NURS 4211 Week 5 Assignment – Walden
NURS 4211 Week 5 Assignment – Walden
Description: NURS 4211 Week 5 Assignment – Walden
Windshield Survey – Disaster Planning
Disaster Planning for Public Health: Huntington, WV
Huntington, WV, located on the banks of the Ohio River in southwestern West Virginia, is a small, diverse urban community located in Cabell County, WV. The largest city in the tristate region, Huntington’s population of roughly forty-eight thousand (48,000) people makes up slightly more than fifty percent of the county’s ninety-five thousand nine-hundred eighty- seven (95,987) residents (United States Census Bureau, 2016; “Huntington, WV,” n.d.). Huntington is known for its commerce and heavy industrial processing for oil, coal, gas, chemicals, and steel (“Huntington, WV,” n.d.). The city is also the largest inland waterway port in the U.S., making use of Huntington’s intricate railroad systems that run through the heart of the city (“Huntington, WV,” n.d.).
NURS 4211 Assignment – Role of the Nurse Leader in Population Health Essay Paper
Nurses play an important role in promoting public health. Traditionally, the focus of health promotion by nurses has been on disease prevention and changing the behaviour of individuals with respect to their health. However, their role as promoters of health is more complex, since they have multi-disciplinary knowledge and experience of health promotion in their nursing practice. This paper presents an integrative review aimed at examining the findings of existing research studies (1998-2011) of health promotion practice by nurses. Systematic computer searches were conducted of the Cochrane databases, Cinahl, PubMed, Web of Science, PsycINFO and Scopus databases, covering the period January 1998 to December 2011. Data were analysed and the results are presented using the concept map method of Novak and Gowin. The review found information on the theoretical basis of health promotion practice by nurses, the range of their expertise, health promotion competencies and the organizational culture associated with health promotion practice. Nurses consider health promotion important but a number of obstacles associated with organizational culture prevent effective delivery.
What does it mean, really? How does someone promote health? I’m going to address the concept of health promotion from my perspective as a Registered Nurse in Ontario. Nurses play a huge role in illness prevention and health promotion. We, as nurses assume the role of ambassadors of wellness. Yes, I do believe that nurses play just as an important role in caring for the well as they do in caring for the sick. Perhaps caring for the well is the more important role. In this day and age of budget cuts, cost reduction and staffing shortages, health promotion makes sense. If we can preserve wellness, we reduce the number of times a person needs to enter the health-care system, thus reducing costs.
The World Health Organization (WHO) defines health promotion as a process of enabling people to increase control over and to improve their health (WHO, 1986). To facilitate that process, we must provide people with appropriate information. Nurses have a key role in providing that information in the form of health teaching. Nurses are highly educated, experienced health professionals who are accessible through many settings. Telehealth Ontario is a great example of how anyone can access the expertise of a nurse. Anyone can call in with a question, concern or health issue and gain information while being advised of a plan of action right over the phone. Of course, without being able to use hands-on assessment skills, this can be limiting when it comes to dealing with an acute scenario. Telehealth is not for resolving situations that require immediate attention. Nurses can direct people to local resources and give out health and wellness information. Telehealth would be useful when parents seek well-baby/well child information, information on vaccines, smoking cessation, addiction counseling, adolescent mental health resources, nutrition information etc. These are examples of situations where access to accurate health information can assist people in staying healthy.
There are an increasing number of web pages with good health information available to the general public such as the Healthy Ontario website which is run by the Ontario government and has links to various health related resources. We must be aware that internet searching poses the threat of inaccurate, outdated information. Part of the role of a nurse is to assist clients to decide which websites and what information is indeed suitable. Nurses can use the internet resources to expand their knowledge about specific conditions or treatments, retrieve materials to integrate into teaching or to help patients use the internet to self-educate.
When nurses are working within a health promotion model, every interaction with a client can be an educational intervention (Rankin 2005). For example, while changing the dressing of a diabetic foot ulcer, there is the opportunity to discuss blood sugar testing and diabetic control. When in a clinic or doctor’s office, if a patient comes in with a cut, it’s the perfect time to check the chart for the last tetanus booster. During a home visit to discuss newborn care, it is the perfect opportunity for the nurse to discuss the childhood vaccine schedule, recommended vitamin supplements or even the developmental milestones of an older sibling. Nurses are practicing health promotion strategies constantly. Recognition of these subtle yet effective interactions is important in giving credit to the significance of nurses as health promoters.
Everyone will interact with a nurse at some point in their lives. I challenge you to make the most of the expertise of a nurse. Nurses are high level thinkers with exceptional skills and considerable ability to communicate, negotiate, coordinate, and collaborate in order to deliver care (Sullivan, 2004). I am proud to be a part of such a dynamic, caring profession. The next time you are in the presence of a nurse, read a health-care article or are part of a health related discussion, think about nursing and the impact the occupation has on the health and wellness of our society. Ask a nurse a question about his or her career, daily tasks, and routines and ask questions about how he/she can assist you to achieve your goals for health and wellness.
As life expectancy in the United States is declining and the number of people struggling with chronic conditions continues to rise, nurses are everywhere: in our hospitals, schools, businesses, homes, and communities. There are many social, political, and economic influences shaping healthcare delivery today that are expanding the scope of responsibility for the executive nurse leader. The focal point of change is the passing of the Patient Protection and Affordability Care Act (ACA), where there is a clear strategic shift to provide patient care in the right setting with the formation of Accountable Care Organizations (ACOs). Financial reimbursement strategies are being aligned to facilitate these changes. Executive nurse leaders are trying to navigate through these healthcare changes by developing cost-effective care delivery models, supporting the role of the professional and advanced practice nurse, and advocating for the patient. In healthcare reform, this translates to healthcare being delivered in community venues and the executive nurse leader being the advocate for the healthcare needs of the population in the community.
Consistently named as the most trusted health profession, nurses are trained to see each person they care for in the context of his or her life. Regardless of their specific backgrounds or assignments, nurses have a responsibility and obligation to promote public and population health no matter where or how they practice. To truly achieve the best possible health and well-being for everyone in our nation, it is increasingly essential for nurses to play an expanded role.
Stemming from a range of Robert Wood Johnson Foundation (RWJF) programs focused on the nursing profession, this collection includes analysis and perspectives how to more fully leverage nurses in addressing critical public health issues across our nation, and incorporate a stronger population health focus into nursing education and practice.
Public health nursing (PHN) involves working with communities and populations as equal partners, and focusing on primary prevention and health promotion (ANA, 2007). These and other distinguishing characteristics of PHN evolved in the context of historical and philosophical perspectives on health, preventive health care, and the professionalization of nursing. Specifically, these are roles that involve collaboration and partnerships with communities and populations to address health and social conditions and problems.
The focus of this course is on application of theories and concepts from nursing and public health sciences in assessing health status, preventing and controlling disease, and promoting a healthier population by working with families, aggregates, communities, and healthcare systems. Students apply system thinking by using epidemiological and community assessment techniques to examine at-risk populations, health promotion, and levels of prevention with special emphasis on ethnically diverse and vulnerable populations. Major local, state, and national health issues are considered including, communicable disease, chronic illness, environmental and occupational health, bioterrorism, emergency and disaster preparedness and response. Practice experiences provide learning experiences in population-based health promotion by collaborating with interdisciplinary public health partners in a local community.
Public health nursing developed as a distinct nursing specialty during a time when expanding scientific knowledge and public objection to squalid urban living conditions gave rise to population-oriented, preventive health care. Public health nurses were seen as having a vital role to achieve improvements in the health and social conditions of the most vulnerable populations. Early leaders of PHN also saw themselves as advocates for these groups.
In the 21st century, public health nurses practice in diverse settings including, but not limited to, community nursing centers; home health agencies; housing developments; local and state health departments; neighborhood centers; parishes; school health programs; and worksites and occupational health programs. High-risk, vulnerable populations are often the focus of care and may include the frail elderly, homeless individuals, sedentary individuals, smokers, teen mothers, and those at risk for a specific disease.
Contemporary PHN practice, like the practice of early PHN leaders, is often provided in collaboration with several agencies and focused on population characteristics that cross institutional boundaries (Association of Community Health Nursing Education [ACHNE], 2003). PHN practice and roles are defined from, …the perspective, knowledge base, and the focus of care, rather than by the site in which these nurses practice. Even though they are frequently employed by agencies in which direct care is provided to individuals and families, these nurses view individual and family care from the perspective of the community and/or the population as a whole (ACHNE, 2003, p. 10).
…PHN knowledge and competencies prepare nurses to take a leadership role to assess assets and needs of communities and populations… At an advanced level, PHN knowledge and competencies prepare nurses to take a leadership role to assess assets and needs of communities and populations and to propose solutions in partnership. Community- or population-focused solutions can have widespread influence on health and illness patterns of multiple levels of clients including individuals, families, groups, neighborhoods, communities, and the broader population (ACHNE, 2003).
The purpose of this article is to describe evolving roles in the specialty of public health nursing. A brief history of PHN provides a historical and philosophical background for current practice. A model for community participation with ethnographic orientation, and an exemplar of its use in a rural youth substance use prevention project, illustrates current advanced PHN practice. The article concludes with a discussion of essential PHN competencies, evidence that supports evolving PHN roles, and implications for contemporary public health nursing roles.
Brief Background and History of PHN Role
Prevention and curative care have been distinct concepts since ancient times. In Greek mythology, Hygeia was the goddess of preventive health, and her sister Panacea was the goddess of healing (Lundy & Bender, 2001). The notion of health care as healing, or treating those already sick, maintained dominance over preventive care for many centuries. During the mid-19th century however, new scientific understanding of transmission of disease enabled successful sanitation interventions that prevented disease on a large scale.
To carry preventive care forward, district nursing evolved as the first role for public health nurses, and Florence Nightingale concurrently professionalized nursing as an occupation (Brainard, 1922, 1985). Evolving PHN practice required an understanding of how culture, economics, politics, psychosocial problems, and sanitation influenced health and illness and the lives of patients and families (Fitzpatrick, 1975). Public health nursing in the United States (U.S.), England, and other countries quickly grew to include working with vulnerable populations in diverse settings including communities, homes, schools, neighborhoods, and worksites.
The new public health nursing role struggled, and continues to struggle, with appropriate interventions that would achieve quick results, but also leave lasting improvements in the population. With the advent of preventive health care, a moral tension arose between giving resources to the needy, and teaching them how to meet their own needs. Nursing of the acutely ill fits more easily into a model of one-way flow of resources from nurse to patient (Buhler-Wilkerson, 1989). The new public health nursing role struggled, and continues to struggle, with appropriate interventions that would achieve quick results, but also leave lasting improvements in the population. The Christian principle of helping those who help themselves guided this tension, but could not easily resolve it (Brainard, 1922, 1985). Public health nurses were urged to balance “wisdom and kindness” (Buhler-Wilkerson, 1989, p.32). Giving free services or free supplies to the poor was seen as creating dependency and upsetting the natural social fabric of communities. Public health nurses have addressed this moral tension over many years with innovative solutions that seek positive health outcomes, as well as advocate for vulnerable populations.
By the early 1900s, public health nursing roles extended beyond the care of the sick to encompass advocacy, community organizing, health education, and political reform (American Nurses Association [ANA], 2007). Several examples of exceptional PHN initiatives show how these roles improved the health of communities and populations. The visionary work of Lillian Wald’s Henry Street Settlement, started in New York City in 1906, evolved from finding and caring for the sick poor, to advocating and educating about the poor to other organizations. Wald expanded this mission to advocating for new federal agencies and a host of local improvements (Stanhope & Lancaster, 2011).
In the 1920s in Mississippi, Mary Osborne formed a collaborative between public health nurses and African-American (AA) lay midwives to improve perinatal mortality of AA women and babies (Lundy & Bender, 2001). In the 1960s in Detroit, Nancy Milio integrated community organizing, community decision-making, and PHN to develop a maternal-child health center that was highly accepted and even protected by the AA neighborhood during the “Detroit riots” (Milio, 1970). Public health nurses and other community professionals have continued to recognize the advantages of community participatory methods, including the potential for more effective intervention outcomes and capacity-building for long term benefit to the community (Savage et al., 2006).
Community Participatory Health Promotion Model
The community participation and ethnographic model (see Figure 1) is an innovative framework that demonstrates evolving public health nursing practice. It was developed, based on the work of Aronson, Wallis, O’Campo, Whitehead, and Schafer (2007a), by an inter-professional research team from the University of Virginia (UVA), Virginia Polytechnic Institute and State University (Virginia Tech [VT]), and Carilion Clinic (CC) (Kulbok, Meszaros, Bond, Botchwey, & Hinton, 2009) to address youth substance use prevention in a rural tobacco-growing county of Virginia. The community participation and ethnographic model builds on assumptions underlying community-based participatory research (CBPR) and encourages engagement of community members and trusted community leaders in processes from problem identification to project evaluation and dissemination. The CBPR approach is philosophically based in critical and social action theory; it builds partnerships with community members across social-economic status and focuses on community assets and resources rather than on deficits (Israel, Eng, Schulz, & Parker, 2005; Kretzmann & McKnight, 1997). CBPR seeks balance between community members and practitioners or researchers through shared leadership, co-teaching, and co-learning opportunities; it benefits from the expertise of both community members and practitioners or researchers (Anderson, Calvillo, & Fongwa, 2007; Isreal et al., 2005).
Hospitals are taking a stance on patients’ lifestyles since non-medical factors such as social, behavioral and environmental issues have a substantial impact on patient health.Public health nursing (PHN) practice is population-focused and requires unique knowledge, competencies, and skills. Early public health nursing roles extended beyond sick care to encompass advocacy, community organizing, health education, and political and social reform. Likewise, contemporary public health nurses practice in collaboration with agencies and community members. The purpose of this article is to examine evolving PHN roles that address complex, multi-causal, community problems. A brief background and history of this role introduces an explanation of the community participation health promotion model. A community-based participatory research project, Youth Substance Use Prevention in a Rural County provides an exemplar for description of evolving PHN roles focused on community health promotion and prevention. Also included is discussion about specific competencies for PHNs in community participatory health promoting rolesand the contemporary PHN role.
A standard definition of population health emerged from a 2003 report published in the American Journal of Public Health entitled, What is Population Health? In the report, authors David Kindig and Greg Stoddart defined population health as: “Health outcomes of a group of individuals, including the distribution of such outcomes within the group.”Nurses are trained to think holistically, to consider the context of a patient’s life and how that impacts his or her health,” says Paul Kuehnert, DNP, RN, FAAN, assistant vice president for RWJF Program staff, who commissioned the study. Whole care also means assessments of the patient’s healthcare environment, which can include acute, ambulatory, home, behavioral health and community interventions. “Because of the nature of their roles, nurses often spend more face-to-face time with patients, which allows them to gain insight into the community and societal factors that impact patients’ lives and health. Armed with this insight, nurses can work with primary care physicians to help connect patients to resources within the community that can improve their overall well-being.”
This was the definition used by the NACNEP in its 2016 report, “Preparing Nurses for New Roles in Population Health Management.” While it has become the accepted definition of the term, the concept continues to evolve as the role of healthcare professionals is refined.
In 2015, the online publication Healthcare IT Newssought clarity by asking 37 healthcare leaders to offer their personal definitions of population health. The definitions varied, but a consensus emerged around opportunities for health systems, agencies and organizations to work together for better health outcomes in their respective communities.
And that is where the idea of population health begins to be revealed as a practical concept for understanding and meeting the needs of patient communities throughout the nation.
Tech companies have also been stepping into the population health ring. In March 2018, Uber announced Uber Health: a way to partner with healthcare organizations to provide reliable, comfortable transportation for patients. The announcement mentioned that over 100 U.S. healthcare organizations, are already using Uber Health to encourage patients to be more proactive in their care.
As more organizations focus on population health initiatives, healthcare workers adjust their practice to fit those needs. The role of the bedside nurse continues to shift beyond acute care.
Promoting wellness and disease prevention is not new to nurses at the bedside. However, since the Affordable Care Act in 2010, more reimbursement programs are encouraging hospitals to be catalysts in community health engagement. Many U.S. facilities require nurses to be patient health advocates in helping people stay healthy and avoid chronic diseases.
In 2016, the National Advisory Council on Nurse Education and Practice (NACNEP) called for changes in nursing education to better align with a new emphasis away from acute care and toward population health management.
Population health management programs are geared toward closing the gap of health disparities across demographics because of social determinants of health. Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks, according to Healthy People 2020.
Nurses who desire to succeed in health promotion take an active role in educating families and communities to improve their health status. Ordinarily, health promotion activities involve the assessment of individuals, or families and whole communities to plan, implement and evaluate intervention programs.
The best form of health promotion goes beyond education on healthy living to include disease prevention. Nurses use a robust advocacy approach to promoting health by identifying health risk factors in every person’s life. These are the factors that prevent underserved groups of the population from engaging in the health promoting activities. Some of the risk factors are:
- Socio-political factors
Health promotion thrives when people access professional advice from someone who enables them to have more control of their health and improve their wellness. Nurses facilitate the process by providing appropriate information. Many patients get help promotion from nurses as they are the health personnel that they interact with frequently. Nurses are also easy to reach. They trust nurses because they are well educated, experienced and accessible in many settings.
For example, some people rely on telehealth service to call in with questions, concerns or discuss a health issue. Nurses use their experience to offer advice on their phone. For acute cases that require immediate attention, nurses providing telehealth help direct callers to local resources or facilities that can solve their health issues.
When nurses work in the traditional health promotion model, they interact with all sorts of individuals.
Those who want to promote health can do it at every interaction. For instance, a nurse who is changing the dressing on a wound can use the opportunity to inform the patient about the importance of taking a blood sugar test or determine the last tetanus booster from the chart. A home visit to a new mother is a chance to pass information about childhood vaccines, best vitamin supplements and healthy feeding methods for older siblings. Nurses consistently provide health promotion strategies hence are significant promoters.
Nurses play a dynamic and crucial role in healthcare. A nurse is usually the first person a patient interacts with. Nurses are responsible for assessing patients’ needs and diagnosing illnesses. As such, nurses are an integral part of the comprehensive standards of care and health promotion. The World Health Organization (WHO) defines health promotion as “the process of enabling people to increase control over the determinants of health and thereby improving their health.” Before we can examine the role of nurses in health promotion, we must first assess the guiding principles of health promotion.
The three main tenets of health promotion are advocate, enable and mediate. Nurses advocate on behalf of their patients and the community at large by supporting causes that help optimize health, such as nonprofit organizations and educational campaigns. Nurses enable or empower their patients by striving for equal access to healthcare services. Race, gender and ethnicity are important factors to consider. Finally, to promote health for all citizens, nurses play the role of mediator between healthcare providers, governments, businesses and the media. A collaboration between various institutions is the only way to ensure the health of a population.
A comprehensive health education — the use of different learning approaches to help improve health through knowledge and experience — is essential to effective health promotion. Thus, health promotion underpins a nurse’s role within a healthcare setting. Nurses are able to improve their capacity for promoting health in an online RN to BSN program that incorporates health promotion strategies into the curriculum and learning environment.
In 2016, the Centers for Medicare and Medicaid Services announced a 5-year, $157 million test of a payment model called Accountable Health Communities to accelerate the development of a scalable delivery model for addressing upstream determinants of health. Hospitals in lower-income areas have more pressure from Medicaid to enact population health management initiatives. The impact of population health programs is much greater in lower-income urban communities than in suburban counterparts.
Through the practice of health promotion, nurses provide patients the information they need to manage and ultimately improve their health. A nurse’s work environment makes it easy to take advantage of a routine interaction with a patient and use it as an opportunity to educate.
For example, a nurse can educate new parents at their baby’s wellness visit on their child’s upcoming vaccines. Or a nurse can use the time treating a patient’s diabetes-related foot ulcer to review tips and tricks regarding how to best control blood sugar levels. Equipping patients with accurate information, while also advocating for a healthy lifestyle, can help them gain better control of their health.
It can also have a big effect on healthcare costs. With an industry-wide focus on cost reduction and staffing shortages in healthcare facilities, effective health promotion can reduce the frequency with which an individual must seek out treatment.
The Journal of Professional Nursing acknowledged health promotion has become a popular buzzword, and concluded health promotion is aimed at mitigating the determinants of health through community action, action by health professionals and group action.
Health promotion focuses on holistically addressing health issues, as opposed to lecturing individuals concerning habits that are negatively affecting their health. Often, individuals may be aware of health practices they should make habits (exercise) or stop (smoking). However, health promotion is more about ensuring access to the resources needed to improve healthy behavior. On a much higher level, nurses might also be able to advocate for societal changes to reduce resource scarcity that may impede health promotion.
There are a number of conceptual models that attempt to organize the main elements that affect health. Some models list five elements, some six. In general, though, there are six main dimensions of health that comprise most models:
- Biophysical: Physical risk factors for disease, including age, genetics and any anatomical abnormalities
- Psychological and emotional: Coping mechanisms, ability to adapt, level of cognition, and inclination and drive to adapt healthy behaviors
- Behavioral: Lifestyle choices that impact health, whether beneficial, like an exercise regimen or detrimental, like a smoking habit
- Social-cultural: Individual-level attributes like socioeconomic status and support systems, as well as broader social influences including beliefs, practices and values influenced by culture
- Physical environment: Anything in a patient’s environment that may impact health, including water and air quality
- Health systems: A patient’s ability to access healthcare systems, both because of the individual’s willingness to do so and his or her ability to pay for and access appropriate care
As technology continues to develop, educating patients through the practice of health promotion will become easier. Nurses no longer must be face-to-face with their patients in to share information.
Medical technology improvements such as telehealth have expanded patient access to nurses, which allows patients to contact a healthcare professional via phone or a video chat.
When one thinks of health care, notions of treatment and management for existing medical conditions come to mind. A major component of health care, however, also involves the prevention of illness. Known as preventative health care, a number of strategies fall under this banner. A United Healthcare fact sheet details that procedures performed in a doctor’s office, such as physical examinations, drawing blood for testing, immunizations and screenings for certain illnesses can be considered preventative health care measures. This classification is used because the procedures are performed in order to uncover illness in its early stages or to look for signs that may indicate elevated risk for certain conditions.
A health care professional will screen for certain kinds of cancers — colon and breast cancer — as these diseases are typically far easier to treat if they are discovered in their earliest stages, before the onset of symptoms. A primary care provider also may test a patient’s blood sample for evidence of problems that could lead to disease further down the road: High cholesterol and high blood pressure can foreshadow the development of heart disease, for example.
As noted in the United Healthcare article, preventative measures such as screenings, physical examinations and immunizations often are implemented in accordance with demographic factors like age, gender and family history. A fact sheet from the U.S. Centers for Disease Control and Prevention (CDC) detailed one such example, being colorectal cancer, which is widely screened for but only in adults over the age of 50. The CDC suggests the age threshold of 50 because adults younger than this are statistically at a much lower risk for exhibiting with disease.
Texture Health combines deep healthcare and technical expertise to create integrated, advanced and highly-configurable, cloud-based and mobile technology solutions that help providers, health plans, patients and the people who care for them connect, communicate, and collaborate like never before.
We help ACOs, Integrated Delivery Networks, Behavioral Health Collaboratives, Hospitals and Health Systems, Health Plans and MCOs improve patient health and achieve their value-based initiatives, by caring for more patients, in less time, with less resources.
The Interprofessional Student Hotspotting Learning Collaborative is an annual program that trains interdisciplinary teams of professional students from schools around the country to learn to work with complex medical and social needs using a patient-centered approach. Student Hotspotting is part of the Camden Coalition of Healthcare Providers’ effort to educate and provide mentorship for the next generation of health care professionals and is run through the National Center for Complex Health and Social Needs.
- Available WIPs: Foundations of Population Health Science and Practice – Mini Course for Public Health Professionals
Health departments and community-based organizations that operate with public health central to their mission have unique needs, modalities, approaches, regulatory, and public policy contexts to inform their population health improvement efforts. Population health trainings/mini courses that specifically address the unique needs and goals of public health are not universally accessible. There is a need for training that provides high yield information that equips the public health workforce with foundational knowledge in population health science and best practices in population health. The proposed WIP will contribute to the ongoing professional development of the public health workforce by increasing their foundational knowledge of population health science and the effective design, implementation, and evaluation of population health practice activities.
According to the 2015 study Moving From Patient Care to Population Health: A New Competency for the Executive Nurse Leader, the goal in population health management is to keep the patient population as healthy as possible and minimize the need for acute care interventions such as emergency room visits and hospitalizations. If population health initiatives are measured successfully in terms of a reduction in the total cost to the organization, hospitals are rewarded with increased reimbursements.Our task force put together a list of education programs that can help nurses gain the knowledge they need to be visionary thinkers in this new model of care,” Zangerle said. “There are everything from graduate to certificate programs available, and nurses will need to self-determine which class or program would best help them to acquire the knowledge they need to assist in leading PHM efforts.
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