· How can nurses help families live optimally in spite of the many complex issues they may face?
· How does the nurse help to promote health and wellness to families?
· How do the social determinants of health (SDOH) affect families’ ability to achieve optimal health and wellness?
· How can nurses assist families to address identified needs?
Health promotion is an essential component of nursing care for varying and diverse patient populations. Health promotion goes beyond education and management of disease and encompasses the social determinants of health (SDOH) that have an effect on health and wellness overall. Health promotion also addresses the provision of tools and resources given to patients that enable them to take personal action and achieve accountability for their own wellness. In doing so, the nurse must remain aware of the new and developing challenges patients and families face in an ever-changing world to provide them with practical and applicable resources to handle such challenges.
According to the World Health Organization (WHO) (2018b), health promotion is “the process of enabling people to increase control over, and to improve their health” (para 1). Health education is defined as “any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes” (World Health Organization [WHO], 2018a, para 1). Nurses are actively involved in both health promotion and health education, providing education that is necessary to help patients achieve control over the promotion of their own health. The SDOH have a heavy influence on health and wellness. Families are directly influenced first on an internal level, which can mean having a steady income that provides adequate financial security, a well-stocked pantry, or access to health care. On a larger scale, environmental factors may include the safety of the neighborhoods where patients and their families lives; access to transportation to and from school, work, and physician’s offices; and the rates of illicit drug and alcohol abuse in the community. On a global scale, factors such as political distress as well as natural and man-made disasters also have a stark impact on health and wellness. Though many of these elements are beyond control, there are plans that can be devised, resources that can be offered, and tools that can be used to assist with preparation and help to work toward achieving wellness goals.
In order to help patients control and improve their health, they require the tools necessary to do so. Nurses provide health education in numerous ways to provide patients with the essential tools for health promotion. One example of health education for health promotion is providing discharge instructions prior to the patient going home after a hospitalization. The nurse may go over the patient’s new medications, when to take them, what side effects to watch for, who to call if he or she has questions or concerns, and the importance of attending follow-up visits. When discussing health promotion, the nurse should also offer proper resources that the patient may need, such as application for insurance or numbers for domestic violence outreach.
Similar to all other nursing functions, health education is provided by using the nursing process (see Table 5.1). The nurse will assess, diagnose, plan, implement, and evaluate to provide the proper health education to the patients. These steps vary to some degree when addressing the provision of health education, but the basic foundations remain the same.
|Assessment||29-year-old female patient is to be discharged after being hospitalized for 2 days with influenza. After discussion, the nurse discovers the patient is at a high risk for domestic violence and does not have medical insurance. The nurse also recognizes the need for vaccination education.|
|Diagnose||Risk for ineffective relationship related to patient’s fear of her partner, as evidenced by the patient not wanting her partner to be present during questioning and crying during the interview.
Readiness for enhanced knowledge related to expressed interest in education regarding flu vaccine.
|Plan||Assist patient in use of educational materials and resources for intimate partner violence (IPV). Assist patient in seeking medical insurance for future care. Provide information about vaccinations and offer the influenza vaccine.|
|Implement||The nurse should provide her with education and resources regarding IPV. The nurse, with the help of the case manager and social worker, allocate resources for domestic violence outreach programs in the area. The nurse and social worker help the patient apply for insurance. The nurse makes sure the patient understands the education provided to her regarding domestic violence outreach centers and the details of her new insurance. The nurse also educates the patient regarding the influenza and other vaccinations prior to discharge. The nurse receives consent to administer the flu vaccine to the patient and provides her with thorough education regarding its benefits.|
|Evaluate||The nurse may not be able to evaluate the results once the patient is discharged from the hospital. The nurse may anticipate results, such as “the patient utilizes the domestic violence outreach center when necessary.”|
Note. Adapted from “NANDA International Nursing Diagnoses, Definitions & Classification, 2015-2017,” by T. H. Herdman & S. Kamitsuru (Eds.), 2014. Copyright 2014 by NANDA International.
Nurses provide health education while considering the cultural differences for care. While provision of education and resources may seem straightforward enough, it may change drastically depending upon a patient’s cultural needs. For instance, providing domestic violence resources to a patient from a traditional Muslim culture may be considered intrusive, disrespectful, and rude to the patient and his or her family members (Rassool, 2015). Simply asking questions of this nature may be seen as finger pointing and meddlesome. In circumstances like this, the nurse must devise ways in which to support and advocate for the patient without being disrespectful to the patient’s culture.
What are some ways the nurse can support the patient and provide health education without disrespecting the patient’s culture?
Providing appropriate tools and resources for health education can vary depending on a number of factors. The selection of tools and resources occurs after the assessment step of the nursing process and the patient’s specific education needs are identified. The nurse also works in conjunction with interdisciplinary team members, such as case management and social work, in order to allocate resources including insurance or transfer of care needs. Care should also be taken to select tools that are appropriate to the patient’s level of literacy and health literacy as well as language needs. Tools should be tailored to fit with what is best for the patients to get the best results when applying their new skills to their everyday lives. Tools can be as basic as written pamphlets or handouts that use written information or pictograms. Other tools include demonstrations, classes, videos, question and answer sessions, or providing website links if appropriate to the patient’s available resources. While comprehension of the information provided is a goal of health education, it should not be the only purpose; health education should also focus on how the education can be applied to patients’ daily lives to improve their overall wellness and prevent complications of existing issues, or the development of new issues.
John is a 35-year-old male who has recently been diagnosed with high cholesterol. He is a truck driver, is sedentary most of the time, knows he has a very poor diet, and admits he worries that making changes will be difficult. John tells the nurse, with some hesitation, that he dropped out of high school in his sophomore year and is not a very confident reader. The nurse needs to provide education to John related to his new diagnosis and lifestyle changes. The nurse provides basic written information at the appropriate reading level for John, but also ensures that it includes pictures for easy reference. The nurse also shows John instructional videos that provide an overview of his new cholesterol medication and offers advice regarding good food choices.
Check for Understanding
1. How can the nurse ensure that John has understood the information provided to him?
2. What are other methods of providing education that would be appropriate for John given his education level?
When addressing health promotion education in today’s world, there are a number of issues that the nurse must be knowledgeable about in order to provide education to others. As times change, the problems that patients and their families face also change and can become more complex. Families need support and guidance to face these challenges in order to continue to foster the health and wellness of all family members. In order for nurses to help form a plan of care that addresses each family’s specific and varying needs, nurses need to understand how these issues affect the family’s health and wellness.
Safety concerns begin internally within the home environment. Safety issues on a community level as well as globally can also have a stark effect on families and family health. Within the home, safety issues such as fire safety, falls, gun safety, drowning, and poisoning each require attention. Nurses are involved in the education and planning to ensure a safe environment that promotes the development, maintenance, and growth of the healthy family.
Fire safety and fire safety education can potentially decrease fire-related injury and fire-related deaths. Families should be educated regarding the proper installation and maintenance of fire alarms throughout the home. In addition, the family should develop a safety plan in the event of a fire, which would include where to meet once safely out of the home, and the proper steps to take if smoke is smelled or flames are seen. The family should also have safety equipment, such as a fire extinguisher in an accessible location, and designated family members should be trained how to properly use the fire extinguisher. Nurses are often in a position to discuss these topics with patients because of their close provider/patient relationship. Nurses can help develop a family safety plan and discuss details of necessary fire safety education with patients and their families.
Sonny and his wife Tasha are newlyweds with a baby on the way. Their neighbor a few doors down just experienced a devastating house fire a few weeks ago, which prompted their desire to be more prepared for such an event. During a routine maternity checkup, they ask the nurse for advice regarding fire safety. They admit they know very little about fire safety and are not even sure if their fire alarms are working properly.
Check for Understanding
1. What education and advice should the nurse provide to this growing family?
2. How can the nurse develop a plan to help the family incorporate safety features into their home and create a safety plan in the event of a fire?
Falls can occur in any age group, but may be a more prevalent concern for pediatric and geriatric patients. Falls are a leading cause of death and disability for older adults and are nearly always a preventable occurrence (Centers for Disease Control and Prevention [CDC], 2017e). Examples of ways to prevent falls include installation of home safety equipment such as grab bars in the bathroom or clearing out clutter in the home. Patients at high-risk for falling should discuss their medications and medical conditions with their primary care provider to see if any could cause dizziness or lethargy. Strength and balance exercises are also recommended to improve balance and further decrease the risk of falls. Additionally, patients should have their vision checked routinely (CDC, 2017c).
Stopping Elderly Accidents, Deaths & Injuries (STEADI) is a program for health care providers who treat older adults to assess and take steps to prevent older adult falls and injuries. Three basic questions guide providers in assessing the older patient for risk of falls:
1. Have you fallen in the past year?
2. Do you feel unsteady when standing or walking?
3. Do you worry about falling?
If the patient answers “yes” to any of these questions, he or she is considered a fall risk and will require further assessment and intervention to prevent a fall (CDC, 2017e). If the patient is a significant fall risk, the nurse will conduct an assessment and help to develop a safety plan, which may include obtaining the proper assistive medical equipment, such as a walker or cane. Collaboration with the case management worker to coordinate with the patient’s insurance company is a necessary part of this process. The nurse also provides education and advice about making changes to increase safety at home, such as the removal of small throw rugs and improving lighting.
Note. Adapted from “STEADI – Older Adult Fall Prevention,” by the Centers for Disease Control and Prevention, 2017.
Falls among children are a frequent and avoidable occurrence. The Centers for Disease Control and Prevention (CDC) highlight four primary areas to be addressed when it comes to protecting children from falls or other avoidable injuries: play safety, home safety, sport safety, and supervision. Safe play means ensuring safe playground equipment and environments. Home safety refers to the utilization of home safety devices, such as window and door locks, gates, and guardrails. Sport safety includes use of appropriate safety gear, including helmets and sunscreen, and reiterating the importance of hydration and rest. Supervision means guidance from a responsible adult at all times to ensure safety (CDC, 2016b).
Brenda, a 40-year-old mother of three young children, cares for her aging father, Bill, who moved into her home last year. Bill has been having mobility issues after his hip surgery in November. During a recent doctor visit, the STEADI assessment revealed he is a high risk for falls. The nurse works with Brenda and Bill to discuss reasons for concern, namely removing small throw rugs in the hall near Bill’s room, as well as increasing the lighting in areas of the home that Bill frequents. The nurse also contacts the case management worker to discuss the need for a physical therapy evaluation and approval for an assistive device, such as a walker. Although Bill has been resistant to use such a device, he understands why he may need one to avoid falling.
Brenda also expresses concern regarding her youngest child, Matthew, who is 3 years old and very adventurous. Matthew seems to be taking small tumbles during active play. Although his injuries have been minor, Brenda worries that one day he could have a more serious injury. Brenda asks the nurse for advice on how to increase safety and decrease risk of falls for Matthew.
Check for Understanding
1. What kinds of safety interventions can the nurse recommend to Brenda in order to increase safety for Matthew at home?
Gun safety is an important issue that warrants education and extreme caution to keep individuals and families safe. For gun owners, education must include proper gun storage and safety precautions within the home. All guns should be kept unloaded in a locked safe at all times, with ammunition stored in a separate locked location. Keys to gun safes should be kept in a separate location far from the reach of children. Children should be taught never to touch or play with guns if found anywhere within or outside of the home. Parents should be cautious and ask questions regarding gun ownership and safety when children are spending time at another person’s home. Nurses should take time to ask questions regarding gun safety and provide education in order to help families create safe environments within the home (KidsHealth, 2018).
Gun Safety Case Scenario
Henry and Maria are the parents of two teenage boys, Devin and Dimitri. Dimitri is 13 years old and asks to go to a friend’s house after school to study. That evening at dinner, Dimitri tells his parents that his friend Alex was showing him his father’s gun collection. Henry and Maria are extremely disturbed by this information and are concerned with Dimitri’s safety. Maria brings the situation up to the school nurse the following week when she stopped by to replace Dimitri’s rescue inhaler. The school nurse discusses Maria’s concerns with her and educates her on proper gun safety. She also recommends that Maria contact Alex’s parents to discuss gun safety in their home.
Drowning accidents do not occur solely during recreational swimming in pools, an ocean, or a lake. Drowning occurs quickly and can happen in a few inches of standing water. The CDC states that drowning remains a leading cause of death for children 1-14 years of age (CDC, 2016a). Key prevention tips include: learning to swim; learning lifesaving skills, such as cardiopulmonary resuscitation (CPR); fence installation and use; life jacket use; and close supervision at all times. Nurses can encourage and provide resources for learning CPR and swim lessons that may be provided for free or at a low cost at community recreation centers. The nurse can provide education on the importance of proper self-closing and latching pool fences/gates in order to prevent wandering children from falling into pools. The nurse should also discuss the importance of close and constant supervision of children near any body of water, from the bath to the beach. It only takes seconds for someone to drown; lack of supervision even for a moment can lead to devastating results.
Note. Adapted from “Know the Facts: Fatal Child Drownings,” by PoolSafely.gov, 2017; “Morbidity and Mortality Weekly Report (MMWR), Drowning—United States, 2005-2009,” by the Centers for Disease Control, 2012; “Racial/Ethnic Disparities in Fatal Unintentional Drowning Among Persons Aged ≤29 Years— United States, 1999-2010,” by the Centers for Disease Control and Prevention, 2014.
Tony is a single father of two children, Amber who is 5 years old, and Sophie who is 3 years old. He frequently relies on his mother for child care, as he is the sole care provider. His mother recently moved to a new home, and he visited to help her move some furniture and see her new home. Tony immediately noticed the pool in the backyard and became concerned because there was no security fence around the pool. He asked his mom if she was planning on having one installed. She tells him, “No, there is no need. I will be here watching them, and they will be fine.”
Check for Understanding
1. How can the nurse assist in educating Tony and his mother regarding water safety and the importance of fences surrounding pools?
2. What facts regarding pool and water safety should be highlighted?
3. How does the nurse remain respectful and avoid sounding judgmental during this conversation?
Within the home, poisoning is a child-safety concern. Many household products, as well as common medications, are hazards to children. All poisonous or toxic substances, such as household cleaners and medications, should remain in their original containers, be kept in a locked area, and remain out of reach of children at all times (Safe Kids Worldwide, n.d.). Nurses can help provide advice regarding the reorganization and proper storage of such items in order to help create a safer home environment for families.
Another major concern regarding poisoning is the abuse of prescription opioid narcotics that often leads to intentional or unintentional overdose. In addition to protecting small children from accidentally ingesting such medications, older children and teenagers should be advised of the dangerous effects of using illicit drugs and the use of alcohol.
Adults should also be educated regarding the proper use of such medications and following the prescriber’s instructions regarding their use. Adults should also be advised not to drive or work when taking these types of medications, as they may alter mental functioning that could cause a motor vehicle accident or lead to legal repercussions such as a DUI offense (driving under the influence) (DMV.org, n.d.).
Additionally, families should be provided with the poison control phone number in the event of an accidental poisoning and be advised to call 911 in the event of a life-threatening injury.
Josephine is a 65-year-old woman with multiple health problems that require a number of different prescription medications on a daily basis. Josephine lives with her adult daughter, son-in-law, and their four children, ranging in ages from 4 to 17. Josephine currently keeps her medications on her nightstand because they are easy to reach and keep organized. One morning Josephine’s daughter, Karie, finds her youngest son, Chris, playing with two of Josephine’s medication bottles because he said, “It sounds like music.” Karie is very upset and brings this concern up to Josephine. The family would like help creating a safer home environment and they turn to the nurse for recommendations and education regarding medication safety.
Check for Understanding
1. What would a safety plan look like for this family?
2. What safety interventions are essential to help incorporate in the family’s home?
3. What kinds of things should the nurse include in the education of this family?
Motor vehicle accidents are a leading cause of death, injury, and disability in America. Contributory factors include distracted driving, intoxicated driving, misuse or non-use of seatbelts and car seats, and speeding or negligent driving (CDC, 2016d). The CDC provides recommendations to decrease the risks that must be reiterated and reinforced whenever possible. Namely, using a seat belt and proper use and installation of car seats at all times, not driving while impaired and encouraging others to do the same, following speed limits and traffic laws, and driving with no distractions, such as cell phone use and texting (CDC, 2016d). Nurses can help families develop plans in which these tips can be applied to daily life more regularly. Recommendations can be made to have car seat installation checked by the local fire department and having teen drivers enroll in driving school classes to ensure proper understanding of traffic laws.
April is a 38-year-old mother with a newly licensed teenager, Lisa, who is excited and anxious to start driving. Lisa asks April repeatedly to borrow the car. April is very apprehensive because of all the news reports about distracted teenage drivers and rates of accidents. Lisa ensures her mom that she will not look at her phone while she is driving. One week later April gets the phone call she had been dreading, Lisa was involved in a fender bender, and though she was badly shaken up, she had no physical injuries. When the nurse is assessing Lisa for injuries, April expresses a desire for more education regarding safe driving. The nurse provides resources regarding student driving courses and support groups for parents with teenage drivers. The nurse educates April and Lisa about the statistics of distracted driving and that, although Lisa’s circumstance did not end tragically, it very well could have.
Check for Understanding
1. What are some other resources the nurse could provide to April and Lisa?
Violence is a concern for every family and encompasses a wide range of issues within the home, community, and the world. Within the home issues, such as child abuse, intimate partner violence (IPV), sexual violence, and suicide are prevalent, while within the community issues such as gang violence, active shooter situations, sex trafficking, and bullying are issues that demand attention. Families should be provided with education regarding the signs and symptoms of each of these and given the resources to contact in the event that such circumstances are suspected.
Child abuse includes physical, sexual, or emotional abuse, as well as neglect of a minor child. Anyone who encounters the child can be an abuser, not solely the child’s primary caregiver. Child abuse occurs more often than most people may think. The CDC defines child abuse as “any act or series of acts of commission or omission by a parent or other caregiver (e.g., clergy, coach, teacher) that results in harm, potential for harm, or threat of harm to a child,” (CDC, 2018c). More than 2 million reports of child abuse are investigated annually by Child Protective Services (Christian, 2015). Nurses should understand and familiarize themselves with the signs and symptoms of child abuse in order to advocate for their pediatric patients’ safety. In most instances, cases of child abuse occur within the home and the perpetrator is often a close family member or direct caregiver. Risks associated with abuse of any kind include poverty, mental illness, and alcohol or substance abuse (Ho, Gross, & Bettencourt, 2017). The nurse must be well informed and aware of these issues and properly evaluate the child for signs and symptoms of abuse.
Long-term effects of child abuse are often lifelong and require ongoing support and therapy (Young & Widom, 2014). Parents should be educated on the prevention of abuse, understanding the signs and symptoms of abuse to prevent abuse from occurring, and to intervene quickly if such abuse does occur. The nurse can refer caregivers to social workers and case management workers to coordinate psychological therapy on an outpatient basis.
Intimate partner violence (IPV) is a collective term that includes physical, sexual, or psychological harm by a partner or spouse (CDC, 2018g). Though rates of IPV are high nationwide, with 1 in 4 women and 1 in 9 men reporting that they are IPV victims, IPV is considered preventable and, with proper assessment and support, the hope is to decrease its life altering effect on individuals and families nationwide (CDC, 2017f). Nurses work first hand with individuals and families affected by IPV. Often nurses may be the first person to discover that IPV exists within a patient’s home and their reaction and provision of proper intervention may be lifesaving for the patient and their loved ones. Though the topic of abuse may prove difficult to discuss, the nurse must compassionately and patiently ask sensitive questions to obtain more information regarding the circumstances of the abuse. Once this crucial information is gathered the nurse can work with the patient and his or her family, along with members of the interdisciplinary health care team, to provide the appropriate services and resources to allow for healing, protection, and restoration of health. For victims of IPV that have successfully moved on from negative circumstances, learning positive relationship skills and how to avoid IPV in future intimate relationships is also essential to break the cycle of violence and to aid in the promotion of health within families.
Barb, a nurse at a local pediatrician’s office is assessing a 4-year-old girl, Isabel, at a wellness visit. Her mother Irene is with her for the visit. Isabel is quiet and does not speak much during the interview. During the assessment, the nurse notices small circular burns on her upper arm. Irene is quick to intervene and tells the nurse “those marks are from her picking at her skin. I always tell her not to.” Irene seems nervous and does not make eye contact with the nurse. Isabel whispers to the nurse that when she frustrates Daddy, he has to punish her. The nurse has an open conversation with Irene, and Irene discloses that her husband is very angry much of the time and has hit her a few times but never leaves any marks. Barb educates Irene on the signs and symptoms of abuse and provides her with emergency resources regarding IPV and child abuse.
Check for Understanding
1. What other resources does this family need?
2. Does Barb have a legal obligation to contact anyone regarding the abuse of the child? Why or why not?
3. Who should Barb contact regarding the abuse?
Suicide is a preventable occurrence accounting for nearly 45,000 deaths in the U.S. annually (American Foundation for Suicide Prevention, n.d.). Suicide has no specific cause and often occurs because of a combination of increased life stressors causing feelings of extreme hopelessness. Risk factors may include previous suicide attempts; history of mental illness or substance abuse; major life events, such as death or divorce; and prolonged life stressors, such as chronic illness, bullying, or harassment. Signs and symptoms of impending suicide may include withdrawal from typical life events, discussing death and dying frequently, giving prized possessions away, sleep-pattern disturbances, saying goodbye to loved ones, and increased depression or anxiety. Families should be educated regarding the signs and symptoms of those at risk for suicide and be provided with the appropriate resources to get help for the distressed individual in order to prevent suicide. Preventative methods include early intervention by detection of early warning signs of depression and/or suicide ideation, as well as providing crisis relief services for those affected by a recent suicide. The hope is that the suicide will be prevented altogether but the reality is that resources must be provided in the face of tragedy. Secondary prevention aims to support those affected by suicide in the future through crisis programs and outreach to schools and communities who are grieving or dealing with shock related to a suicide within their community.
Edward is a 48-year-old executive at an insurance company. He has two children who are about to go to college, a large mortgage, and an impending divorce from his wife of more than 20 years. He is stressed, exhausted, and depressed, often working 60-hour workweeks. He receives word that he is being let go from his current position, and he immediately goes into a deeper depression. He begins drinking heavily and often sleeps until noon. His 17-year-old daughter Elena is very worried and contacts her mother immediately.
Check for Understanding
1. What services does this family need?
2. What education and resources need to be provided to avoid tragedy?
Gang violence has collectively decreased in many cities across the country, but it remains a prominent concern, particularly in impoverished and inner-city areas. The definition of a gang is “a group that has three or more members generally age 12-24, who share an identity typically linked to a name, and often other symbols and is involved in an elevated level of criminal activity,” (Jennings-Bey et al., 2015, p. 948). Studies have revealed that primary predictors of gang affiliation include poor parental supervision and monitoring, failure in school and lack of commitment to school/education, and presence of gang activity within the community (O’Brien, Daffern, Chu, & Thomas, 2013). Families should be educated regarding the risk factors associated with gang involvement and provided with advice on how to help adolescents avoid gang affiliation. This may be different for each family, but could include an increase in family involvement, assistance with schoolwork through tutoring, or psychological resources for anxiety and low self-esteem. Families that live within communities that are at an increased risk for gang violence should be educated regarding ways to detect and avoid gang violence. This may include organizing a neighborhood block watch program and reporting suspicions of gang activity to the local police (New Hope of Arizona, Inc., n.d.).
Antonio and Julia live in an impoverished neighborhood. They emigrated from Mexico 3 years ago, and the home they live in is all they can afford at this time. They have four children between the ages of 8 and 15. Antonio and Julia worry because there has been a rise in local gang activity and their eldest son, Donny, has had difficulty doing well in school and making friends. Recently, Donny has been hanging out with a few teenagers who live a few blocks away. Julia is concerned the teenagers may be involved in the gang that is associated with the area. Donny tells his parents he does not want to join a gang and that they have no reason to worry. During a visit to the community health center where the children receive free medical care, Julia shares her worry with the clinic nurse.
Check for Understanding
1. What education can the nurse provide the family?
2. What methods of education could the nurse use?
3. What are some things the family can do to help deter Donny from getting involved with gang activity?
Over the past few decades, there has been an increase in mass shootings across the United States, often resulting in multiple casualties, many injuries, and often a lifetime of devastation for the victims and victims loved ones (Terrades, 2017). According to the Federal Bureau of Investigation, there have been 160 active shooter situations between 2000 and 2013, and approximately 16.7 per year between the years 2008 and 2013 (Maryniak, 2016). It is essential that nurses and all health care professionals take steps to prepare for such an event in their local communities. This involves education regarding response and survival during an active shooter event in every setting, from schools to churches to businesses. This also involves preparing acute care facilities and emergency management to respond to such a crisis and having plans in place that are well thought out and practiced in advance. Educating parents and caregivers regarding gun safety and the importance of keeping guns unloaded and in a locked safe at all times should be reiterated and stressed at every opportunity. Mandatory survival training and education is often being implemented in many workplaces to help employees understand how to respond in the event of an active shooter event in their place of business (Department of Homeland Security [DHS], n.d.; DHS, 2016). The Department of Homeland Security offers several free training handouts and videos for use in educating the public about how to survive active shooter situations.
Marsha and Phillip have two children. Rene is 14 and just starting her freshman year in high school, and Tom is a 12-year-old middle school student. Rene and Tom have had several conversations with their parents about the recent school shootings they have seen on television. Marsha and Phillip are anxious and always feel apprehensive when they say goodbye to their children in the morning before school. One afternoon after school, Rene comes home in tears saying, “I don’t want to go to school anymore, I’m terrified.” The family is frightened and in distress, Marsha and Phillip attempt to console her but feel unsure of how to provide their children with the support they need.
Check for Understanding
1. What education can be provided to help this family?
2. How can the nurse help develop a family plan in case of emergencies for this family?
3. What resources does this family need that the nurse can provide?
Sex trafficking is a disturbing and widespread issue in the United States and throughout the world that is often not publicized or brought to the public’s attention. By definition, sex trafficking “involves the recruitment, harboring, transportation, provision, obtaining, soliciting or patronizing of a person for the purpose of a commercial sex act using force, fraud, or coercion” (Greenbaum, n.d., p. 1). Risks associated with this type of exploitation include poverty, familial violence, family dysfunction, immigration or migrant status, gender bias/discrimination, and objectification of females. Those at risk of Internet exploitation require a wide range of resources and assistance from varying agencies, such as law enforcement, child protective services, mental health and medical professionals, school personnel, and public health professionals to provide the victim with holistic care following such exploitation. Families need to be educated regarding the realities of sex trafficking and warning signs to be aware of in order to help identify victims, prevent new occurrences, and bring offenders to justice. Involvement and supervision is key. Parents should be aware of whom their children are communicating with online and what type of information is being shared with these individuals. Children should be educated regarding the dangers of sharing personal information and the reality of sex trafficking.
Diane is a 16-year-old teenager who lives with her mother and three younger siblings. They live in a two-bedroom apartment in a very low-income area. Diane’s mom works two jobs and is in school part-time, leaving Diane to help with her siblings and around the house a lot. Diane enjoys communicating on social media with her peers. Over the past few weeks, a man named Scott has been talking to her through private message. He is funny and charming and tells Diane about all of the places he visits all around the world and about the other girls he helps travel internationally. He tells Diane that if she would model for his company she could travel and make a lot of money to support her family. This idea excites Diane, and she arranges to meet Scott the following week for an interview. The next day she discloses this information to the school nurse when she goes to get some feminine hygiene products. The nurse needs to develop a plan of care that intervenes and protects Diane from becoming a victim of sex trafficking.
Check for Understanding
1. What does the nurse need to do in this circumstance?
2. What resources does the nurse need to provide?
3. What education needs to be provided to Diane and her family and how should it be delivered?
Bullying within the adolescent community is a growing concern affecting nearly 20-30% of students who admit to being the perpetrator or victim of such harassment (Jantzer, Haffner, Parzer, Resch, & Kaess, 2015; StopBullying.gov, n.d.). Bullying can be defined as “an aggressive behavior that is intentional, repeated, and involves a power imbalance” (Sampasa-Kanyinga, Roumeliotis, & Xu, 2014). As society has changed over the past few decades, the prevalence of bullying and the way in which it occurs has changed drastically. With the advancement of technology and social media platforms, bullying has taken new forms. With such capability, the perpetrator is able to remain anonymous, thus allowing bullies to be much crueler in their approach to hurt their victims (Messias, Kindrick, & Castro, 2014). The use of technology as a method of harassment is considered cyberbullying. Collectively there also seems to be a misunderstanding of the repercussions such harassment actually has on the victims (Messias, Kindrick & Castro, 2014). In addition, media influences such as the television show “13 Reasons Why” as well as the recent celebrity suicides of Chester Bennington and Robin Williams have brought the topic of depression and suicide to center stage for adolescents. In light of these concerning facts, it is evident that intervention is vital to impede this damaging trend. Doing so requires adolescent groups to be educated on the effects of bullying, as well as educating professionals and parents on recognizing the signs and symptoms of depression, bullying, and suicidal ideation.
Jennifer and Marco are married with five children. Jennifer has two children from a previous marriage, Marco has one child from a previous marriage, and together they have welcomed a new set of twins. Recently, Jennifer’s ex-husband, George, told Jennifer that their oldest child, Hannah, who is 12, has been talking about not wanting to go back to school because she is always being teased. Jennifer talks to Hannah, and Hannah reveals that the bullying has been going on for months. Hannah tells Jennifer that the kids who are bullying her somehow got her phone number and text her or call her to say mean things. Hannah tells her mom that she does not want to tell on them because she fears it will only get worse.
Check for Understanding
1. How can the nurse provide education regarding bullying to this family?
2. What resources should be provided to them?
3. What is Hannah at risk for because of this incessant bullying? Why?
4. How can the nurse assess for other issues such as depression or suicidal thoughts and why is this relevant?
The health of the populations around the globe have a definite effect on families throughout the United States and the world. Commonly known diseases such as influenza are not a new occurrence. New and developing strains of the virus cause concern for the efficacy of vaccinations and mortality rates associated with contracting the virus, particularly in more vulnerable populations, such as the very young, those who are immunocompromised, and the very old. Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) remain widespread and require education, resources for their prevention, and early detection and treatment. Other diseases are emerging, such as Ebola, Zika, and methicillin-resistant staphylococcus aureus (MRSA). The effects of decreased rates of vaccinations worldwide are causing the recurrence of once nearly eradicated illnesses such as measles (CDC, 2015).
Prior to the development of the influenza vaccination, many people died because of flu-related complications. Two primary flu strains, Influenza A and Influenza B, are responsible for most cases of flu today. Though contraction and spread of the flu remains prevalent, mortality rates have gone down because of flu vaccinations (CDC, 2017d). Those at risk remain the very young, immunocompromised patients, and the very old. The most effective way to decrease the spread of the flu virus is to receive the influenza vaccination (CDC, 2017d). Families need to be educated regarding the safety and efficacy of the influenza vaccination. Misconceptions, such as the vaccine causing the flu virus, should be discussed. Education should be provided to explain the reality of the safety of the vaccine and how the vaccine works to protect the body from the flu (CDC, 2017d). Other infection prevention advice should also be provided, such as proper hand hygiene and staying home when sick. Receiving prompt treatment and recognition of symptoms are also key to help decrease the spread of the flu virus.
Vivian is a 62-year-old woman who is in the hospital for a right knee replacement. During her preoperative assessment, the nurse discovers she lives with her daughter and 6-month-old grandson. The nurse asks Vivian if she has had the flu vaccination this year, and Vivian replies, “No, I don’t want one. It will give me the flu for sure.” The nurse educates Vivian about the safety and efficacy of the flu vaccine and reiterates its importance, especially given that she lives in a household with an infant who is more susceptible to getting the flu.
Check for Understanding
1. What else can the nurse discuss with Vivian regarding the flu and the flu vaccine and its relation to her grandson?
2. How can the nurse explain the importance of immunizations without upsetting Vivian?
HIV and AIDS is widespread, both nationally and globally, and affects individuals from every socioeconomic background (CDC, 2018e). At one time HIV/AIDS had no treatment, and led to devastating symptoms and decreased lifespan. Today, individuals diagnosed and appropriately treated with antiviral medications are living longer lives with fewer AIDS-related complications (CDC, 2018b). Prevention is the optimal way to address HIV/AIDS, along with sexually transmitted infection (STI), which is why education regarding safe-sex methods is crucial. In addition, those at high risk for contracting HIV/AIDS should be encouraged to be tested in order to provide antiviral treatment early, as well as to advise any previous or current partners who may have been exposed so they can get tested as well.
Those who are at risk of sexual exposure from someone with HIV/AIDS can be offered a preexposure prophylaxis medication (PrEP) in order to reduce the risk of being infected with HIV (CDC, 2018a). Individuals who think they might have been exposed to HIV in a recent sexual encounter can receive a postexposure prophylaxis (PEP), which is an antiretroviral medication (ART) that has been proven to decrease the chance of becoming infected if taken within 72 hours after the sexual encounter (CDC, 2018f)
The CDC has developed several programs that incorporate HIV/AIDS awareness and education. The #DoingIt campaign highlights the importance of being tested for HIV/AIDS. The Talk campaign encourages open conversation regarding prevention of HIV/AIDS among gay and bisexual men, and the HIV Treatment Works campaign highlights the efficacy of HIV treatment (CDC, 2017a).
The school nurse at the local high school has had several parents approach him regarding their teenage children being sexually active. They have come to him seeking support and advice on how to help talk to their children about safe sex and the realities of HIV/AIDS. The school nurse meets with the students and their parents to provide education regarding safe-sex methods, including abstinence and condom use, as well as methods of pregnancy prevention, such as birth control pills. The nurse reiterates that birth control pills do not protect against STIs. The nurse also stresses the realities of STIs like HIV/AIDS and discusses the availability of testing, treatment, and prophylactic medication available to help decrease the risk of contracting HIV.
Check for Understanding
1. What else should be discussed with the parents and the students?
2. What other resources are indicated?
There are different diseases that have developed around the world that have caused concern and anxiety for families. Though the publicity surrounding these diseases is frightening, with the proper education and prevention measures, families can feel reassured and take protective measures for their loved ones. In 2014, an outbreak of Ebola virus in western Africa caused fear and concern worldwide. The transmission of Ebola occurs very quickly and spreads rapidly, and treatment is difficult and the symptoms of the illness often lead to death (CDC, 2018d). Though the disease was largely confined to the continent of Africa, the fear of it spreading to other countries caused a degree of widespread panic (CDC, 2018d). Thought the epidemic is largely contained, the chances of another epidemic of similar nature is something all families should be aware of and feel prepared to deal with (CDC, 2018d). To protect themselves from any infectious disease, families should ensure proper hand washing and sanitation. Nurses can help educate families regarding hand-washing skills and using household cleaning products to clean surfaces and household items that may cause the spread of disease. Nurses can also educate families regarding the importance of staying home when feeling sick, reporting any unusual symptoms to their primary care provider, and disclosing any and all travel to their care providers. Additionally, the importance of having vaccinations that are available for communicable diseases cannot be understated. Though there is no vaccine for the Ebola virus, a fully vaccinated individual is less likely to contract this preventable illness, helping the immune system to fight off diseases.
Misuse and overuse of antibiotics have led to the formation of a wide range of resistant bacteria, such as MRSA, as well as vancomycin-resistant enterococcus (VRE). Antibiotic resistant bacteria can live in the blood, a wound, sputum, or urine and spread through contact with the source of the infection. For example, when an uninfected person is exposed to the blood or urine of the infected person, the uninfected person is at risk for infection. Persons with compromised immune systems, as well as those who spend ample amount of time in communal facilities, such as prisons, nursing homes, day cares, military barracks, and schools, are at higher risk of contracting such infections (CDC, 2016c).
Nurses can provide education to families regarding the preventative steps to take to avoid spread of these resistant infections. The primary focus is on the importance of hand hygiene, keeping any open wounds covered at all times until fully healed, and ways for covering coughs (CDC, 2016c). Families should also be educated about the overuse of antibiotics and the proper use of antibiotics when they are prescribed. Antibiotics are not needed for illnesses such as the common cold that are typically viral and for which antibiotics will have no effect. Primary care providers will make the best decision regarding the administration of antibiotic therapy. When an antibiotic is prescribed, the importance of finishing the entire course of medication prescribed should be reinforced. Symptoms may begin improving before the course of medication is over, but the full treatment should be taken. Doing so decreases the risk of the development of resistant bacteria (CDC, 2017b).
Note. Adapted from “Antibiotic/Antimicrobial Resistance: About Antimicrobial Resistance,” by the Centers for Disease Control and Prevention, 2018.
Note. Adapted from “Enterovirus: What Parents Need to Know,” by HealthyChildren.org, 2015. Copyright 2015 by the American Academy of Pediatrics.
Scientific evidence strongly emphasizes the safety and efficacy of immunizations to prevent diseases (CDC, 2017g). The decision to immunize beginning at birth is not only essential to protect the child’s health, but the health and well-being of the community as well. Without the use of vaccinations, disease would once again become rampant, spreading throughout the country and the globe, causing a massive loss of life (CDC, 2017g). The American Academy of Pediatrics recommends that all children begin vaccination at birth and follow the recommended vaccination schedule in order to ensure full immunity and decrease risk of disease occurrence (HealthyChildren.org, 2016).
The questions raised regarding vaccine safety should be laid to rest with the ample amount of scientific evidence that proves their safety. Vaccinations have a 90-99% efficacy rate, protecting children and teenagers from 16 diseases that would cause devastating repercussions if allowed to spread (HealthyChildren.org, 2016). Once vaccinations are licensed by the CDC and Food and Drug Administration, immunizations are continually reviewed for adverse reactions by the Vaccine Adverse Event Reporting System (VAERS). Nurses are important advocates for patient safety and should strongly encourage parents to follow recommended vaccination guidelines and provide parents with the necessary education to reassure them of vaccination efficacy, importance, and safety.
Parents who choose not to vaccinate their children should be educated regarding the consequences of not doing so. This education includes the dangers of exposing children to communicable diseases that are easily prevented with vaccines. Explanation should be provided highlighting the concept of “community immunity.” In some circumstances, vaccinations may not be safe for patients, such as patients with weakened immune systems or severe allergies. When the majority of the population is vaccinated against communicable diseases, those who are unable to be vaccinated are kept safe (Vaccines.gov, 2017). Scientific evidence should be provided that highlights the safety and efficacy of vaccines and how they protect the patient and the community. Parents should also be informed about school safety and the requirements of vaccinations from preschool to college. Additionally, there are waivers that may be signed excusing children from having vaccines because of religious or personal reasons.
Tanya is a new mother to 3-week-old Xavier. She is at a wellness visit at the pediatrician’s office and expresses some confusion and concern over vaccinations. She tells the nurse that she has a friend who is avidly against vaccinations and has been providing her with a lot of information about how awful they are, and it has made her question whether or not she should vaccinate Xavier. She also says her mother is very much in support of vaccinations and tells her she has to have Xavier vaccinated for his safety and everyone else’s safety. The nurse needs to provide Tanya with education regarding vaccines.
Check for Understanding
1. What should the nurse include in this vaccination education?
2. What are some different approaches the nurse can take to provide such education?
3. Why is this topic such a sensitive one among parents today?
4. How does the nurse approach sensitive subjects such as this?
Disaster preparedness, whether for a natural or man-made disaster, warrants attention. Disasters can strike at any time in any part of the country. Hurricanes, floods, fires, tornadoes, mudslides, monsoons are all examples of natural disasters that require proper planning. Man-made disasters, such as terrorist activity or nuclear detonation, also necessitate proper planning in order to help families retain a sense of clarity in an otherwise chaotic and frightening situation. Planning includes creating a kit with basic necessities in the event of a disaster. This includes items such as bottled water, flashlights, batteries, first-aid kit, and canned or nonperishable food items. The plan also needs to include a discussion of where to take shelter during the event, where to meet if family members are displaced during the event, and proper care of pets if applicable. Families should also take the time to discuss types of disasters with members of the family, including small children. These events can cause a great deal of stress and fear, so discussing what might happen may help to alleviate the fear of the unknown when an event strikes. The nurse can discuss the creation of such a plan and reiterate the importance of planning for the unthinkable before it happens.
Government websites, such as Ready.gov, provide a wide range of knowledge to individuals and families regarding preparation for common emergencies and disaster events. These websites are great resources for nurses to recommend and offer assistance in creating a plan that includes evacuation, safety skills, financial concerns, and what to include in an emergency supply kit (Ready.gov, n.d.). Preparedness is essential, yet often overlooked as a necessity in American society. A recent national survey conducted by Columbia University determined that two-thirds of American households do not have adequate plans for disasters, making the need for preventative plans of action to be instituted into communities all the more necessary (Petkova et al., 2016). The nurse can be helpful in the development of action plans for families in the event of chaos.
June and Lily are the parents of two adopted children, Joseph who is 6, and Sara who is 3. They live in a coastal town in Florida that is frequently the target of hurricanes. The last hurricane season has made them interested in being more prepared for future events. The nurse helps the family create a list of supplies for a family kit and discusses a plan for evacuation, including where the family would go, if time permits.
Check for Understanding
1. What other education can the nurse provide to the family regarding disaster preparedness?
2. What are other things to include in a family disaster plan?
3. What other resources would this family benefit from in regards to disaster management and preparedness?
Health promotion for families during a time when complex concerns continue to arise is crucial to helping families live well. Nurses are instrumental in the fostering of health promotion through education and provision of resources. Personalization for each families’ various needs means addressing cultural differences as well as considering the SDOH that affect the types of resources that may be indicated. The nurse works with the family and the interdisciplinary team to develop an approach that fully meets family needs and enables the patient and the family to take control of their health and wellness.
Acquired Immunodeficiency Syndrome (AIDS): Advanced stage of HIV when HIV has been left untreated, immune system is damaged, and body is left open to opportunistic infections that may lead to death.
Bullying: Unwanted aggressive behavior that involves a real or perceived balance of power, typically seen among school-age children and teenagers.
Child Abuse: “Any act or series of acts of commission or omission by a parent or other caregiver (e.g., clergy, coach, teacher) that results in harm, potential for harm, or threat of harm to a child” (CDC, 2018c).
Family: A complex, diverse, and dynamic societal unit often consisting of parents and children related by legal, genetic, or emotional ties.
Health Education: Any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes (WHO, 2018a, para 1).
Health Promotion: Educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living, and preventive self-care that enables them to improve their health by making positive decisions.
Human Immunodeficiency Virus (HIV): Sexually transmitted virus that, if left untreated, can lead to acquired immunodeficiency syndrome (AIDS); characterized by the reduction in T cells within the immune system, leading to a severely compromised immune system.
Immunizations: Specific disease-fighting medications recommended on a timed schedule per the Centers for Disease Control and Prevention.
Intimate Partner Violence (IPV): Physical, mental, emotional, and/or psychological abuse occurring in people in close sexual or nonsexual relationships
Methicillin Resistant Staphylococcus Aureus (MRSA): A type of staphylococcus bacteria that is resistant to several antibiotics
Sex Trafficking: Involves the recruitment, harboring, transportation, provision, obtaining, soliciting, or patronizing of a person for the purpose of a commercial sex act using force, fraud, or coercion.
Social Determinants of Health (SDOH): Conditions of living, such as housing, socioeconomics, transportation needs, quality of education, that directly affect health and access to health care needs.
Vancomycin-Resistant Enterococcus (VRE): Type of enterococcus bacteria that is resistant to vancomycin.
American Foundation for Suicide Prevention. (n.d.). Suicide statistics. Retrieved from https://afsp.org/about-suicide/suicide-statistics/
Centers for Disease Control and Prevention. (2015). Epidemiology and prevention of vaccine-preventable diseases: Measles. Retrieved from: https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html
Centers for Disease Control and Prevention. (2016a). Drowning prevention. Retrieved from https://www.cdc.gov/safechild/drowning/index.html
Centers for Disease Control and Prevention. (2016b). Protect the ones you love: Child injuries are preventable: Fall prevention. Retrieved from https://www.cdc.gov/safechild/falls/index.html
Centers for Disease Control and Prevention. (2016c). Staphylococcus aureus (MRSA): General information about MRSA in the community. Retrieved from https://www.cdc.gov/mrsa/community/index.html
Centers for Disease Control and Prevention. (2016d). Vital signs: Motor vehicle crash deaths. Retrieved from https://www.cdc.gov/vitalsigns/motor-vehicle-safety/index.html
Centers for Disease Control and Prevention. (2017a). Act against AIDS: Campaigns and materials. Retrieved from https://www.cdc.gov/actagainstaids/campaigns.html
Centers for Disease Control and Prevention. (2017b). Antibiotic prescribing and use in doctor’s offices: Antibiotic resistance questions and answers. Retrieved from: https://www.cdc.gov/antibiotic-use/community/about/antibiotic-resistance-faqs.html
Centers for Disease Control and Prevention. (2017c). Important facts about falls. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
Centers for Disease Control and Prevention. (2017d). Influenza (flu): Misconceptions about seasonal flu and flu vaccines. Retrieved from https://www.cdc.gov/flu/about/qa/misconceptions.htm
Centers for Disease Control and Prevention. (2017e). STEADI – Older adult fall prevention. Retrieved from https://www.cdc.gov/steadi
Centers for Disease Control and Prevention. (2017f). Violence prevention: NISVS infographic. Retrieved from https://www.cdc.gov/violenceprevention/nisvs/infographic.html
Centers for Disease Control and Prevention. (2017g). Why immunize? Retrieved from https://www.cdc.gov/vaccines/vac-gen/why.htm
Centers for Disease Control and Prevention. (2018a). Act against AIDS: PrEP. Retrieved from https://www.cdc.gov/actagainstaids/basics/prep.html
Centers for Disease Control and Prevention. (2018b). Act against AIDS: Prevention is care. Retrieved from https://www.cdc.gov/actagainstaids/campaigns/pic/index.html
Centers for Disease Control and Prevention. (2018c). Child abuse and neglect: Definitions. Retrieved from https://www.cdc.gov/violenceprevention/childabuseandneglect/definitions.html
Centers for Disease Control and Prevention. (2018d). Ebola (Ebola virus disease): Transmission. Retrieved from https://www.cdc.gov/vhf/ebola/transmission/index.html
Centers for Disease Control and Prevention. (2018e). HIV/AIDS: HIV by group. Retrieved from https://www.cdc.gov/hiv/group/index.html
Centers for Disease Control and Prevention. (2018f). HIV/AIDS: PEP. Retrieved from https://www.cdc.gov/hiv/basics/pep.html
Centers for Disease Control and Prevention. (2018g). Violence prevention: Intimate partner violence. Retrieved from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html
Christian, C. W. (2015). The evaluation of suspected child physical abuse. Pediatrics, 135(5), 1337-1354.
Department of Homeland Security. (n.d.). Active shooter preparedness program—Human resources or security professional. Retrieved from https://www.dhs.gov/human-resources-or-security-professional
Department of Homeland Security. (2016). Active shooter preparedness program. Retrieved from https://www.dhs.gov/sites/default/files/publications/dhs-active-shooter-preparedness-program-fact-sheet-01-16-508.pdf
DMV.org. (n.d.). DUI & DWI FAQ. Retrieved from https://www.dmv.org/automotive-law/dui/faq.php
Greenbaum, V. J. (n.d). Child sex trafficking in the United States: Challenges for the healthcare provider. Plos Medicine, 14(11). doi: 10.1371/journal.pmed.1002439
HealthyChildren.org. (2016). Vaccine safety: The facts. Retrieved from https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Safety-The-Facts.aspx
Ho, G. W., Gross, D. A., & Bettencourt, A. (2017). Universal mandatory reporting policies and the odds of identifying child physical abuse. American Journal of Public Health, 107, 709-716.
Jantzer, V., Haffner, J., Parzer, P., Resch, F., & Kaess, M. (2015). Does parental monitoring moderate the relationship between bullying and adolescent nonsuicidal self-injury and suicidal behavior? A community-based self-report study of adolescents in Germany. BMC Public Health, 15(1), 1-8. doi:10.1186/s12889-015-1940-x
Jennings-Bey, T., Lane, S. D., Rubinstein, R. A., Bergen-Cico, D., Haygood-El, A., Hudson, H., & … Fowler, F. L. (2015). The trauma response team: A community intervention for gang violence. Journal of Urban Health, 92(5), 947-954. doi: 10.1007/s11524-015-9978-8
KidsHealth. (2018). Gun safety. Retrieved from https://kidshealth.org/en/parents/gun-safety.html
Maryniak, K. (2016). Active shooter: Know the facts. Retrieved from https://www.rn.com/nursing-news-active-shooter-know-the-facts/
Messias, E., Kindrick, K. & Castro, J. (2014). School bullying, cyberbullying, or both: Correlates of teen suicidality in the 2011 CDC Youth Risk Behavior Survey. Comprehensive Psychiatry, 55(5), 1063-1068. doi: 10.1016/j.comppsych.2014.02.005
New Hope of Arizona, Inc. (n.d.). Take action – What families can do. Retrieved from http://www.newhopeofarizona.com/taking_action.php
O’Brien, K., Daffern, M., Chu, C. M., & Thomas, S. M. (2013). Youth gang affiliation, violence, and criminal activities: A review of motivational, risk, and protective factors. Aggression and Violent Behavior, 18(4), 417-425.
Petkova, E. P., Schlegelmilch, J., Sury, J., Changler, T. E., Duran Herrera, C., Bhaskar, S., … Redlener, I. E. (2016). Children in disasters: Do Americans feel prepared? A national survey. Columbia University Academic Commons. doi: 10.7916/D85M65J9
Rassool, G. H. (2015). Cultural competence in nursing Muslim patients. Nursing Times, 111(14), 12-15. Retrieved from https://www.nursingtimes.net/roles/nurse-educators/cultural-competence-in-nursing-muslim-patients/5083725.article
Ready.gov. (n.d.) Make a plan. Retrieved from https://www.ready.gov/make-a-plan
Safe Kids Worldwide. (n.d.). Poison. Retrieved from https://www.safekids.org/poisonsafety
Sampasa-Kanyinga, H., Roumeliotis, P., & Xu, H. (2014) Associations between cyberbullying and school bullying victimization and suicidal ideation, plans and attempts among Canadian schoolchildren. PLoS ONE 9(7). doi: 10.1371/journal.pone.0102145.
StopBullying.gov. (n.d.). Facts about bullying. Retrieved from https://www.stopbullying.gov/media/facts/index.html#ftn15
Terrades, V. (2017). Mass shootings and offenders’ motives: A comparison of the United States and foreign nations. ILSA Journal of International & Comparative Law, 23(3), 399-423.
Vaccines.gov. (2017). Vaccines protect your community. Retrieved from https://www.vaccines.gov/basics/work/protection/index.html
World Health Organization. (2018a). Health education. Retrieved from http://www.who.int/topics/health_education/en
World Health Organization. (2018b). Health promotion. Retrieved from http://www.who.int/topics/health_promotion/en
Young, J. C., & Widom, C. S. (2014). Long-term effects of child abuse and neglect on emotion processing in adulthood. Child Abuse & Neglect, 38(8), 1369-1381. doi: 10.1016/j.chiabu.2014.03.008