals and families. Community/public
health nurses also may care for individuals and families; ­however,
they are cared for in the context of a vision of a healthful com-
munity. Beliefs underlying community/public health nursing
­summarized from Chapter 2 are presented in Box 1-5. Community/
public health nursing is nursing for social betterment.
 ommunity health nursing focuses on the health of a group,
C revealed. Nurses can assist in this process by fostering hope and
community, or population.
BOX 1-5  BELIEFS UNDERLYING
COMMUNITY/PUBLIC HEALTH
NURSING
• Human beings have rights and responsibilities.
• Promoting and maintaining family independence is healthful.
• Environments have an impact on human health.
• Nurses can make a difference and promote change toward health
for individuals, families, and communities.
• Vulnerable and at-risk populations/groups/families need special
attention, especially the aged, infants, those with disabilities and
illnesses, and poor persons.
• Poverty and oppression are social barriers to achievement of health
and human potential.
• Interpersonal relationships are essential to caring for others.
• Hygiene, self-care, and prevention are as important as care of the sick.
• Community/public health nurses can be leaders and innovators in
developing programs of nursing care and programs for adequate
standards of living.
• Community/public health nursing care should be available to all,
not just to the poor.
Community/public health nurses seek to empower ­individuals,
families, groups, community organizations, and other health and
human service professionals to participate in c­ reating health-
ful communities. The prevailing theory about how ­healthful
communities develop has been that individuals and social
­
groups clarify their identities first and then protect their own
rights while also considering the rights of others. More recent
studies on the moral development of women in the United
States suggest that women first participate in a network of
­relationships of caring for others and then consider their own
rights (Gilligan, 1982).
The ideal for a healthful community is a balance of
­individuality and unity. Community/public health nurses seek
to promote healthful communities in which there is individual
freedom and responsible caring for others. It is impossible for an
individual to consider only his or her desires without infringing
on the freedom of others. For collective well-being to exist, we
must also be concerned about caring accountability. We must
“ask about justice, about … each person having space in which
to grow and dream and learn and work” (Brueggemann, 1982,
p. 50). We must ask about the conditions that promote health.
Empowerment for Health Promotion
Because community/public health nurses often work with
persons who are not ill, emphasis is placed on promoting and
preserving health in addition to assisting people to respond
to illnesses. Although not all illnesses can be prevented and
death cannot be eliminated, community health nurses seek
to empower human beings to live in ways that strengthen
resilience; decrease preventable diseases, disability, and
­
­premature death; and relieve experiences of illness, vulnerabil-
ity, and suffering.
Empowerment is the process of assisting others to uncover
their own inherent abilities, strengths, vigor, wholeness, and
spirit. Empowerment depends on the presence of hope. Power
is not actually provided by the community/public health nurse.
Empowerment is a process by which possibilities and opportu-
nities for the expression of an individual's being and abilities are
by removing barriers to expression.
Community/public health nurses use the information
and skills from their education and experiences in medi-
cal–surgical, parent–child, and behavioral or mental health
­nursing to assist individuals, families, and groups in ­creating
­opportunities to make choices that promote health and whole-
ness. In c­ommunity/public health nursing, nurses rarely
make the choices for ­others. Instead, as a means of ­expanding
opportunities for others, c­ommunity/public health nurses
­
provide i­nformation about interpersonal relationships and
alternative ways of doing things. This is especially true when
community/public health nurses instruct others in how to care
for those with illnesses or how generally to support the growth
and development of other members of families or groups. For
example, a husband might be shown how to safely transfer his
wife from the bed to a chair, or a young father might be taught
how to praise his son and set limits without resorting to threats
and frequent punishment.
Being related to people can invite a person to risk being
connected and to trust in the face of his or her fears. This is
particularly true for those who have experienced intense or pat-
terned isolation, abuse, despair, or oppression. A nurse is said
 CHAPTER 1 Responsibilities for Care in Community/Public Health Nursing
to be “present” with a client when the nurse is both physically
near and psychologically “being with” the person (Gilje, 1993).
Various ways a community/public health nurse can be “present”
are revealed in the case study at the end of this chapter.
Culturally competent care is essential in both public health
and nursing practice (ACHNE, 2010; ANA, 2007; Campinha-
Bacote et al., 1996; USDHHS, 1997). Community/public health
nurses must recognize the diverse backgrounds and preferences
of the individuals, families, populations, and communities
with whom they work. Cultural influences on health problems,
health promotion and disease prevention activities, and other
health resources should be assessed. In addition, cultural differ-
ences must be considered when developing and adapting nurs-
ing interventions.
THEORY AND COMMUNITY/PUBLIC
HEALTH NURSING
Nursing practice is based on the concepts of human beings,
health and illness, problem-solving and creative processes, and
the human–environment relationship (Alligood & Marriner-
Tomey, 2010; Hanchett, 1988). Our environment includes
­physical, social, cultural, spiritual, economic, and political facets.
Our knowledge of these concepts evolves from several routes,
including personal experience, logic, a sense of right and wrong
(ethics), empiric science, aesthetic preferences, and an under-
standing of what it means to be human (Alligood & Marriner-
Tomey, 2010). Concepts are labels or names that we give to our
perceptions of living beings, objects, or events. Theories are a set
of concepts, definitions, and hypotheses that help us describe,
explain, or predict the interrelationships among concepts
(Alligood & Marriner-Tomey, 2010).
Although Florence Nightingale began the formal develop-
ment of nursing theory, most theory development in nurs-
ing has occurred since the 1960s (Choi, 1989). Alligood &
Marriner-Tomey (2010) describe the work of numerous nurs-
ing theorists. (Obviously, we cannot discuss all of them here.)
In community/public health nursing, general systems theory
­provides a way to link many of the concepts related to n ­ ursing.
The nursing theories of Johnson (1989), King (1981), Neuman
and Fawcett (2002), and Roy (Roy & Andrews, 1999) rely,
in part, on general systems theory. Perspectives on client–­
environment r­elationships from these theories are discussed
later in this chapter.
General Systems Theory
An open system is a set of interacting elements that must
exchange energy, matter, or information with the external envi-
ronment to exist (Katz & Kahn, 1966; von Bertalanffy, 1968).
Open systems include individuals as well as social systems such
as families, groups, organizations, and communities with whom
the community/public health nurse must work (Figure 1-2).
Systems theory is especially useful in exploring the numerous
and complex client–environment interchanges. For example,
a community/public health nurse might provide postpartum
home visits to a woman and her newborn, simultaneously
focusing on the adjustment of the entire family to the birth. The
same nurse might also teach teen parenting classes in a high
school and monitor the birth rates in the community, identi-
fying those populations at statistical risk of having low-birth-
weight infants.
7
COMMUNITY
Group
Person
Person
Person
Family Person
Person
Person
Organization
Person
Person
Person
Person
FIGURE 1-2 Social systems.
Compared with inpatient settings, the environments in
c­ommunity/public health nursing practice are more variable
and less controllable (Kenyon et al., 1990). General ­systems
theory provides an umbrella for assessing and analyzing the
­various clients and their relationships with dynamic environ-
ments. In this text, family and community assessments are
approached from a general systems framework.
Each open system has the same basic structures (Smith &
Rankin, 1972) (Figure 1-3, A). Figure 1-3, B, is an example
of application of the open system model to a specific organi-
zation. The boundary separates the system from its environ-
ment and regulates the flow of energy, matter, and information
between the system and its environment. The environment is
­everything outside the boundary of the system. The skin acts
as a ­physical boundary for human beings. A person's preference
for ­relatedness is a more abstract boundary that helps deter-
mine the ­pattern of interpersonal relationships. Family bound-
aries might be determined by law and culture, such as a rule that
a family consists of blood relatives. A family can have more open
boundaries and define itself by including persons not related
by blood. Groups, organizations, and some c­ ommunities have
membership criteria that assist in defining their ­boundaries.
Other community boundaries might be geographic and
­political, such as city limits.
Outcomes are the created products, energy, and ­information
that emerge from the system into the environment. Health
behaviors and health status are examples of outcomes. External
influences are the matter, energy, and information that come
from the environment into the system. External influences
can be resources for or stressors to the system. Each system
uses the external influences together with internal resources to
achieve its purposes and goals. Feedback is information chan-
neled back into the system from its environment that describes
the ­condition of the system. When a nurse tells a mother that
her child's blood pressure is higher than the desired range,
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Turk and Armenian are in the wrong, and that, as very often
happens, it is the innocent who have suffered for the
wrong-doings of the guilty. When it is asserted on behalf of
the Turks that they are engaged in suppressing a revolutionary
movement in Armenia, the statement is fully justified by the
facts of the case. There does exist in Armenia an extremely
vigorous revolutionary movement, and it is equally beyond
question that the methods of some of the leaders of this
movement are no less shocking than the barbarity of the Turk
in suppressing it. At every step," he added, "I became more
and more convinced that the inhuman ferocity displayed in this
terrible struggle for the mastery has not been in the least
exaggerated in the reports of the massacres already published
in England. At Bitlis I heard the story of a Turkish soldier
who boasted, as one who had achieved a glorious feat, that he
had taken part in the disembowelling of thirty pregnant
women. 'Two lives in one,' was the rallying cry of the armed
men who perpetrated this butchery. Another soldier, who had
taken part in a massacre in a church, described, gloating upon
every ghastly detail, how he had slipped and slid along the
blood-washed floor while the inhuman work proceeded.
Unfortunately, something very like a counterpart of these
atrocities is presented by the methods of some of the leaders
of the Armenian revolutionary movement. I believe there is no
doubt of the fact that certain of these Armenian conspirators
arranged to murder the Reverend Dr. Edward Riggs and two other
American missionaries at Marsovan, and fasten the blame upon
the Turks, in order that, as they imagined, the United States
might inflict summary punishment upon the Turkish Government,
thereby rendering Armenian independence possible. The
missionaries only escaped through a timely warning which they
received from an Armenian friend. Dr. Riggs has devoted his
life to the education of the Armenian youth in the missionary
schools, but the conspirators, in their blind fanaticism, gave
this fact little heed."

There could be no denial however, that the treatment of

 Armenia and the Armenians by their Turkish political masters
was horribly bad. In May, the governments of Great Britain,
France and Russia united in proposing certain reforms for
Armenia, over which there were evasive and dilatory
negotiations carried on by the Porte for several months.
Meantime, the Armenians became more aggressive and
threatening, and a secret society called the "Hintchak," which
had been in existence among them since 1887, assumed great
activity. Connected with the Hintchak there was said to be an
organization of spies and "executioners," the latter of whom
carried out decrees of assassination, arson, and
bomb-explosion which the society had pronounced. Finally, on
the 17th of October, an imperial irade (edict, or decree) was
issued, approving and adopting the project of reform which the
British, French and Russian ambassadors had submitted to the
Porte.
{538}
But the appearance of the sultan's ineffectual irade was
speedily followed by fresh reports of frightful massacres of
Armenians, at Trebizond, Erzeroum, Bitlis, Zeitoun, and
elsewhere, with outraging of women and destruction of
property, which increased rather than diminished as time went
on. There was no sign that anything had been done towards
carrying out the promised reforms; though the sultan wrote
personally to Lord Salisbury to remonstrate against an
expression of skepticism concerning them, which the latter had
let fall in a speech, and to say to the British Premier: "I will
execute the reforms. … This is my earnest determination, as to
which I give my word of honour." But nothing came of it all,
and the Powers which had received the Sultan's promises could
agree on no steps further, except to demand and obtain
permission to bring, each, an additional gunboat into the
Bosphorus.

Annual Register, 1895,

pages 284-294 and 190-193.
In response to a resolution of the Senate of the United States
asking for information relative to the treatment of the
Armenian subjects of the Turkish government, the Secretary of
State, Mr. Olney, on the 19th of December, 1895, communicated
the following, among other statements of fact: Of the
massacres at Sassoun, which occurred in August, 1894, "the
Department of State has little trustworthy information. …
Since that time appalling outbreaks against the Armenians have
occurred in many other parts of Asia Minor, where these
unfortunate people form but a small minority of the
population. At first they were scarcely more than local riots,
as at Tokat, in the vilayet of Sivas, in March last, where one
Armenian was killed outright and more than 30 wounded by the
Turkish soldiery. In June last an attempted rising of
Armenians in the province of Aleppo in the mountains of
Kozar-Dagh and Zeitoun was thwarted without bloodshed by the
arrest of the alleged conspirators. … In July a band of armed
Armenians crossing into the vilayet of Erzerum from Russia was
dispersed, several being killed or captured. By August the
Moslem feeling against Armenians had become so far aroused
that rumors of intended massacres came from several
independent quarters, Harpoot, Marsovan, and Bitlis among
them, which led to urgent demands by the United States
minister for adequate measures looking to the due protection
of American citizens in those places.

"On the 30th of September grave disturbances began at

Constantinople itself. Several hundred Armenians, who had
gathered for the purpose of going in a body to the Sultan's
palace and demanding redress for the grievances of their
countrymen, were dispersed by the police after a severe
conflict in which a number of Turks and Armenians were killed
and wounded. Mob violence followed, the Armenians resident in
various quarters of the capital being assailed by an excited
Turkish rabble, and over 50 were slain. The rioting continued
the next day, October 1, in Constantinople and its suburbs.
Some 800 or 1,000 Armenians were captured or arrested, many of
them being armed with new revolvers of a uniform pattern. By
the third day order was restored, and the Armenians who had
sought refuge in their churches returned to their homes. The
effect of this outbreak at the national capital was most
disastrous in the provinces. The danger of a general massacre
of Christians in the vilayets of Adana and Aleppo seemed so
imminent, that renewed orders for the effective protection of
American citizens in those quarters were demanded and
obtained. Fears for their safety at Hadjin, Mersine, and
Marash were especially felt, and the cruiser Marblehead was
promptly ordered to Iskanderoun (Alexandretta), the nearest
seaport.

"On October 8 a Turkish uprising occurred at Trebizond, due,

it is reported, to an attempt to assassinate the late Vali of
Van as he was about to leave for Constantinople, the Turks
claiming that the act was done by an Armenian and that they
were in danger of a general Armenian attack. On the 9th the
disturbance was renewed, many Armenians being killed and their
homes and shops looted by the mob. The authorities attempted
to quell the riot, but having only some 400 soldiers and
policemen at command, were powerless, and murder and pillage
ran their course as long as an Armenian was in sight. The
official Turkish reports give the number of Armenians slain as
182, of Turks 11, but the general estimate places the total
number at some 500. Reinforcements of troops soon arrived, and
quiet was restored. No injury to American citizens or property
occurred.

"From this time the reports of conflicts between Turks and

Armenians, with great loss of life, become frequent and
confused. At Akhissar, some 60 miles from Smyrna, 50 Armenians
were killed October 9. Koordish raids terrorized many parts of
the Armenian provinces. At Bitlis over 500 were reported
killed, the Turkish accounts alleging that the Armenians
attacked the Moslem mosques during the hour of prayer. At
Diarbekir 5,000 are said to have lost their lives, of which
 2,300 were Mussulmans—but the Turkish authorities pronounce
this estimate exaggerated. From Malatia comes the report of a
'great massacre' early in November, when every adult male
Christian is said to have perished. Another sanguinary
outbreak, with great slaughter, is reported from Sivas on
November 12; some 800 Armenians and 10 Koords are said to have
been killed. At Hadjin and Ourfa loss of life is reported, the
American missionaries at those places being protected by
Turkish guards under orders from the Porte.

"The Kaimakam of Hadjin is credibly said to have announced

that he would destroy the town and sow barley on its site.
There being an American school at that place, directed by
American teachers, the United States minister thereupon
notified the Porte that if one of those American ladies
received injury from the riotous conduct of the populace, he
would demand, in the name of the United States, 'the head of
that Kaimakam.' That officer has since been removed. Later
reports allege massacres at Marsovan and Amasia. The consular
agent at Aleppo telegraphs that a severe conflict had occurred
at Aintab, and that great fear prevailed at Aleppo. The
burning of the American buildings at Harpoot took place during
a bloody riot, and many persons are said to have perished in
the province of that name. At Kurun 400 deaths are reported.
Particulars of the recent outbreak at Marash, on November 19,
in which American missionary property was destroyed, have not
yet been received.

{539}

"These scattered notices, for the most part received by

telegraph, are given, not as official averment of the facts
stated, but as showing the alarming degree to which racial
prejudices and fanatical passions have been roused throughout
Asia Minor. As above said, the Department of State has and can
have official knowledge regarding but few of these reported
massacres, and though up to the early part of December the
United States minister estimated the number of the killed as
exceeding 30,000, it is more than likely that the figures are
greatly exaggerated. At latest advices mob violence and
slaughter appear to have been checked, or at least to have
partially subsided. The Turkish Government has been emphatic
in assurances of its purpose and ability to restore order in
the affected localities; new governors have been appointed in
many of the provinces, troops have been sent to the scene of
recent or apprehended disorders, and forces have been massed
to subdue the Armenians who had gained the ascendant in
Zeitoun."

Of the American missionary establishments in Turkey, and of

the extent to which they suffered harm during the outbreaks,
the same report gave the following account:

"The number of citizens of the United States resident in the

Turkish Empire is not accurately known. According to latest
advices there are 172 American missionaries, dependents of
various mission boards in the United States, scattered over
Asia Minor. There are also numbers of our citizens engaged in
business or practicing professions in different parts of the
Empire. Besides these, more or less persons, originally
subjects of Turkey and since naturalized in the United States,
have returned to the country of their birth and are
temporarily residing there. The whole number of persons
comprising these several classes can not be accurately
estimated, but, the families of such citizens being
considered, can hardly be less than five or six hundred, and
may possibly exceed that total.

"Outside of the capital and a few commercial seaport towns,

the bulk of this large American element is found in the
interior of Asia Minor and Syria, remote from the few consular
establishments maintained by this Government in that quarter,
inaccessible except by difficult journeys, and isolated from
each other by the broken character of the mountain country and
the absence of roads. Under these circumstances and in the
midst of the alarming agitation which for more than a year
past has existed in Asia Minor, it has been no slight task for
the representative of the United States to follow the
interests of those whose defense necessarily falls to his
care, to demand and obtain the measures indispensable to their
safety, and to act instantly upon every appeal for help in
view of real or apprehended peril. It is, however, gratifying
to bear testimony to the energy and promptness of the minister
in dealing with every grievance brought to his notice, and his
foresight in anticipating complaints and securing timely
protection in advance of actual need. The efforts of the
minister have had the moral support of the presence of naval
vessels of the United States on the Syrian and Adanan coasts
from time to time as occasion required. …

"While the physical safety of all citizens of the United

States appears up to the present date to have been secured,
their property has, on at least two recent occasions, been
destroyed in the course of local outbursts at Harpoot and
Marash. The details of the Harpoot destruction have so far
been only meagerly reported, although it took place about the
middle of November. It is stated that the buildings at that
place were set on fire separately by Kurds and citizens, in
the presence of the Turkish soldiery, during an Armenian riot.
Besides the chapel, girls' theological school and seminary
building, the ladies' house, boarding house, and residences of
three American missionaries were burned, the aggregate loss on
the buildings, personal property, stock, fixtures, and
apparatus being estimated in the neighborhood of $100,000. The
United States minister has notified the Porte that the Turkish
Government will be held responsible for the immediate and full
satisfaction of all injuries on that score. The American
Missionary School of Science at Marash was burned during a
sanguinary outbreak on November 19. The value of the property
destroyed has not been ascertained, but after prompt
investigation the minister will make like demand for adequate
indemnity."

United States, 54th Congress, 1st Session,

Senate Document, Number 33.

"On November 9 one of tho Foreign Consuls arrived at

Constantinople from Erzeroum on leave, and he reported the
scene on his journey as heartrending. 'The whole country
between Trebizond and Erzeroum was devastated. He counted 100
dead bodies lying by the road near one town. Nearly all the
villages were burnt, and in many cases the male population
entirely wiped out.' At last, on December 13, 1895, Lord
Salisbury received the following telegraphic despatch from Sir
Philip Currie: 'It may be roughly stated that the recent
disturbances have devastated, as far as the Armenians are
concerned, the whole of the provinces to which the scheme of
reforms was intended to apply; that over an extent of
territory considerably larger than Great Britain all the large
towns, with the exception of Van, Sassun, and Moush, have been
the scene of massacres of the Armenian population, while the
Armenian villages have been almost entirely destroyed. A
modest estimate puts the loss of life at 30,000. The survivors
are in a state of absolute destitution, and in many places
they are being forced to turn Mussulmans. The charge against
the Armenians of having been the first to offer provocation
cannot be sustained. Non-Armenian Christians were spared, and
the comparatively few Turks who fell were killed in
self-defence. The participation of the soldiers in the
massacres is in many places established beyond doubt.'

"Of the appalling horror of this account I wish it were

needless to speak. … [It] would be none the less horrible if
the whole of the people massacred and outraged, ruined, and
starved, and driven to the snowy mountains in the middle of
winter, had been all the rudest villagers of the most rustic
village communities. But when we know that many thousands of
the victims have been people educated at Christian schools and
 colleges, and who had acquired there, in addition to the
ineradicable virtues of their native and ancient faith, much
also of the refinements and activities of civilised life, we
may reach some true conception of the agonies which have been
inflicted on such a people in the face of Europe and of the
world by the cruelty and brutality of the Turks.
{540}
It is, indeed, right that our first indignation should be
directed against the infamous Government of Turkey. … Let us
remember that this is not a Government with which we have had
nothing to do, or for which we have had no responsibility, but
a Government which the European Powers, and we especially,
have been protecting and nursing for half a century. … Then we
may indeed begin to think, with remorse and shame, of our
handiwork, and of its results. In this particular case,
indeed, the immediate blame lies almost alone with Russia. By
a complete departure from all her previous great traditions
she deliberately refused to join the other Powers of Europe
for the purpose of compelling the Sultan to act with decent
humanity to those of whom she had been the declared defender.
She had the physical power and the geographical opportunity
which others had not; and there can be no doubt whatever that
a joint occupation of the waters of Constantinople by the
fleets of the European Powers would have secured the very
moderate demands that Europe made upon the Porte."

The Duke of Argyle,

Our Responsibilities for Turkey,
pages 116-122.

TURKEY: A. D. 1896.
Conflict in Crete between Christians and Mussulmans,
and its preceding causes.

In 1868, the Cretans, for the second time, were thrust under
the Turkish yoke. "By way of solace the Powers exerted
themselves feebly in inducing the Porte to concede the
so-called 'Organic Statute'

See (in volume 3)

GREECE: A. D. 1862-1881.
Organic Regulation.

… As the Charter remained a dead letter, the Cretans seized

the next favourable opportunity to rise in 1877. Their case
was brought before the Congress of Berlin; but the only relief
the Powers could extend to them was a fresh promise on the
part of the Porte, recorded in the XXIII Article of the
Treaty, to observe scrupulously that Organic Statute, which
had been proved to be unworkable. Meanwhile, the Cretans had
remained under arms during the whole of 1878, the island being
again almost completely devastated by the half-naked and
famishing troops which had survived the Russo-Turkish War.
Ultimately, through the mediation of England, the Porte was
induced, in November of that year, to concede the Pact of
Halepa, so named after the village near Canea where it was
negotiated, and signed under the supervision of the British
Consul, Mr. T. B. Sandwith—this fact being expressly recorded
in the preamble of the document. The arrangement was accepted
by the Cretans as a compromise, in spite of its many and
manifest drawbacks. Nevertheless, it brought about, at the
outset, certain beneficial results. Political parties were
formed in which the Mohammedan Cretans blended, irrespective
of religious differences, with their Christian countrymen; and
the unprecedented phenomenon of a Christian Vali completing
his four years' tenure of governorship was witnessed in the
person of Photiades Pasha.

"But this tendency to conciliation of the conflicting elements

in the island was by no means to the liking of the Porte. The
presence of a Mussulman military governor was therefore
discovered to be necessary; and as his grade was usually
superior to that of the Vali, and the Mussulman sub-governor
was the official whose recommendations were of weight with the
Porte, nothing was easier than to create insuperable
difficulties for the Christian Vali. Thus successive Valis
were compelled—often by private wire from Constantinople—to
tender their resignation; while, at the same time, the Porte
took care not to fulfil the financial engagements prescribed
by the Pact. By these means an acute crisis was brought about
under the Governorship of Sartinski Pasha, a Pole, in 1889,
when a preconcerted plan of deception and treachery was
carried out by the Porte with consummate skill.

"The Cretans, as it is but natural, are guided in critical

contingencies by the advice they seek at Athens. The Porte
therefore promised to the Greek Government, as soon as things
began to assume a threatening aspect in Crete, to satisfy the
demands of the islanders, provided they were prevailed upon to
abstain from occupying certain important positions. In spite
of the transparent perfidy of the proposal, M. Tricoupis, the
then Greek Premier, fell into the snare. While the Cretans
were held back, troops were poured into the island, and the
strategical points having been seized, the Greek Government
and the Cretans were defied. An Imperial firman, issued in
November of that year, abrogated the Pact of Halepa and the
British Government, under whose auspices it was concluded, was
now powerless to exact respect for what was virtually an
international arrangement. There was no longer any question of
a Christian Vali with a fixed tenure of office, or of an
Assembly of Cretan representatives. Shakir Pasha, the
commander of the Turkish troops, was invested with absolute
civil and military authority; Mussulman Albanians occupied the
Christian villages as gendarmes, and Crete continued to submit
to this kind of martial law up to 1894. When, however, Mahmoud
Djelaleddin Pasha, the then Mussulman Vali, surpassed even his
predecessors in arbitrariness, and actually dictated to the
tribunals decisions in favour of Mohammedan litigants, the
Cretans began to lose patience and another outbreak appeared
imminent. It was only then that the Great Powers moved in the
matter and prevailed upon the Porte to revert partly to the
 pre-existing order of things, by appointing Alexander
Karatheodory Pasha, a Christian and a Greek, as Governor.
Beyond this, however, the Pact of Halepa was not observed.
True to its traditional tactics, the Porte took with one hand
what it had given with the other. The Mussulman Deputy
Governor and the military commander frustrated every effort of
the Vali, the very funds necessary for the maintenance of the
gendarmerie being denied him. Karatheodory was consequently
forced to resign. Complete anarchy now reigned in the island."

Ypsiloritis,
The Situation in Crete
(Contemporary Review, September, 1896).

"Occasional skirmishes between the Christian inhabitants and

the soldiers kept the excitement simmering and ushered in the
sanguinary scenes that finally followed. Turkhan Pasha, taking
time by the forelock, armed the Cretan Moslems for the combat
with the approval of the commander of the troops, and the
city of Canea prepared for a blood bath. The Mohammedan Lent
(Ramazan) was drawing to a close, and the three days of
rejoicing which invariably follow (Bairam) were supposed to be
fixed for the attack on the Christians. These anticipations
were duly realised, and on the 24th May, 1896, at 1 o'clock P.
M., the Turks fired the first shots, blowing out the brains of
several Christians to make that Moslem holiday.
{541}
Forearmed, however, is forewarned, and the Christians defended
themselves to the best of their ability on that day and the
25th and 26th, during which every house in Canea was
barricaded, and neighbours living on opposite sides of the
absurdly narrow streets fired at each other from behind stone
heaps piled up in the windows of their bedrooms. The streets
were deserted, all traffic suspended, and it was not until the
27th that the thirty Christian corpses (including two women
and four children) and the twenty lifeless Turks were removed
for burial.
 "These events provoked a new administrative change of scene:
Turkhan Pasha was recalled, and Abdullah Pasha, at the head of
four battalions from Salonica, came to take his place. These
troops laid waste the villages and fields of the provinces of
Apokorona, Cydonia, and Kissamo, burning houses, huts, and
churches on the way. The best soldiers in the world, however,
run terrible risks in the interior of Crete, and Abdullah was
repulsed with the loss of two hundred men at the town of
Vamos. The foreign consuls at Canea, having verified these
facts, strongly blamed his conduct in a joint verbal note, and
the Porte shortly afterwards recalled him, and appointed
Berovitch Pasha [Prince of Samos] in his place. This was the
beginning of the end. The Christians of the island meanwhile
met, and through their delegates formulated certain demands,
which the foreign consuls referred to their ambassadors at
Constantinople, and the famous 'Modifications of the
Convention of Halepa' were framed in consequence. The sultan,
too, yielding to tardy pressure, graciously conceded the
nomination of a Christian governor-general in the person of
Berovitch, the summoning of the National Assembly, and other
demands. … The questions of the tribunals and the gendarmerie
[for the enforcement of peace and order in the island] were to
be arranged by international commissions; but weeks and months
passed away before they were even appointed. … At last the
commissions arrived and began their work in December [1896]."

E. J. Dillon,
Crete and the Cretans
(Fortnightly Review, May, 1897).

TURKEY: A. D. 1896 (January-March

Turkish opposition to English and American measures
for relief to Armenian sufferers.
Work of Miss Clara Barton and the Red Cross Society.

For some time the distribution of supplies from England and

America to the sufferers in Armenia was forbidden by the
Turkish government, for reasons stated by the Turkish minister
at Washington as follows: "The collections are made on the
strength of speeches delivered in public meetings by
irreconcilable enemies of the Turkish race and religion, and
on the basis of false accusations that Turkey repudiates.
Besides, the Sublime Porte is mindful of the true interests of
its subjects, and, distinguishing between the real state of
things and the calumnies and wild exaggerations of interested
or fanatical parties, will under its own legitimate control
alleviate the wants of all Turkish subjects, irrespective of
creed or race." The Red Cross Society, of which the American
branch had prepared to send its President, Miss Clara Barton,
with a small corps of assistants, to the scene of the
suffering, was especially excluded, by the order of the Porte.
Miss Barton and her staff sailed, however, from New York, in
January, and Mr. Terrell, the American minister at
Constantinople, succeeded in obtaining permission for them to
do their humane work as private individuals, not in the name
of the obnoxious society, and without displaying its insignia:
The single-mindedness, the prudence, the patient energy with
which Miss Barton pursued the one object of giving relief to
the suffering, overcame all opposition and all obstructions,
so that, in April, she was able to report:

"The way is all made clear for sending supplies. The suitable
agents all along the route are now known, and have been
arranged with for service, so that heavy supplies can be sent
at any and all times as they are needed. I feel my breath come
lighter as I think of these poor scourged and fever-stricken
towns without even one doctor, when our sixteen strong,
skilled men, with twenty-five camels' burden of supplies,
shall carry some light of hope and help into their night of
hopeless woe. I am happy to be able to say for the comfort of
contributors, that I hold the written word of the Porte,
officially given through the minister of foreign affairs from
the grand vizier, that not the slightest interference with any
 distribution within the province will be had. This official
document was addressed and delivered to Sir Philip Currie, the
British ambassador, and by him passed to me. The decision is
general and final, without question or reservation, and
settles all doubt."

In September Miss Barton returned home for rest, and to bear

her testimony to America of the immensity of the need still
existing in the Armenian provinces and calling for help. Her
departure from Constantinople was reported by the newspapers
to have been the occasion of a remarkable demonstration, by
cheers, flags and salutes, from ship and shore, of the
estimate put upon the work she had done.

TURKEY: A. D. 1896 (August).

Attack of Armenian revolutionists on the
Ottoman Bank at Constantinople.
Turkish massacre of Armenians in the city.

In the spring of 1896, the Armenian revolutionists, encouraged

by the outbreak in Crete, made fresh appeals for attention to
the sufferings of their country, with threats of some
desperate action if no heed was given. In August, the
desperate act was undertaken, at Constantinople, by 30 or 40
madly devoted men. This reckless little band of misguided
patriots made a sudden attack on the Ottoman Bank, a British
institution which controls finance in the Turkish empire,
gained possession of the building, made prisoners and hostages
of two of its directors and some 80 of its clerks, and were
fully prepared with dynamite to destroy everything within its
walls, including themselves, if certain reforms which they set
forth were not instantly decreed. Their theory was, that "the
Ambassadors would force the Sultan to grant the reasonable
reforms which they demanded for the Armenians, rather than
permit the destruction of the Bank and its staff. It was a
scheme borrowed from the theatre, absurd in itself, and made
ridiculous by the way in which they failed to carry it out.
 They went in bravely, and nothing hindered their destroying
the Bank, but they allowed themselves to be talked out of it
by Mr. Maximoff, the Russian dragoman, and would have been the
laughing stock of the world if its attention had not been
absorbed by the massacre which followed.

{542}

"The real heroism of that day was displayed in another quarter

of the city, by another small party of Russian Armenians, men
and women, who took possession of two stone houses and fought
the Turkish troops to the death, the survivors killing
themselves when they could fight no longer. There was no
serious fighting anywhere else, although dynamite bombs were
thrown from the windows of houses and khans upon the troops in
a number of places, showing that some preparation had been
made for a more extended outbreak. There is nothing to be said
in justification of this attempt of the revolutionists. They had
provocation enough to justify anything in reason, but there
was nothing reasonable in this plan, nothing in it to attract
the sympathy of the Powers or to conciliate public opinion;
and if the statements are true which have been made by
Armenians as to certain unexecuted parts of the plan, it was
diabolical. This only can be said on behalf of these
revolutionary committees. They are the natural outcome of the
treatment of the Armenians by the Turkish Government during
the last twenty years. When oppression passes a certain limit
and men become desperate, such revolutionary organisation
always appears. They are the fruit and not the cause of the
existing state of things in Turkey, and if we can judge by the
experience of other countries, the worse things become here,
the more violent will be the action of these committees,
whether Europe enjoys it or not.

"Revolutionists are the same all the world over, but the
Turkish Government is unique, and it is not the attack on the
Bank which interests us but the action of the Government which
followed it. As we have said, the authorities had full
information of what was to be attempted and did nothing to
prevent it, but they made every preparation for carrying out
their own plan. Bands of ruffians were gathered in Stamboul,
Galata, and Pera, made up of Kurds, Lazes, and the lower class
of Turks, armed with clubs, knives or firearms; and care was
taken that no one should kill or plunder in the quarter to
which he belonged, lest he should be recognised and complaint
made afterwards by the Embassies, with a demand for
punishment. A large number of carts were in readiness to carry
off the dead. The troops and police were in great force to
prevent any resistance, and to assist the mob if necessary. It
was a beautiful day, the streets were crowded, and few had any
idea of what had happened at the Bank, when suddenly, without
any warning, the work of slaughter and plunder began,
everywhere at once. European ladies on the way to the
Bosphorus steamers suddenly found themselves surrounded by
assassins, and saw men beaten to death at their feet. Foreign
merchants saw their own employés cut to pieces at their doors.
The streets in some places literally ran with blood. Every man
who was recognised as an Armenian was killed without mercy. In
general, the soldiers took no part in the slaughter and
behaved well, and this somewhat reassured those in the streets
who were not Armenians; but in a few moments the shops were
closed and a wild panic spread through the city. The one idea
of everyone was to get home; and as the foreigners and better
classes live out of the city in summer they had to go to the
Galata bridge to take the steamers, which ran as usual all
through the three days of massacre. This took them through the
streets where the slaughter was going on, and consequently we
have the testimony of hundreds of eye-witnesses as to what
took place. The work of death and plunder continued unchecked
for two days. On Friday there were isolated outbreaks, and
occasional assassinations occurred up to Tuesday.

"The number killed will never be known. The Ambassadors put it

at 5,000 or 6,000; the official report to the palace at 8,750,
besides those thrown into the sea. Thousands of houses, shops
and offices were plundered, including a number belonging to
Greeks and foreigners. Everything was done in the most
systematic way, and there was not a moment of anarchy, not a
moment when the army and police had not perfect control of the
city during all these days. … The majority of those massacred
belonged to the working class—especially the hamals
(porters)—but a large number of gentlemen, merchants and other
wealthy men, were killed, together with about fifty women and
children. The savage brutality of the Moslem mob was something
beyond all imagination, and in many cases the police joined in
beating men to death and hacking others to death with knives,
in the very face of Europeans. … In may cases European
officials appealed to the officers in command of the troops,
who were looking on at the slaughter of helpless, unarmed men,
to interfere and put a stop to it. The reply was 'We have
orders.' It was an officer who killed the clerk of the British
Post-office on the steps. And some of the most cold-blooded
and horrible murders took place in front of the guard house,
at the Galata end of the bridge, in the presence of officers
of the Sultan's household of the highest rank. They also had
their orders.

"Happily for the honour of the Turkish people, there is

another side to the story. It was the Government and not the
people that conducted this massacre. And although the vile
instruments employed were told that they were acting in the
name of the Prophet, and freely used his name, and are
boasting to-day of what they did for Islam, the Sheik-ul-Islam
forbad the Softas taking any part in the slaughter, and many a
pious Turk did what he could to protect his neighbours. … It
is not the people, not even the mob, who are responsible for
this great crime. It was deliberately committed by the
Government. The Ambassadors of the six Powers have declared
this to be an unquestionable fact in the Joint Note addressed
to the Porte.
 "Since the massacre this same Government has been carrying on
a warfare against the Armenians which is hardly less inhuman
than beating out their brains with clubs. There were from
150,000 to 200,000 Armenians in Constantinople. They were
merchants, shopkeepers, confidential clerks, employés in banks
and offices of every kind—the chief business men of the city.
They were the bakers of the city, they had charge of the khans
and bazaars and the wealth of the city; they were the porters,
house-servants, and navvies. … Now the Government has
undertaken to ruin this whole population. They are hunted
about the city and over the hills, like wild beasts. …
Thousands have been sent off at once to the Black Sea ports,
to find their way as best they can without money or food to
their desolated villages in the interior. … Thousands have
fled to foreign countries."

The Constantinople Massacre

(Contemporary Review, October, 1896).

{543}

TURKEY:A. D. 1897 (January-February).

Fresh conflicts in Crete.
Attitude of Christians and Mussulmans towards each other.
Reports of the British Consul-General and others.

Early in January, 1897, while proceedings for the organization

of the new gendarmerie were under way, and while the
discussion of candidates for the National Assembly, to be
elected in March, was rife, fresh hostilities between
Christians and Mussulmans broke out, and there seems to be
good evidence in the following report, by Sir Alfred Biliotti,
the British Consul-General at Canea, that responsibility for
the state of things in Crete should be charged upon one party
hardly more than upon the other. The despatch of the
Consul-General to Lord Salisbury, written January 9, 1897, is
partly as follows:
"In the afternoon of the 3rd instant a great panic occurred in
the town owing to a wounded Christian having been conveyed to
the hospital, where he died of his wounds in the night, and to
a rumour that two Mussulmans had been killed or wounded at the
same time on the road between Canea and Suda Bay. All the
shops were shut up as usual, but there was no general 'sauve
qui peut,' Christians especially having congregated in the
square near the hospital in the hope of finding out further
information. Happening to be in the town, I took a carriage
and drove towards Suda. When at about a mile distant from
Canea I came upon a number of Mussulmans, who told me that
four Christians going to Apokorona had, without any
provocation whatever, discharged their revolvers on three
Mussulmans, two of whom had been severely wounded. I saw one
of them in his cottage hard by the road with a bullet wound in
the abdomen; the other had been conveyed on horseback to the
village of Tsikalaria (southeast of Suda Bay), 2 miles from
where he had been wounded, of which he was a native. The four
Christians fled across the fields, leaving on the road a horse
and an overcoat, and took to the mountains.

"Between half and a quarter of an-hour after this incident

another Christian, a native, like the Turk, of Tsikalaria, was
passing on the road when he was fired upon by Mussulmans in
retaliation for the wounding of their two co-religionists. Not
having been hit, the Christian jumped from his mule and ran
for his life along the Suda road, being pursued by armed
Turks. He was overtaken by three of them about half-a-mile
farther down, and was shot at and mortally wounded at 20 paces
in front of Commander Shortland, of Her Majesty's ship 'Nile,'
who was coming on foot from Suda Bay to Canea. The wounded
Christian was taken charge of by the Albanian corporal
stationed in a Christian monastery close by, and was
subsequently put in a carriage by the Russian Consul, who was
returning from Suda Bay at that moment, and sent to the town
hospital, where he died. While I was making inquiries on the