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Public Health Nursing Roles for Addressing Diabetes in the American Indian Population in Kent
County, Michigan
Amy K. Johns
Ferris State University


This is a paper written for a Bachelor of Science in Nursing class regarding public health and
community nursing. It examines two roles, direct-care public health nurse and leader/manager
public health nurse in the context of a community change project regarding primary educative
prevention for diabetes in the American Indian population in Kent, County, Michigan. It
examines the eight domains of public health nursing and their specific focus in each role. It
discusses the author’s specific qualities regarding each role.


Public Health Nursing Roles for Addressing Diabetes in the American Indian Population in Kent
County, Michigan
Diabetes is a huge and growing problem worldwide. The International Diabetes
Federation (2013) estimates that 366 million people have been diagnosed with diabetes in the
year 2011 and they project that that number will grow to 522 million by the year 2030. It is also
estimated that global expenditure for diabetes was 465 billion US dollars, or 11% of all health
care expenditures for adults 20-79 years of age. In the United States in 2010, 25.8 million people
or 8.3 % of the population were affected by diabetes (Centers for Disease Control, 2011). Rates
for minority/ethnic populations in the United States are higher. This includes the American
Indian (AI) population. According to the Centers for Disease Control (CDC) (2011), 16.1% of
the total adult population of AIs have diagnosed diabetes. This is variable by region, running as
high as 33.5% of adult AIs in southern Arizona (CDC, 2011). Rates of diabetes for American
Indians in Michigan are also higher than national benchmarks for white people. An American
Indian in the US is twice as likely to have diabetes as a white person (CDC, 2011).
A project entailing an analysis of the diabetes rate, existing resources, and plan for future
interventions for a United States American Indian population (in Kent County, Michigan) from a
public health perspective is being undertaken for a Bachelor of Science in Nursing Community
Nursing class. Direct-care and leadership/management roles needed to carry out this assignment
will be explored in this paper. The American Nurses Association (ANA) Standards of
Professional Practice for Public Health Nursing will be discussed in the context of these roles.
Leadership, personal, and professional characteristics in the nurse that best fulfill this position
will be discussed, as well as characteristics that both suit and present challenges for this nurse

Public Health Nursing Roles
State and County Health Departments are major population-based health care resources
for chronic diseases, especially among disparate populations. There are many roles for public
health nurses, both in direct client care and leadership/management positions.
Direct-Care Role
Type II or adult-onset diabetes is correlated with obesity, diet, and lack of exercise and is
a preventable disease (CDC, 2011). One role for a direct-care nurse is that of educator or
counselor of families or individuals. Public health nurses as counselors and educators can help
guide people at all three levels of prevention: primary, secondary, and tertiary. Ideally,
education resources aimed at fostering healthy eating, weight control and exercise would prevent
the development of type II diabetes. This would save millions of healthcare dollars and improve
the quality of life for millions of people.
The Kent County, Michigan Health Department has two departments that incorporate
direct-care, public health nursing that are being explored for our assignment. These are
departments in which nurse educators and counselors who provide primary diabetes prevention
education. They are the departments of Administrative Health and Community Nursing. The
Administrative Health Division is responsible for Communicable Disease/Epidemiology, Health
Education and Promotion, and the Obesity Initiative (County of Kent, 2013). All of these
branches are involved prevention and treatment of diabetes. Our group has focused its
interventions on the education of American Indian adolescents about the disease of diabetes, its
implications on health and its impact on the AI population. We are using evidence-based
research regarding effective programs used specifically for AI youth (Brown et. al. 2010). We
are also using research ideas from an adolescent outreach program called “Empower U” (Dowdy,

et. al., 2013). We will also provide education and counseling about obesity prevention, nutrition
and exercise and their roles in the prevention of diabetes. A direct-care nurse in the position of
educator in the Health Education and Promotion branch of the Administrative Division of the
Kent County Health Department would be ideal.
Leadership/Management Role
Multi-disciplinary collaboration is crucial for effective intervention that reaches the most
members of the desired population of a public health undertaking. Our project is aimed at
American Indian adolescents in Kent County, Michigan. We would be benefitted by leadership
that had access to many other community institutions, leaders, and funding. It is also crucial that
the Office of the Governor and the State of Michigan be on board with the philosophy of
preventative care, community health, and public health nursing. The CDC, the Association of
State and Territorial Health Officers, the National Association of County and City Health
Officials, and the Association of Community Health Nursing Educators have produced a
statement that promotes a position equivalent to a Chief Nursing Officer. “Public health nurse
directors and chief nurses in state health departments are the key to a strong public health nursing
workforce – vital to maximizing public health nursing’s contribution to healthy populations and
healthy communities” (Association of State and Territorial Directors of Nursing, 2008).
Michigan has this position as of 2008 (RN-AIM, n.d.). This is key to the success of public health
nursing programs.
Specific to our project, having a leader in the position of Administrative Health Officer
for Kent County would be highly beneficial. This position oversees the establishment of
strategic direction and overall goals for the Health Department (County of Kent, 2013). This
would provide strategic access to other collaborative members of the county government as well

as the Health Department. A public health nurse in the role of Administrative Health Officer
would ensure that nursing philosophy of healthy mind-body-spirit would be carried into county
Scope and Standards of Practice for Public Health Nursing
Gail Harkness, DrPH, RN, FAAN writes in Community and Public Health Nursing (p. 9),
that there are eight domains of qualifications specific to Public Health Nursing Practice set forth
by the American Nurses Association. These are the standards of practice and leadership
qualities that are present in a competent public health nurse (Harkness, 2012). They are:
 Analytic assessment skills
 Policy development and program planning skills
 Communication skills
 Cultural competency skills
 Community dimensions of practice skills
 Basic public health science skills
 Financial planning and management skills
 Leadership and systems thinking skills
Other qualities that would be beneficial specific to our project would be experience working
with adolescents, having a rapport with young people, cultural openness, and knowledge of the
American Indian culture of Kent County. Also, knowledge of the condition of diabetes in
American Indians with regard to social determinants of health: a broad knowledge base of all
aspects of lifestyle, health, traditions, socioeconomic implications, etc. (Mitchell, F., 2012). All
of these qualities and competencies are important to both the direct-care and leader/manager
public health nursing roles identified here.

Analysis of Roles
All eight domains specified are important to all public health nursing roles. However,
analytic assessment, communication, cultural competency and basic public health science are
crucial skills to be developed by the direct-care public health nurse. Knowledge of American
Indian culture and communication skills with adolescents are competencies specific to our
project. Policy development and programming, community dimensions of practice, financial
planning and management, and leadership and systems thinking are skills specific to the
leader/manager role. Financial planning and policy development are elements that the
leader/manager may need knowledge of to ensure that the goals and mission of the Health
Department are continually heeded and funded by our State government officials. Knowledge of
politics at the local and state level is crucial to make sure the voices of public health nurses and
those they serve are heard.
Specific Skills and Competencies of This Nurse
With regard to my competencies and skills and how they might be suited to each role, I am a
new nurse with two years of experience in an acute-care, hospital setting. This class and a class
called Population-Based Health Promotion have been my only exposure and experience with
public health nursing. I am lacking in the competencies of policy development and program
planning. I also have no experience with financial systems or community dimensions of
practice. I have limited leadership experience; however, I am in several leadership roles within
my bachelor’s degree program and as the Chair Elect of the Unit Action Council of the unit of
the hospital where I work. I have excellent written and verbal communication skills and have
been told that I am extremely perceptive and empathetic. I get very good feedback from my
patients, my manager and my coworkers. I am a very good educator and take pride in our role as

one of the best teaching floors in a teaching hospital. With experience and education in public
health policy and practice, I could be an effective leader of healthy community change.


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the Diabetes Prevention Program for Northern Plains Indian Youth Through Community-
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