Running head: PREVENTION IN COMMUNITY NURSING

Preventative Care Theory: A Framework at the Highest Level

NR 501 Theoretical Basis for Advanced Nursing Practice

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Preventative Care Theory: A Framework at the Highest Level

The United States has been in a healthcare crisis for a half century with health costs
escalating rapidly, rapid inflation in the economy, expansion of hospital expenses and profits,
and changes in medical care including the broader use of technology, pharmaceuticals, and
conservative approaches to treatment (Silverman, Epstein & Waters, 2000). The National
Federation of Independent Business v. Sebelius changed the face of history when its ruling in
favor of the Patient Protection and Affordable Care Act (PPACA) was announced to a nation of
polarized citizens on June 28, 2012 (U.S. Department of Health & Human Services, 2014). It
was later signed into law on March 23, 2010 by President Obama along with the Health Care and
Education Reconciliation Act of 2010. The PPACAs comprehensive goal of insurance reform
and a nation-wide preventative care focus has been one of great controversy, but it is not a new
concept. Nurse-leaders and pioneers Nancy Milio and Marla Salmon have been preaching
preventative care in community nursing since the 1970s (Anthony, 1994 & Milio, 1976). Their
theories in community nursing have attempted to shift the focus of nursing care from reactionary
to preventative through the development of policy, nursing process adaptation, and emphasis on
inter-professional practice in public health settings (Bigbee & Issel, 2012), but moreover, they
advocate for nation-wide policy change in order to present the population with better, affordable,
health choices.
Why A Nursing Theory?
The problem with healthcare in the nation seems herculean in nature. How could a
nursing theory help in creating solutions to such a crisis? The answer is simple in nature, yet
complex in application. Community and public health practitioners who face the reality of our
nations emergency on a daily benefit from a sense of identity and a recognition of their unique

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contribution to their nation. Nursing theories provide definition and focused care delivery and
help nurses to better understand their purpose and role. Whether it is applied to an intimate
clinical setting or a nation-wide healthcare dilemma, the result can be the same, depending on
how well the theory is adopted (Colley, 2003). In fact, nursing theories have no political or
geographical boundary and can be applicable on a global scale. In the case of preventative care
in community nursing, the World Health Organization (WHO) states that global healthcare is
undergoing a transformation that reflects the increasing importance of community care based on
social, group, and individual needs (Tthov, et al., 2014). Nurses and their skillsets constitute
significant potential in the area of community-based preventative care especially.
Marla Salmon Pioneer of Policy Change
Dr. Marla Salmon, who has served in a number of governmental roles relating to
healthcare such as: director of the Division of Nursing with the Health Resources and Services
Administration, U.S. Department of Health and Human Services (DHHS); chair of the National
Advisory Committee for Nursing Education and Practice; member of the Clinton
Administrations White House Taskforce on Healthcare Reform; and member of the U.S.
Delegation to the WHO, is viewed by many as the pioneer of community nursing policy (The
George Washington University, 2014). Salmons theory revolves around the education of
practitioners and their voluntary change in attitude. In 1993, during her time as director of the
Division of Nursing for the DHHS, she addresses public health nurses nation-wide in an open
letter for Public Health Nursing, in which she looks retrospectively when she projected the role
of the American public health nurse in the 21st century (Salmon, 2009). She states, during the
early years of health care reform public health nurses led the way in health departments
(Salmon, 2009, p. 484). She recaps that the public health nurse (PHN) was increasingly asked to

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serve as the eyes, ears, and voice of the health department relating to the environmental safety
of communities (Salmon, 2009, p. 484). This role soon resulted in education programs adapting
to the PHN discipline producing a cadre of leaders with a strong interdisciplinary foundation
(Salmon, 2009, p. 484). Salmon understood this role and its importance to the national health
care model. She encouraged preventative healthcare models in education, practice and policy
from the beginning. Her theories helped guide legislation over the past few decades to the
policies recently signed into law with the ACA in 2010. However, Dr. Salmons theories are still
considered infantile in the discipline of community nursing (Bigbee & Issel, 2014).
Nancy Milios Framework
On the front lines of public health, PHNs face behavioral patterns of poor health
choices, risky lifestyle decisions, poor nutritional choices, an apathy for healthcare education,
and an overall lack of communal response to the nations healthcare woes and the burden to
society it creates. Nancy Milio forecasted these behaviors in her early years as a doctorate
student in 1976. Milio proposes that health deficits often result form an imbalance between a
populations health needs and its health-sustaining resources (Kenny, 1999). Milio also adds in
her published work A Framework for Prevention: Changing Health-Damaging To HealthGenerating Life Patterns (1976) A more immediate impetus for serious attention to illness
prevention is the uncontrolled rising costs of personal health services (Milio, 1976, p. 435). An
advocate for healthcare policy change like Salmon, Milios proposed framework for prevention
is a thought-provoking complement to the older health belief model (figure1.) and a conduit for
lobbying for nursing interventions at the population level (Kenney, 1999). While the health
belief model was developed to help healthcare communication campaigns target specific
behaviors in the population (Carpenter, 2010), Milio argued that the commonly held assumption

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in health education that knowing health-generating behaviors implies acting in accordance with
that knowledge (Kenney, 1999, p. 131). Most human beings, professional or nonprofessional,
provider or consumer, make the easiest choices available to them most to the time (Kenney,
1999, p. 131). The lifestyle choices of healthcare professionals is an excellent example of her
argument.
Policy Change
Milios framework proposes that a range of choices widely available to the public is
shaped by policy decisions at both governmental and private organizational levels; she advocates
a national-level policy making as the most effective means of favorably affecting the health of
most Americans. Proof of this can be analyzed in the United States government tax on cigarettes
and tobacco products juxtaposed to anti-smoking campaigns targeting smokers and underage
teens who are at risk of starting to smoke. In accordance with Milio, health-promoting choices
must be more readily available and less costly than health-damaging options if populations are to
be healthy and a society is to improve its overall health status (Kenney, 1999 & Carpenter,
2010). Given this framework, strategies for encouraging better decisions which are healthpromoting must be aimed at broadening the options available to people making choices easier
and making the poor decisions harder to make.
Knowledge Gained
A nation in healthcare crisis over the past fifty years has been a frontier for public health
and community health. Nursing theorists Marla Salmon and Nancy Milio have proposed theories
addressing the dilemma of poor health choices and behaviors in the U.S. population and point the
finger upward to public policy and higher education. Addressing the availability of more costeffective and easier choices for the public promoting preventative healthcare models at the

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national level and at the higher education level have shown to be effective in creating a different
climate in public health. Public health nurses have a sense of direction and a source of pride in
their practice as a national team when they understand these underlying theories to their practice
and can help advocate for change at the highest level, even a global level.

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References
Salmon, M. E. (2009). An Open Letter to Public Health Nurses. Public Health Nursing, 26(5),
483-485. doi:10.1111/j.1525-1446.2009.00806.x.
U.S. Department of Health & Human Services. (2014). Affordable care act and title X program.
Retrieved from http://www.hhs.gov/opa/affordable-care-act/index.html.
Silverman, F., Epstein, M., & Waters, S. (2000). Healthcare Crisis: whos at risk? Retrieved
from http://www.pbs.org/healthcarecrisis/index.htm.
Colley, S. (2003). Nursing theory: its importance to practice. Nursing Standard, 17(46), 33-37.
Tthov, V., Brtlov, S., Sedov, L., Treslova, M., Chloubov, I., & Prokov, E. (2014). The
nurse's role in preventive care in the field of community nursing. Neuro Endocrinology
Letters, 35(Suppl), 26-33. \
The George Washington University. (2014). National Health Policy Forum. Retrieved from
http://www.nhpf.org.
Milio, N. (1976). A Framework for Prevention: Changing Health-Damaging To HealthGenerating Life Patterns. American Journal Of Public Health, 66(5), 435.
Kenney, J. W. (1999). Philosophical and Theoretical Perspectives for Advanced Nursing
Practice. Sudbury, Mass: Jones and Bartlett.
Carpenter, C. J. (2010). A meta-analysis of the effectiveness of health belief model variables in
predicting behavior. Health Communication, 25(8), 661-669.
doi:10.1080/10410236.2010.521906
Glanz, K., & Bishop, D. (2010). The role of behavioral science theory in development and
implementation of public health interventions. Annual Review of Public Health, 31:399418, doi: 10.1146/annurev.publhealth.012809.103604.

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Figures

Figure 1. The Health Belief Model developed in the 1950s to help healthcare communication
target specific behaviors in populations (Carpenter, 2010).