Week 3: Community Level Public Health Nursing Interventions
1. Identify your county public health department in the community in which you reside or nearby.
(I live in Scott County MN, zip code is 55378 – for the online research, or you can let me know if you need any help.)
2. List 5 programs offered by your county public health agency and indicate which specific HP 2030 objectives they address (not topic area).
3. Select one program to explore more in-depth. Describe the program. Why and how was the program started? Identify program objectives or goals/mission and vision.
4. Describe how the program is evaluated. If you cannot locate this information, state how you would recommend the program be evaluated?
5. Analyze how the program is consistent with the public health model (Schoon et al., 2019, p. 155).
6. Identify a HP 2030 objective that you feel is not being addressed by your public health agency.
7. Using the resource list provided in the module or another resource, identify an evidence-based program that you feel could be implemented in your community to address the objective.
8. Identify a possible barrier in local implementation.
9. Who would be your community partners? Identify an entity or agency that may be willing to collaborate on this program.
10. Respond to at least two of your group members. Some thoughts to guide your two responses to your peers: similarities, differences, challenges, rural/urban/ partners, etc.
PART I
Foundational Concepts
for Public Health
Nursing Practi
ce
1 Introduction to Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
2 Evidence-Based Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
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AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model
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3
‘‘
’’
CHAPTER
1Introduction to Public
Health Nursing Practice
n Patricia M. Schoon
with Marjorie A. Schaffer and Jill Timm
Abby will soon be starting her public health nursing clinical and is struggling with the idea of practicing
nursing outside the hospital. She is talking about public health clinicals with Alberto and Sia at lunch.
“I can’t imagine myself out in someone’s home, or in a school, or in a community center or public health
agency. I’m not sure I know what I’m supposed to do. I also wonder how I will be respected without scrubs
or my uniform. Is it really true that one of the most important skills in public health is listening and that
sometimes that is all that you do? I feel like I should be doing something more.”
Alberto responds, “My friend, Zack, had public health last semester. He said that it was interesting to
consider listening as its own intervention. It was hard to not jump in and ‘teach’ immediately. He often
wanted to do more. After a while, he started to get comfortable and also started to understand the benefits
of really trying to understand the perspectives of clients in the community.”
Sia comments, “I worry about all of this too. I was talking with Jen, a friend of mine who took public
health last year. She said that on her first home visit, she went with her public health nursing preceptor.
This gave her a chance to get a sense for the family’s needs and possible interventions.”
Abby says, “I am really worried about being out alone. I wonder what the neighborhood where my
family lives will be like and whether I will be safe.”
Sia states, “I’m also curious about the various public health nursing roles that we may be able to
observe or do. It seems like the field is so broad and there are so many things to consider.”
ABBY’S NOTEBOOK
USEFUL DEFINITIONS
Client: A client (syn. patient) is the individual/family, community, population or subpopulation, or system that is
the public health nurse’s focus of care.
Community: A community can refer to (a) a group of people or a population group, (b) a physical place and time
in which the population lives and works, or (c) a cultural group that has shared beliefs, values, institutions, and
social systems (Dreher, Shapiro, & Asselin, 2006, p. 23).
Health Determinants: Health determinants are factors that influence the health of individuals, families, and
populations. Health determinants can potentially have a positive (protective factors) or negative (risk factors)
influence on health.
Health Status: Health status refers to the level of health or illness and is the outcome of the interaction of the
multiple health determinants. Health status indicators, also called global measures of population health, include
birth, longevity, and death rates (mortality); illness (morbidity) patterns; perception of wellness and life satisfac-
tion; level of independence; and functional ability.
(continues)
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4 PART I n Foundational Concepts for Public Health Nursing Practice
USEFUL DEFINITIONS (continued)
Holistic Nursing: Holistic nursing is defined as “all nursing practice that has healing the whole person as its goal
and honors relation-centered care and the interconnectedness of self, others, nature, and spirituality; focuses on
protecting, promoting health and wellness…” (Dossey & Keegan, 2016, p. 3).
Levels of Prevention: The levels of prevention comprise a health-intervention framework applied to the stages of
health and disease for individuals and groups (Leavell & Clark, 1958; Stanhope & Lancaster, 2008). The levels of
prevention are (a) primary—the prevention of disease and promotion of health; (b) secondary—early diagnosis
and treatment; and (c) tertiary— limiting of negative effects of disease and restoring of function.
Population: A population is defined as the “total number of people living in a specific geographic area.”
A subpopulation (syn. group or aggregate) “consist[s] of people experiencing a specific health condition;
engaging in behaviors that have potential to negatively affect health; or sharing a common risk factor or ris
k
exposure, or experiencing an emerging health threat or risk” (American Nurses Association [ANA], 2013, p. 3).
Population-Based Practice: Population-based practice focuses on the population as a whole to determine its
priority needs (Minnesota Department of Health [MDH], 2001).
Public Health: Public health refers to all organized measures (whether public or private) to prevent disease,
promote health, and prolong life among the population as a whole (World Health Organization [WHO], n.d.).
Public Health Nursing: Public health nursing is the practice of promoting and protecting the health of popula-
tions using knowledge from nursing, social, and public health sciences. Public health nursing is a specialty prac-
tice within nursing and public health. It focuses on improving population health by emphasizing prevention and
attending to multiple determinants of health. Often used interchangeably with community health nursing, this
nursing practice includes advocacy, policy development, and planning, which addresses issues of social justice
(American Public Health Association [APHA], Public Health Nursing Section, 2013, p. 1).
Social Determinants of Health: The social determinants of health are the conditions in which people are born,
grow, live, work, and age. The distribution of money, power, and resources at the global, national, and local levels
shape these circumstances. The social determinants of health are mostly responsible for health inequities—
the unfair and avoidable differences in health status seen within and between countries (Modified from
WHO, 2013).
System: A system is an institution or organization that exists within one or multiple communities.
ABBY’S NOTEBOOK
Practicing Nursing Where We All Live
Public health nursing care is provided to individu-
als, families, communities, and populations through a
population-based lens that enables nurses to view their cli-
ents within the context of the community in which they and
their clients live . All aspects of the client’s life are considered
as public health nurses (PHNs) carry out the nursing pro-
cess . PHNs practice in their communities, where they can
make a difference in the lives of their families, the people
they serve, and their communities on a daily basis .
As you practice nursing in a variety of clinical settings,
you will become aware that the health of people in your
families, neighborhoods, and communities affects every-
one in the community both socially and economically .
As you read this chapter, consider the concepts presented
from both your personal and professional perspectives . As
nurses, you are all citizens of the world and have civic and
professional responsibilities to promote health and provide
for a safe environment .
In the case study at the beginning of the chapter, Abby
and her friends are concerned about providing nursing
care in the community . It is difficult for nursing students
to think about practicing nursing outside the acute and
long-term care settings . Many of the skills that nursing stu-
dents learn in the acute or long-term care setting (e .g ., IV
therapy, medication administration, tube care) are part of
the delegated medical functions of nursing practice, which,
by necessity, are priorities when caring for acutely ill, frail,
and elderly individuals . In the community setting, most of
what PHNs do is part of the independent practice of nursing
(e .g ., teaching, counseling, coordinating care), as the focus
of public health nursing practice is primary prevention .
Components of public health nursing can be practiced in
any setting, although they are most often practiced in the
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5CHAPTER 1 n Introduction to Public Health Nursing Practice
whole to determine the community’s priority health needs
(Minnesota Department of Health [MDH], Public Health
Nursing Section, 2000, 2001; MDH, Center for Public Health
Nursing, 2003) . PHNs in a variety of work settings can carry
out population-based practice . To be population based, pub-
lic health nursing practice should meet five criteria:
1. Focus on entire populations possessing similar health
concerns or characteristics
2. Be guided by an assessment of population health
status that is determined through a community
health assessment process
3. Consider the broad determinants of health
4. Consider all levels of prevention, with a preference
for primary prevention
5. Consider all levels of practice (individual/ family,
community, system) (MDH, 2001, pp . 2–3;
MDH, 2003)
PHNs work in homes, clinics, schools, jails, businesses,
religious organizations, homeless shelters, camps, hospitals,
visiting nurse associations, health departments, and Indian
reservations . Public health nursing is defined by its goals,
not by its setting . Although public health nursing is con-
sidered a specialty area of practice, its standards include
expectations for entry-level baccalaureate nursing gradu-
ates . Even at the entry level, PHNs are expected to function
as change agents and to help shape the healthcare system
to meet the public health needs of the 21st century . This
leadership expectation for public health nursing practice is
implicit in the American Nurses Association’s Public Health
Nursing: Scope and Standards of Practice (ANA, 2013) . The
American Public Health Association (APHA) definition of
public health nursing, “the practice of promoting and pro-
tecting the health of populations using knowledge from
nursing, social, and public health sciences” (APHA, 2013,
p . 2), implies the importance of the scientific knowledge
base for PHN practice .
community . Not all nursing practiced in the community
can be described as public health nursing . For example,
home care and hospice care, both very important areas of
nursing, are practiced in the community and exhibit com-
ponents of public health nursing but are not traditionally
categorized as public health nursing . As you work through
this book and engage in nursing activities, think about how
you are integrating the components of public health nursing
into your nursing practice . Also, think about how you prac-
tice nursing where you live and what your civic and pro-
fessional responsibilities are to promote the health of your
community .
Public
Health
The practice of public health nursing includes components
of public health and is a part of the broader field of public
health . It is important to understand the nature and scope
of public health practice . Public health practice focuses on
protecting and promoting the health of entire populations .
This practice includes the prevention of disease and injury
and the promotion of the social conditions and lifestyles
that maintain health and prolong life .
Public health professionals monitor and diagnose the
health concerns of entire communities and promote healthy
practices and behaviors to ensure that populations stay
healthy . The World Health Organization uses the term
“global public health” to recognize that, as a result of glo-
balization, forces that affect public health can and do come
from outside state boundaries . Responding to public health
issues now requires paying attention to cross-border health
risks, including access to dangerous products and environ-
mental change (WHO, n .d .) . PHNs need to take a global
perspective about the nature of population health threats
and issues when practicing in the community .
Public Health Nursing
Public health nursing combines the theory and practice
of nursing and public health . Public health nursing, like
nursing practice everywhere, involves the interaction of the
nurse and client; the health of the client; the influence of the
home, healthcare, and community environment; and the
nursing care provided . One of the unique features of pub-
lic health nursing is that the client can be an individual or
family, a group of people, or a whole community . The client
could also be a system within the community (e .g ., a school,
church, or community health or social service agency) .
PHNs work to improve population health at the local, state,
national, and international levels (ANA, 2013; APHA, 2013) .
Public health nursing goals are to promote and preserve
the health of populations and the public, prevent disease
and disability, and protect the health of the community as
a whole .
Public health nursing practice is considered population-
based because it starts by focusing on the population as a
Definition of Public Health Nursing Practice
Up to this point in your nursing education, you have focused
on nursing care of individuals and families. Public health
nursing is population based and focuses on population
health. “Public health nursing is the practice of promoting
and protecting the health of populations using knowledge
from nursing, social, and public health sciences. Public
health nursing is a specialty practice within nursing and
public health. It focuses on improving population health by
emphasizing prevention, and attending to multiple deter-
minants of health” (APHA, 2013, p. 1). While public health
nursing practices include primary, secondary, and tertiary
prevention, the focus is on primary prevention.
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6 PART I n Foundational Concepts for Public Health Nursing Practice
in 1881 (Kulbok, Thatcher, Park, & Meszaros, 2012; Kub,
Kulbok, & Glick, 2015; see Figure 1 .1) . PHNs saw themselves
not only as caregivers but also as advocates for those living
in unhealthy conditions and experiencing unmet health-
care needs . Care of the ill soon expanded to care of those
at risk for poor health and to populations and entire com-
munities . Disease prevention and health promotion for vul-
nerable or at-risk populations in diverse settings became a
second focus .
Until the late 1960s, PHNs working for governmental
public health agencies generally provided services to two
at-risk populations: mothers and children, and adults living
at home with chronic diseases and disabilities . When Medi-
care legislation was enacted in 1966, home care became a
covered service, and private agencies began to offer home
care services (see Chapter 7) . Many public health agencies
renewed their commitment to the goals of health promotion,
disease prevention, and protection and risk reduction, and
they stopped providing home care to adults with chronic
diseases and disabilities . PHNs increased their efforts to
address the social determinants of health, which are dis-
cussed later in this chapter . Today, public health nurses
often work with community groups as well as individuals
and families . Community engagement, population-based
advocacy, collaboration with other community agencies
and groups, and community organizing are all part of the
scope of practice of public health nurses (see Chapters 2, 5,
and 10) . At the same time, nurses practicing in a variety of
non-traditional public health settings (e .g ., home care, hos-
pice, faith-based nursing, institutional and insurance care
coordination and care management, etc .) use public health
nursing principles and public health interventions in their
practice .
Emerging threats to public health require a dramatic shift
in the focus of healthcare, public health, and public health
nursing . ANA (2013, p . 2) has identified six 21st- century
threats that form a context for the current and future direc-
tions of public health nursing practice:
1. Reemergence of communicable disease and increas-
ing incidence of drug-resistant organisms
2. Environmental hazards
3. Physical or civic barriers to healthy lifestyles (e .g .,
food “deserts”)
4. Overall concern about the structure and function of
the healthcare system
5. Challenges imposed by the presence of modern
public health epidemics, such as pandemic influenza,
obesity, and tobacco-related diseases and deaths
6. Global and emerging crises with increased opportu-
nities for exposure to multiple health threats
Nursing continues to expand its leadership role in
healthcare in all settings, but in public health nursing, that
leadership role often takes place in the community, includ-
ing in the public policy–making arena (ANA, 2003, 2013) .
As students, you have already learned about nursing
core concepts that also shape public health nursing, which
include (Keller, Strohschein, & Schaffer, 2011):
n Care and compassion
n Holistic and relationship-centered practice
n Sensitivity to vulnerable populations
n Independent nursing practice
This book also introduces you to additional public health
core concepts that shape public health nursing, which
include (Keller et al ., 2011):
n Social justice
n Population focus
n Reliance on epidemiology
n Health promotion and prevention
n The greater good
n Long-term commitment to community
Evolution of Public Health Nursing
In this chapter, you will read about how nurses practice pub-
lic health nursing in the community, and you will consider
how important nurses are to the health of communities at
the local, national, and international levels . It is important
to mention two key founders of public health nursing . Since
the time of Florence Nightingale, the first public health
nurse, nurses have always been essential participants in
improving and maintaining the health of individuals, fami-
lies, and communities . Nightingale, who started her nursing
career in 1850, provided leadership for the health of vulner-
able populations by advocating for changes in the organiza-
tions and communities that were responsible for providing
healthcare (Selanders & Crane, 2012) . Nightingale focused
on managing the environment of those who needed care,
whether it was on the Crimean War battlefields or work-
ing with the London poor . Her concerns about the impact
environmental conditions had on health and her work to
advocate for healthful environments is as relevant today as
it was in the 1800s (Davies, 2012) . Lillian Wald, the founder
of modern-day public health nursing, founded the Henry
Street Settlement in 1893 to provide nursing services to the
indigent citizens of New York . In 1903, Wald, in collabo-
ration with Metropolitan Life, started the first insurance
reimbursement for nurse home visiting and demonstrated
its effectiveness (Abrams, 2008; Buhler-Wilkerson, 1993) .
The Henry Street Settlement House continues to provide
health and social services today .
Public health nursing in the United States developed out
of a need to provide nursing services to individuals and
families who had unmet health needs, and started with
Clara Barton, who founded the American Red Cross as a
response to the needs of injured and ill Civil War soldiers
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7CHAPTER 1 n Introduction to Public Health Nursing Practice
‘‘
’’
Cornerstones of Public Health Nursing
The Cornerstones of Public Health Nursing (Minnesota
Department of Health [MDH], Center for Public Health
Nursing, 2007) provide the foundation for population-based
nursing practice (Keller et al ., 2011) . The Cornerstones reflect
the values and beliefs that guide public health nursing prac-
tice, and they are also closely related to the ANA Principles
of Public Health Nursing Practice (ANA, 2013), as repre-
sented in Table 1 .1 .
These Cornerstones are reflected in PHNs’ daily practice
when they:
n Organize their workload and schedule based on priority
health needs of clients and comm
unity
n Take time to establish trust when visiting families in
their homes
n Carry out holistic assessments of individuals and
families within the context of culture, ethnicity, and
communities
n Use evidence-based practice from nursing and pub-
lic health sciences to select appropriate and effective
interventions
n Collaborate with other members of the healthcare team
n Make critical decisions about the needs of their clients
and the selection, implementation, and evaluation of
interventions based on their professional knowledge and
professional licensure
A key principle to keep in mind is that PHNs must place
more importance on goals related to the public good than
goals for the benefit of individuals in the social and eco-
nomic systems (see Chapter 13 for a discussion of social jus-
tice and Chapter 14 for a discussion of public health nursing
leadership) .
“I still don’t really understand how we are going to factor in
community or environmental needs when we are working
with individuals.” Albert sighs.
Sia responds, “What I remember from our public health
theory class this morning is that even though we are meet-
ing people in their homes, we have to take into account the
home environment and the community. Our instructor
also talked about public health nurses having a responsibil-
ity to improve the health of the public at the local, national,
and international levels. She mentioned that this idea can
be overwhelming for nursing students and suggested that
we focus on what we could do to improve the health of indi-
viduals and families as a way to help improve the health of
our community. She used the term ‘glocal,’ which means to
think global, but act local.”
Abby adds, “Maybe we should read more about this in
our textbook and look at some of the websites suggested.”
“Good idea,” says Sia.
FIGURE 1.1 Public Health Nursing in the United States
Sources: Abrams, 2008; Buhler-Wilkerson, 1993; Kub, Kulbok, & Glick, 2015;
Visiting Nurses Association of Western New York, n.d.
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8 PART I n Foundational Concepts for Public Health Nursing Practice
‘‘
’’
and developmental delays. Abby’s PHN preceptor modifies
her home-visiting plan for the day so that she can make
an initial visit to this family at the local family homeless
shelter. The family speaks Spanish but the PHN does not, so
she arranges for an interpreter to accompany them on the
visit to this family. The PHN has Abby gather information
about local homeless shelters and food banks to take to the
visit and has her get some bus passes for the family to use
when they go to different agencies to apply for assistance.
The PHN also brings along important phone numbers so
that she can assist the family with follow-up regarding their
application for cash assistance. After her busy day with her
PHN preceptor, Abby discusses her visit to the homeless
family with Alberto and Sia that evening. Their instructor
has challenged them to identify the Cornerstones of Public
Health Nursing found in their clinical visits that day.
Activity
Keep a log of your nursing activities. Reflect on how you have
demonstrated the cornerstones of public health nursing in your
clinical activities.
Abby is spending the day with her PHN preceptor. Her pre-
ceptor receives a referral to visit a family who just moved
into the community and is homeless. The PHN knows
that a health priority for her community and agency is to
improve the health of homeless populations, particularly
those in the population with young children. Recent data on
the health needs of her county demonstrate that young chil-
dren in homeless families have higher rates of malnutrition
TABLE 1.1 Cornerstones of Public Health Nursing and Related ANA Principles of PHN Practice
Cornerstones of Public Health Nursing ANA Principles of Public Health Nursing Practice
Focuses on the health of entire populations The client or unit of care is the population .
Reflects community priorities and needs The primary obligation is to achieve the greatest good for the greatest
number of people or the population as a whole (also related to the
social justice cornerstone) .
Establishes caring relationships with communities,
systems, individuals, and families
NA
Is grounded in social justice, compassion, sensitivity to
diversity, and respect for the worth of all people, especially
the vulnerable
A public health nurse is obligated to actively identify and reach out to
all who might benefit from a specific activity or service .
Encompasses mental, physical, emotional, social, spiritual,
and environmental aspects of health
Public health nursing focuses on strategies that create healthy envi-
ronmental, social, and economic conditions in which populations
may thrive .
Promotes health through strategies driven by
epidemiological evidence
Optimal use of available resources and creation of new evidence-
based strategies is necessary to ensure the best overall improvement
in the health of the population .
Primary prevention is the priority in selecting appropriate activities .
Collaborates with community resources to achieve those
strategies but can and will work alone if necessary
Public health nurses collaborate with the client as an equal partner .
Collaboration with other professions, populations, organizations, and
stakeholder groups is the most effective way to promote and protect
the health of the people .
Derives its authority for independent action from the
Nurse Practice Act
NA
Sources for Cornerstones: Keller et al ., 2011; MDH, Center for Public Health Nursing, 2007
Source for ANA Principles: ANA, 2013, pp . 8–9
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9CHAPTER 1 n Introduction to Public Health Nursing Practice
Holistic Foundations of
Public Health Nursing
Public health nursing and holistic nursing practice have
common roots . Florence Nightingale, who believed in care
that focused on unity, wellness, and the interrelationship of
human beings and their environment, is considered to be
one of the first holistic nurses . She is known for her global
vision, leadership, and advocacy (Beck, 2010; Dossey &
Keegan, 2016; Selanders & Crane, 2012) . Lillian Wald was
as concerned about the health of the indigent of New York
as she was about their social welfare, the tenement envi-
ronment in which they lived, and the cultural and political
environment that needed to change in order to improve the
health of her clients and her community (Buhler- Wilkerson,
1993) . Both Nightingale’s and Ward’s nursing practices have
informed contemporary holistic public health nursing
practice .
A contemporary nursing theory that reflects the synthe-
sis of nursing and public health and reflects holistic pub-
lic health nursing practice is Watson’s Theory of Human
Caring, in which the nurse and the client exist within a
caring-healing environment . Watson was greatly influenced
by the practice of Florence Nightingale and built upon Night-
ingale’s work in emphasizing the “curative factors” of dis-
ease and illness, embracing the wholeness of the individual .
The Theory of Human Caring reflects an expansive sharing
process that changes the self, others, the culture, and the
environment; respects the beliefs of others; and recognizes
and is open to unexpected life events (Parker & Smith, 2010;
Watson, 2008, p . 34, 2010) . Some of the public health nursing
theoretical perspectives that you will find in later chapters
reflect this synthesis of public health nursing and holistic
nursing into holistic public health nursing practice .
Scope and Standards of
Public Health Nursing Practice
All professional nurses, regardless of their clinical areas of
practice, have a scope of practice . A scope of practice refers
to the boundaries of safe and ethical practice (see Chapter 6
for a discussion of the scope of practice of public health
nursing) and depends on four components: educational
preparation, credentials, state licensure law, and clinical or
employer role description . A PHN’s job description is a good
measure of the nurse’s scope of practice .
Professional nurses are also guided by standards of prac-
tice developed by their professional nursing organizations .
One nationally accepted set of standards for public health
nursing is the American Nurses Association (ANA) publi-
cation Public Health Nursing: Scope and Standards of Prac-
tice (2013); Table 1 .2 lists these standards . Specific criteria
for operationalizing these standards and measuring perfor-
mance are included in the publication .
TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance
Standards of Public Health Nursing Practice
Standard 1. Assessment: The public health nurse collects comprehensive data pertinent to the health status of populations .
Standard 2. Population Diagnosis and Priorities: The public health nurse analyzes the assessment data to determine the diagnosis
or issues .
Standard 3. Outcomes Identification: The public health nurse identifies expected outcomes for a plan specific to the population or
issues .
Standard 4. Planning: The public health nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes .
Standard 5. Implementation: The public health nurse implements the identified plan .
Standard 5A. Coordination of Care: The public health nurse coordinates care delivery .
Standard 5B. Health Teaching and Health Promotion: The public health nurse employs multiple strategies to promote health and a
safe environment .
Standard 5C. Consultation: The public health nurse provides consultation to influence the identified plan, enhance the abilities of
others, and effect change .
Standard 5D. Prescriptive Authority: Not applicable .
Standard 5E. Regulatory Activities: The public health nurse participates in the application of public health laws, regulations,
and policies .
Standard 6. Evaluation: The public health nurse evaluates progress toward the attainment of outcomes .
Standard 7. Ethics: The public health nurse practices ethically .
(continues)
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10 PART I n Foundational Concepts for Public Health Nursing Practice
Standards of Professional Performance
Standard 8: Education: The public health nurse attains knowledge and competence that reflect current nursing practice .
Standard 9. Evidence-based Practice & Research: The public health nurse integrates evidence and research findings into practice .
Standard 10. Quality of Practice: The public health nurse contributes to quality nursing practice .
Standard 11. Communication: The public health nurse communicates effectively in a variety of formats in all areas of practice .
Standard 12. Leadership: The public health nurse demonstrates leadership in the professional practice setting and the profession .
Standard 13. Collaboration: The public health nurse collaborates with the population and others in the conduct of nursing practice .
Standard 14. Professional Practice Evaluation: The public health nurse evaluates her or his own nursing practice in relation to
professional practice standards and guidelines, relevant statutes, rules, and regulations .
Standard 15. Resource Utilization: The public health nurse utilizes appropriate resources to plan and provide nursing and public
health services that are safe, effective, and financially responsible .
Standard 16. Environmental Health: The public health nurse practices in an environmentally safe, fair, and just manner .
Standard 17. Advocacy: The public health nurse advocates for the protection of the health, safety, and rights of the population .
Source: American Nurses Association, 2013, pp . 28–64
TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance (continued)
Activity
n Review your preceptor’s job description with your preceptor.
n Share the list of the ANA practice standards for public
health nursing.
n Discuss how your preceptor’s job description and nursing
practice incorporate specific ANA standards.
Global Nature of Public Health Nursing
Public health nurses are citizens of the world as well as
their own communities . Travel, communication technol-
ogy, immigration patterns, the global spread of disease, and
the universality of the social determinants of health in all
geographic areas and cultures have changed the nature of
public health nursing practice .
In 2015, the United Nations (UN) General Assembly
adopted resolution 70/1. Transforming Our World: The 2030
Agenda for Sustainable Development (2015) . This resolution
addresses the social determinants of health at a global level
and sets out an action plan for people, the planet, prosper-
ity, peace, and partnership . This action plan identifies 17
Sustainable Development Goals (SDGs) . These goals, repre-
sented by the following set of icons (see Figure 1 .2), provide
a framework for the public health nursing practice wherever
PHNs practice . Examples of how SDGs are addressed will
be highlighted throughout the chapters of this book .
EVIDENCE EXAMPLE 1.1
Health in All Policies
In 2017, an International Health in All Policies Conference
was convened in Adelaide, Australia to strategize over how
to make progress in achieving the SDGs. A major outcome
of the conference was Health in All Policies: Governance, Part-
nerships and the Sustainable Development Agenda, Adelaide
Statement II on Health in All Policies 2017.
The statement stresses that:
n “Health is a political choice, and as such any political,
economic, social and ecological decision has health and
equity impacts. Mayors play a critical role in agenda
2030 and health.
n The SDGs are indivisible and universal and should not
be addressed in silos but rather through taking into
consideration their interconnectedness.
n The transformative strategies for implementing the
SDGs require joint action and policy coherence through
the various levels of the government. Thus, health
literacy is critical to good governance” (WHO, 2017).
As nurses who care about the social environment in
which you and the populations you serve live, you need to
consider how your nursing practice fits into both the SDGs
and the Health in All Policies approach within your local,
national, and global communities .
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11CHAPTER 1 n Introduction to Public Health Nursing Practice
Ethnic diversity in the community requires a complex ethi-
cal framework that includes the complementary approaches
of rule ethics, virtue ethics, and feminist ethics (Racher,
2007; Volbrecht, 2002) .
Rule ethics uses a framework of guiding principles
for decision-making (Racher, 2007) . Examples of rules
or principles include autonomy, beneficence (promoting
good), nonmaleficence (preventing harm), justice, loyalty,
truth-telling, and respect (Aiken, 2004; Beauchamp & Chil-
dress, 1979; Purtilo, 2005; Scoville Walker, 2004) . Rule eth-
ics is based on a biomedical model of decision-making .
In contrast, virtue ethics is based on good character
(Racher, 2007) . One’s actions are evaluated in the context
of one’s community . Examples of nursing virtues include
compassion, honesty, courage, justice, self-confidence, resil-
ience, practical reasoning, and integrity (Volbrecht, 2002) .
Feminist ethics focuses on building relationships and
reducing oppression in society (Volbrecht, 2002) . Key values
in a feminist ethics approach are inclusion, diversity, partic-
ipation, empowerment, social justice, advocacy, and inter-
dependence (Racher, 2007) . Table 1 .3 provides additional
explanations about these three ethical approaches .
This three-pronged ethical approach is used throughout
the book to highlight ethical concerns and principles related
to specific public health nursing competencies .
Ethical Framework for
Public Health Nursing
The ever-changing healthcare environment, complex health-
care systems, and technological changes require a dual
approach according to Ivanov and Oden (2013) . They recom-
mend that PHNs employ a rights-based approach consistent
with the Universal Declaration of Human Rights passed by
the United Nations (UN) in 1948 (United Nations, 1948) and
an ethical approach based on ethical standards for nursing
practice published by the American Nurses Association . The
International Council of Nurses (ICN), in its position state-
ment on Nurses and Human Rights (2011; p . 1), states that “all
human rights are interdependent and indivisible and that
individuals’ health and wellbeing can be harmed when their
human rights in any category are violated .”
Other authors propose a complementary ethical frame-
work that addresses the diversity of client populations and
settings . PHNs might experience ethical problems when
they have to consider the impact or benefits and burdens
of their decisions on multiple clients, population groups,
and communities (Racher, 2007) . Culturally diverse soci-
eties and communities might have moral standards differ-
ent from each other’s and from those of the PHNs, which
could lead to conflicts between the PHNs and clients .
FIGURE 1.2 UN Sustainable Development Goals With Icons
Source: United Nations General Assembly, 2015
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12 PART I n Foundational Concepts for Public Health Nursing Practice
’’
‘‘
The Cornerstones, health determinants framework, and
levels of prevention are included in this chapter . The pub-
lic health nursing process and Public Health Intervention
Wheel are discussed in Chapter 2 . In the United States,
PHNs and other public health professionals who work for
governmental public health agencies have a scope of prac-
tice that is based on identified core public health functions
and the essential services of public health (IOM, 1988) . Chap-
ter 7 discusses the responsibility and accountability of PHNs
who work in governmental agencies .
“Well, this is all very interesting. But I still don’t have a clue
how I am actually going to practice public health nursing,”
Albert sighs.
Sia responds, “I’m realizing that there are a variety of
roles in public health nursing. Some PHNs might spend
their time working with individual families, but they still
have to consider global impacts on health. Our instruc-
tor told us we would be practicing at the individual/fam-
ily level of practice during most of our clinical time. But, I
know we still need to consider how basic human rights are
impacted by public health nursing work. There are a lot of
good internet videos on human rights. I suppose we could
look at them. And there is additional information in the
textbook itself.”
Abby states, “Great! But I think I want to spend more
time actually doing something. I am going to spend a day
with my preceptor tomorrow. Maybe I can apply some of
what I have read and watched on the web.”
Practicing Public Health Nursing
As a student, you will probably be spending most of your
clinical hours working with individuals and families . How-
ever, the role of the PHN is broader; PHNs also spend time
working with community groups and other members of the
community team . Public health nursing is carried out at
different levels of practice within society: individual/family,
community, and systems (MDH, 2001, pp . 4–5) .
Individual/Family Level of Practice
PHNs work with individuals and families to promote health
and reduce risks . The family is the essential unit of all com-
munities and societies . A family is defined as a social unit
of two or more people who identify themselves as a fam-
ily, share emotional bonds, and carry out the functions of a
family, including managing healthcare (Clark, 2008; Fried-
man, Bowden, & Jones, 2003; Martin, 2005) .
PHNs work with individuals and families in many differ-
ent community settings (see Chapter 3 for information on
TABLE 1.3 Ethical Framework for
Public Health Nursing Practice
Rule Ethics
n Rule ethics defines rules or principles that are based on
perceptions of fairness .
n Ethical principles are standards of conduct that guide
behavior and specify moral duties and obligations
(Racher, 2007) .
n Community rights might be given priority over individual
rights in some situations .
n Resources are given based on need and thus might be
distributed unequally (distributive justice) .
n Those who have been unfairly burdened or harmed are
compensated (compensatory justice) .
Virtue Ethics
n Virtue ethics identifies characteristics of the individual
(moral agent) and that person’s intentions and behaviors .
n An individual is responsible for developing good character
and good community (Volbrecht, 2002) .
n This type of ethics provides the foundation for professional
ethics, which specifies professional values and virtues .
Feminist Ethics
n A core ideal is achieving social justice; feminist ethics
applies social justice and distributive justice to social struc-
tures and context .
n This ethical approach focuses on characteristics of rela-
tionships, strengthens relationships and connectedness,
eliminates oppression, and realigns power imbalances .
n Feminist ethics is committed to restructuring relation-
ships, social practices, and institutions so that people can
live freer and fuller lives (Volbrecht, 2002) .
Key Components of
Public Health Nursing
The key components of public health nursing practice dis-
cussed in this book include:
n Cornerstones of Public Health Nursing (MDH, 2007)
n Core public health functions and essential services of
public health (IOM, 1988)
n The standards of public health nursing practice
(ANA, 2013)
n Health determinants framework (U .S . Department of
Health and Human Services [U .S . DHHS], n .d .-b)
n Levels of prevention (Leavell & Clark, 1958; Stanhope
& Lancaster, 2008)
n Public health nursing process (ANA, 2013; MDH, 2001)
n Public Health Intervention Wheel (MDH, 2001)
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13CHAPTER 1 n Introduction to Public Health Nursing Practice
PHNs practice at the systems level when they work with
providers and professionals like teachers, social workers,
nurses, doctors, government officials, and members of the
business community working for different agencies . If you
are working with members of systems to help these systems
adapt or change their values, health beliefs, or the way they
conduct their business (behaviors) so that they can improve
their capacity to meet the health needs of those they serve,
then you are working at the systems level of practice .
The Relationships Between
Individuals/Families, Communities,
and Systems
Individuals, families, and systems are best understood
within the context of the community in which you live .
Individuals and families interact with, and are influenced
by, their social and physical environments and the systems
that influence their health . For example, families living in
an inner-city neighborhood might not have access to a gro-
cery store with fresh fruits and vegetables or transportation
to the store . The neighborhood’s characteristics influence
family access to quality food and their nutritional well-
being . Figure 1 .3 shows an example of the interrelationships
among families, communities, and systems .
home visiting and family assessment) . Working with fam-
ilies in the community helps you understand the diverse
socioeconomic, cultural, and environmental factors that
influence the health, wellness, and disease of individuals
and families . If you are working with an individual or fam-
ily to help them adapt or change their values, health beliefs,
or behaviors to improve their health status, then you are
working at the individual/family level of practice .
Community Level of Practice
We tend to think of a community as a geographic place, but
a community may refer to any group of people who share
common values, culture, characteristics, and goals, whether
they live in a specific geographical locale or are separated
by distance (Skemp, Dreher, & Lehmann, 2016) . Commu-
nities are composed of people, organizations, and social
patterns of behavior . If you are working with members of
the community to help the community adapt or change its
values, health beliefs, or behaviors to improve the members’
health status, then you are working at the community level
of practice .
PHNs work with two types of populations in the commu-
nity: populations of interest and populations at risk (MDH,
2001, p . 2) . Table 1 .4 defines and provides examples of these
populations .
Systems Level of Practice
A system is an institution or organization that exists within
one or multiple communities . Key systems include health-
care systems, public health systems, schools, churches, gov-
ernment agencies, nonprofit organizations, and businesses .
TABLE 1.4 Populations Served by
Public Health Nurses
Population Examples
Population of Interest:
Population who is
essentially healthy but
could improve factors
that promote or protect
health (MDH, 2001)
n Families who live in urban
areas with little opportunity
for exercise because of lack
of parks, playgrounds, or
bike paths
n College students who have
increased stress because of
study needs and college debts
and are looking for ways to
reduce their stress level
Population at Risk:
Population with a
common identified risk
factor or risk exposure
that poses a threat to
health (MDH, 2001)
n Children who are not immu-
nized for major childhood
illnesses, such as measles and
chickenpox
n Older members of a church
congregation who live alone
and are at risk for falls
FIGURE 1.3 Interrelationships of Families, Communities,
and Systems
Individual/Family—
No access to grocery store
with fresh fruit and vegetables;
no transportation to
supermarket 5 miles away
Community—
No community
action plan
exists to bring
supermarket
or community
market to
inner-city
neighborhood
System—
No for-profit grocery store
chain wants to locate in
inner-city neighborhood
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14 PART I n Foundational Concepts for Public Health Nursing Practice
To make a difference for these families and others in
their inner-city neighborhood, PHNs might carry out the
following interventions:
n Refer families who are eligible for food benefits and
nutrition services to Women, Infants, and Children
(WIC)—individual/family level of practice .
n Work with a community action council to make its
members aware of problems in their inner-city neigh-
borhood and assist them with taking action to obtain
bus service from the neighborhood to a shopping center
or supermarket—community level of practice .
n Help form a coalition of nonprofit organizations and
businesses to bring a cooperative store or other full-
service grocery store to the neighborhood—systems
level of practice .
Table 1 .5 summarizes the three levels of PHN practice
and provides examples of how public health nursing is car-
ried out at these levels . These are all actions that you as a stu-
dent or a newly practicing public health nurse can also take .
TABLE 1.5 Levels of Public Health Nursing Practice
Individual/Family Level Examples
“Population-based, individual-focused practice changes knowl-
edge, attitudes, beliefs, practices, and behaviors of individuals .
This practice level is directed at individuals, alone or as part of
a family, class, or group . Individuals receive services because
they are identified as belonging to a population at-risk” (MDH,
2001, p . 5) .
n Make home visits to newborns and their parents .
n Teach hand-washing to a first-grade class .
n Assess for the presence of lead-based paint in a home with
preschool children .
n Develop a fall-prevention plan for an elderly person living
alone .
Community Level Examples
“Population-based, community-focused practice changes com-
munity norms, community attitudes, community awareness,
community practices, and community behaviors . They [PHNs]
are directed toward entire populations within the community
or occasionally toward target groups within those populations .
Community-focused practice is measured in terms of what pro-
portion of the population actually changes” (MDH, 2001, p . 4) .
n Write a letter to the editor of a local paper to stress the
value of home visits to parents of newborns .
n Create a billboard about the hazards of lead-based paint .
n Participate in a community “town hall” meeting to make
the community aware of safety hazards for elderly people
living alone .
Systems Level Examples
“Population-based, systems-focused practice changes organiza-
tions, policies, laws, and power structures . The focus is not directly
on individuals and communities but on the systems that impact
health . Changing systems is often a more effective and long-lasting
way to impact population health than requiring change from every
single individual in a community” (MDH, 2001, pp . 4–5) .
n Meet with legislators to advocate for reimbursement for
home visits with families of newborns .
n Develop a hand-washing program at an elementary school .
n Teach real-estate agents how to recognize lead-based paint
in a home .
n Develop a fall-prevention protocol for nurses working with
the elderly in the community .
Health Determinants
Public health nurses consider the multiple factors that
determine the health of their clients . Health determinants
are factors that influence the health of individuals, families,
and populations . Health determinants can have a positive or
negative influence on health . Table 1 .6 presents examples of
protective and risk factors at all three levels of practice for
communicable disease in childhood:
n Protective factors are health determinants that pro-
tect a person from illness or assist in improving the
person’s health .
n Risk factors are health determinants that contribute
to the potential for illness to occur or to a decrease in
health or well-being .
Just as holistic nursing practice focuses on the whole,
public health nursing focuses on the whole by identifying
all of the factors that influence the health of individuals,
families, and communities . To ignore this wholeness of the
living condition is to ignore many factors that impact health
and the ability of public health nurses to promote health .
Biological, behavioral, and environmental factors interact
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15CHAPTER 1 n Introduction to Public Health Nursing Practice
TABLE 1.6 Protective and Risk Factors for Childhood Communicable Diseases
Protective Factors by Level of Practice
Individual/Family Level
n Family has insurance that covers
immunizations .
n Children are up to date on
immunizations .
n Parents teach children proper
hand-washing and the benefits of
covering their mouths when coughing .
Community Level
n 95% of children in the community are
immunized (herd immunity) .
n Community billboards urge parents to
immunize their children .
n Low-density housing or single-
dwelling homes reduce contact
between infected and noninfected
children .
Systems
n Immunizations are available at public
health clinics, pharmacies, and medi-
cal clinics .
n Free or low-cost immunizations are
available to the uninsured .
n Childcare center has effective infection
prevention and control practices .
Risk Factors by Level of Practice
Individual/Family Level
n Family is uninsured .
n Family members are not aware of the
need for immunizations .
n Parents are not aware of how to pre-
vent the spread of infectious diseases .
Community Level
n 45% of children in the community are
immunized (no herd immunity) .
n Some community groups oppose
childhood immunizations .
n Many high-density housing and apart-
ment complexes in the community
place people living close together at
greater risk .
Systems
n Immunizations are not available at the
public health clinic .
n Funding for low-cost immunizations
for the uninsured is lacking .
n School district does not track students’
immunization records .
and contribute to the health and illness of individuals, fam-
ilies, and populations (ANA, 2013; Marmot & Wilkinson,
1999; Zahner & Block, 2006) . Individuals and families are
able to influence or control some of their biological and
many of their behavioral health determinants but are not
able to control many of the physical and social environmen-
tal determinants of health that occur at the community and
systems levels . Health determinants shaped by social, eco-
nomic, and political forces, including systems put in place to
deal with illness, are called the social determinants of health .
(See Chapter 13 for further discussion on the social determi-
nants of health .) These social determinants of health affect
population health in all nations of the world .
The social determinants of health are the conditions in
which people are born, grow, live, work, and age . These cir-
cumstances are shaped by the distribution of money, power,
and resources at global, national, and local levels . The social
determinants of health are mostly responsible for health
inequities—the unfair and avoidable differences in health
status seen within and between countries (WHO, 2013) .
Health Status
PHNs use the community assessment process and public
health nursing process (see Chapter 3) to determine the
health statuses of individuals, families, communities, and
populations . Health status refers to the level of health or ill-
ness and is the outcome of the interaction of the multiple
health determinants . Health status indicators are frequently
represented by statistical measures, such as rates and per-
centages . Some common examples of population health
status indicators are teen pregnancy rates, percentage of
low-birthweight babies, neonatal mortality rates, percentage
of malnutrition in a group, and obesity rates . Rates and per-
centages of various population groups can be compared to
determine similarities or differences in the health status of
those groups . Health status comparisons can also be applied
at an individual level, such as identifying a child with mal-
nutrition as having a lower level of health than a child who is
not malnourished . Health status comparisons allow PHNs
to determine their priorities for actions with specific indi-
viduals, families, communities, and populations . Figure 1 .4
illustrates a health determinants model .
All of the Healthy People 2020 health determinants,
including access to healthcare, are represented in Fig-
ure 1 .4 (U .S . DHHS, n .d .-b) . This model represents a holistic
approach to assessment of the protective and risk factors
that determine health status in individuals, families, and
communities . Health determinants, including protective
and risk factors, exist at individual/family, community,
and systems levels, so nursing interventions should address
health determinants at all levels as needed . PHNs can use
this holistic approach to organize and identify the complex
contributors to the health status of specific individuals,
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16 PART I n Foundational Concepts for Public Health Nursing Practice
families, and populations and to develop interventions
to improve health . PHNs collaborate with their clients by
building and strengthening their protective factors and
helping them reduce their risk factors . The social determi-
nants of health that play a significant role in health dispari-
ties are discussed in Chapter 13 .
Activity
Review the following Health Determinants Analysis Case Study:
n Identify the health status indicators for this community.
n Identify health determinants, including protective and
risk factors that contribute to the health status of this
community.
n Determine how you would work with community members to
build on their protective factors and reduce their risk factors.
CASE STUDY
Health Determinants Analysis
A community assessment in a small rural community determines
that more than one-third of the adult residents are overweight
or obese. The assessment reveals that 40% of the adults in this
community report that they have high cholesterol, and 30%
report that they have high blood pressure. The majority of adults
admit to eating out at fast-food restaurants at least five times
a week. This community contains many fast-food restaurants,
and the most common foods sold in them are high in fat, sodium,
sugar, and calories. This community has few outdoor recreational
sites, such as bike and walking paths, and the county board has
voted against increasing tax levies to provide those paths. The
local hospital does provide evening and weekend health educa-
tion classes on modifying diet and exercise to lead a healthier life.
A coalition of healthcare clinics, the public health agency, and
local businesses is working on a plan to increase healthy living
resources in the community.
FIGURE 1.4 A Health Determinants Model for Individuals/Families, Communities, and Populations
Health Status
Levels of Health and/or Illness
Morbidity Rates (illness)
Mortality Rates (death)
Levels of Independence
Life Satisfaction
Comparisons with Others
• biological factors
• physical characteristics
• genetic factors
• health conditions
Biology
Behaviors
• health-seeking actions
• health-limiting actions
• lifestyle patterns
• socioeconomic status
• family, work, and
community roles
• levels of coping and
resilience
• language and literacy
• health literacy
Social Environment
• culture
• government
• education
• commerce
• religion
• health systems
• media
• social & economic
patterns Access to Healthcare
Physical Environment
• geography
• climate
• weather
• natural resources
• agriculture
• urban versus rural
• natural versus
built environment
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17CHAPTER 1 n Introduction to Public Health Nursing Practice
‘‘
’’
Levels of Prevention
The levels of prevention (primary, secondary, and tertiary)
provide a framework for health-promotion and disease-
prevention efforts in the stages of the natural history of dis-
ease (Leavell & Clark, 1958; Stanhope & Lancaster, 2008) .
The health-promotion progression from primary to sec-
ondary to tertiary prevention provides a framework for
population-based public health nursing interventions at all
levels of public health nursing practice (MDH, 2001; Skemp
et al ., 2016) . It is important to determine the health status
of individuals/families, communities, and populations and
to determine the level of prevention for specific health con-
cerns to implement the appropriate interventions . Figure 1 .5
provides an overview of the stages of health, the levels of
prevention, and intervention approaches .
Although the focus of public health nursing is primary
prevention, public health nursing practice encompasses
all three levels . In contrast, within the hospital setting,
the focus of most nursing care is on ill patients and their
family members, and nurses more often provide secondary
and tertiary prevention but may also provide some primary
prevention . Table 1 .7 shows the definition of each level with
examples .
healthypeople.gov
Healthy
People
Healthy People, a program of the U.S.
Department of Health and Human Services,
has established science-based benchmarks
and 10-year national objectives for improving the health of all
Americans. Healthy People 2020 is the third set of national
health priorities identified over the last 3 decades. Its vision is “a
society in which all people live long healthy lives” (U.S. DHHS,
n.d.-b, p. 1). The mission and goals are displayed in Table 1.8.
This national program seeks to involve all Americans by encour-
aging community and organizational collaboration, empowering
individuals to make informed health decisions, and measuring
the outcomes of prevention activities (U.S. DHHS, n.d.-b).
“Okay! Now I understand why public health nurses do what
they do, but I am still not clear about what I am supposed
to do!” Albert states in an exasperated tone of voice.
Sia responds, “I guess we have to assess our clients’
health status, identify their health determinants, and
develop a plan of care that builds on their protective factors
and reduces their risk factors. Now it makes sense that we
would be mostly listening, teaching, and counseling. Did
you know that the words listen and silent have the same
letters? I guess we need to use silence to listen to our clients!”
Abby states, “I really like all the secondary and tertiary
prevention interventions that I do in the hospital setting, so
I am afraid I am going to get bored working in the commu-
nity. I can only sit and listen for so long. I like action!”
Albert reflects, “Primary prevention doesn’t have to
mean you are not doing anything. Just because there isn’t
already an illness or disease doesn’t mean there isn’t work
to do. Primary prevention is the way that we can identify
health determinants and make an impact. Our instructor
says we can apply public health nursing in any nursing
practice setting. Maybe I will think about how I can use
everything I learn in my community clinical in my hospital
practice. But, who knows, maybe I will decide to become a
public health nurse!”
Sia asks, “I understand what we are supposed to focus
on when we work with individuals and families, but I am
not sure how identifying their health statuses and health
needs fits in with the concept of population-based practice.
I guess I need to talk to my preceptor about how our home
visits fit in with the priority health needs of our community.
How do I know whether what we are doing reflects what the
community really wants public health nurses to do?”
FIGURE 1.5 Stages of Health and Disease and Levels of
Prevention
Key
Interventions
Health
Promotion and
Prevention
Screening,
Diagnosis, and
Treatment
Rehabilitation,
Remediation,
Maintenance
Level of
Prevention
Primary Secondary Tertiary
Stage
of Health
Healthy Early Disease
or Injury
Chronic
Disease
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18 PART I n Foundational Concepts for Public Health Nursing Practice
TABLE 1.7 Prevention Continuum With Public Health Nursing Examples
Definitions Examples
Primary prevention promotes health and protects against
threats to it . It is designed to keep problems from occur-
ring in the first place . It promotes resiliency and protective
factors or reduces susceptibility and exposure to risk factors .
Primary prevention occurs before a problem develops . It
targets populations that are essentially well .
PHN Antepartal home visit:
n Teaching parents the importance of taking a newborn home from
the hospital in an approved car seat
n Providing parents with information about approved car seats
PHN Postpartum home visit:
n Checking the car seat to determine that it is correctly installed
n Monitoring the parents’ use of car seat
Secondary prevention detects and treats problems in their
early stages . It keeps problems from causing serious or
long-term effects or from affecting others . It identifies risks
or hazards and modifies, removes, or treats them before a
problem becomes more serious . Secondary prevention is
implemented after a problem has begun, possibly before
signs and symptoms appear . It targets populations that
share common risk factors .
PHN at WIC Clinic:
n Using a growth chart to plot children’s heights and weights
n Identifying children who are outside established norms
n Referring parents and children who are above 95th percentile or
below 5th percentile to a primary care provider for assessment
and to a nutritionist for nutritional education and counseling
Tertiary prevention limits further negative effects from a
problem and aims to keep existing problems from getting
worse . Tertiary prevention is implemented after a disease
or injury has occurred . It alleviates the effects of disease
and injury and restores individuals to their optimal levels
of functioning . It targets populations that have experienced
disease or injury .
School Nurse
Beginning of the school year:
n Identifying students with asthma and obtaining asthma plans
n Working with teaching staff to reduce environmental asthma
triggers in the school building
During the school year:
n Monitoring students with asthma for adherence to their asthma
plans and their health status
n Providing nebulizer treatments in the health office
Source: Modified from MDH, 2001, p . 4
TABLE 1.8 Healthy People 2020 Mission and Goals
Mission—Healthy People 2020 strives to: Overarching Goals
n Identify nationwide health-improvement priorities
n Increase public awareness and understanding of the
determinants of health, disease, and disability and
opportunities for progress
n Provide measurable objectives and goals that are
applicable at the national, state, and local levels
n Engage multiple sectors to take action to strengthen
policies and improve practices that are driven by the best
available evidence and knowledge
n Identify critical research, evaluation, and data- collection
needs
n Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death
n Achieve health equity, eliminate disparities, and improve the
health of groups
n Create social and physical environments that promote good
health for all
n Promote quality of life, healthy development, and healthy
behaviors across all life stages
Source: U .S . DHHS, n .d .-b
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19CHAPTER 1 n Introduction to Public Health Nursing Practice
BSN Preparation
The need for nurses to be prepared to both work in the
community and have the ability to practice entry-level pub-
lic health nursing has become more urgent as healthcare
moves from the acute care setting to the community and
new models of healthcare and nursing practice emerge . The
challenge of practicing in the community is influenced by
the persistence of health disparities among all age groups
and diverse populations, the aging of the population, and
the continuous increase in healthcare costs . In addition,
healthcare needs and diseases are not isolated by geographic
boundaries but evolve within a global environment . Recog-
nition of the need for nurses to have the ability to improve
the health of populations by taking leadership roles within
the healthcare system and in their communities and by
partnering with other health professionals and community
leaders has resulted in a renewed commitment to increase
the proportion of nurses with baccalaureate degrees and
to enrich the baccalaureate nursing curriculum to prepare
nurses for the challenges that face them (Education Com-
mittee of the Association of Community Health Nurse
Educators [ACHNE], 2010; Institute of Medicine [IOM],
2011; Robert Wood Johnson Foundation, 2013) . ACHNE has
identified 15 basic core knowledge competencies for bacca-
laureate nursing graduates that should be included in the
baccalaureate nursing curriculum (2010):
n Communication
n Epidemiology and biostatistics
n Community/population assessment
n Community/population planning
n Policy development
n Assurance
n Health promotion and risk reduction
n Illness and disease management
n Information and healthcare technology
n Environmental health
n Global health
n Human diversity
n Ethics and social justice
n Coordination and care management
n Emergency preparedness, response, and recovery
Activity
n Which knowledge areas have you already studied?
n What are your knowledge and competency goals for your
public health nursing clinical?
A set of national health priorities titled Leading Health
Indicators (LHIs) is included in Healthy People 2020 (U .S .
DHHS, n .d . -a) . They include 42 health outcomes orga-
nized into 12 health topics . These priorities reflect the great-
est unmet national health needs based on an analysis of
Healthy People 2010 health outcome data . The 12 health top-
ics are listed in the following “Leading Health Indicators”
box . A mid-course review of progress toward achieving the
42 health indicators shows that 21% of the targets have been
achieved and 19% are improving while 11% are getting worse
(U .S . DHHS, 2017) .
OnlineActivity
Go to the Healthy People webpage (http://
www.healthypeople.gov) and search for the LHIs.
n Read about one of the LHI health outcomes that
interests you.
n Find the Healthy People 2010 statistical data that measured
the achievement of that outcome.
n What is the goal for the Healthy People 2020 outcome?
Which statistic would demonstrate improvement of that
outcome?
Activity
n Explore the community health priorities of your state or local
health department. Compare them with the LHIs.
n Identify programs or activities in your clinical agency that are
related to the LHIs.
n Discuss with your preceptor how nurses are involved in these
programs or activities.
n Consider how you might become involved as a citizen or
as a nurse in working on one of the LHI priorities in your
community.
Leading Health Indicators, Healthy People 2020
n Access to Health Services
n Clinical Preventive Services
n Environmental Quality
n Injury and Violence
n Maternal, Infant, and Child Health
n Mental Health
n Nutrition, Physical Activity, and Obesity
n Oral Health
n Reproductive and Sexual Health
n Social Determinants
n Substance Abuse
n Tobacco
Sources: National Center for Health Statistics, 2012; U .S . DHHS, n .d .-a
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20 PART I n Foundational Concepts for Public Health Nursing Practice
Entry-Level Population-Based Public
Health Nursing Competencies
This chapter has given you a lot to think about . Now it is
time to focus on the entry-level public health nursing com-
petencies that you can work to develop in your community
clinical . This book is going to help you focus on the entry-
level competencies expected of baccalaureate nursing grad-
uates and novice nurses entering public health nursing .
Henry Street Entry-Level PHN Competencies
The Henry Street Consortium (HSC) entry-level population-
based public health nursing competencies, initially pub-
lished in 2003 and updated in 2017, are intended for
baccalaureate nursing graduates and novice public health
nurses (Henry Street Consortium, 2017; Schaffer et al ., 2011) .
These 12 competencies are consistent with national bench-
mark standards for entry-level public health nursing (ANA,
2013; Quad Council of Public Health Nursing Organiza-
tions, 2011) . (See Table 1 .9 .) A consortium of practicing pub-
lic health nurses and educators developed these simplified
entry-level standards to facilitate the teaching and learning
of public health nursing knowledge and skills in the clinical
setting (Schaffer et al ., 2011) .
This list presents each competency in broad statements
that are not measurable by themselves . A more complete
outline of each of the HSC competencies, which provides
measures of how to evaluate PHN achievement of each
competency, is found in Appendix A . Chapters 3 to 14 each
cover one of the 12 competencies and provide specific evi-
dence about best practices for each competency . As you read
this book, you will learn how you might meet these entry-
level competencies in your public health clinical learning
activities .
Activity
n Review the competencies and their related activities in
Appendix A. Make a list of activities within each compe-
tency that you would like to practice during your community
clinical.
n Talk with your preceptor about how you might practice these
public health nursing activities.
TABLE 1.9 Henry Street Consortium
Entry-Level Population-Based Public Health
Nursing Competencies
Entry-Level Population-Based Public Health Nursing
Competencies
For the New Graduate or Novice Public Health Nurse
1 . Applies the public health nursing process to communities,
systems, individuals, and families
2 . Utilizes basic epidemiological (the incidence, distribution,
and control of disease in a population) principles in public
health nursing practice
3 . Utilizes the principles and science of environmental
health to promote safe and sustainable environments for
individuals/families, systems, and communities
4 . Practices within the auspices of the Nurse Practice Act
5 . Works within the responsibility and authority of the
governmental public health system
6 . Utilizes collaboration to achieve public health goals
7 . Effectively communicates with communities, systems,
individuals, families, and colleagues
8 . Establishes and maintains caring relationships with
communities, systems, individuals, and families
9 . Incorporates mental, physical, emotional, social, and
spiritual aspects of health into assessment, planning,
implementation, and evaluation
10 . Demonstrates nonjudgmental/unconditional acceptance
of people different from self
11 . Shows evidence of commitment to social justice, the
greater good, and the public health principles
12 . Demonstrates leadership in public health nursing with
communities, systems, individuals, and families
Source: Henry Street Consortium, 2017
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21CHAPTER 1 n Introduction to Public Health Nursing Practice
n Primary prevention is the focus of public health nurs-
ing, but PHNs also provide secondary and tertiary
prevention interventions .
n PHNs work at all three levels of practice: individual/
family, community, and systems .
n Emerging threats and challenges in health and health-
care require changes in and leadership from public
health nursing .
n The HSC Entry-Level Public Health Nursing competen-
cies, based on accepted national standards, provide a
guide for baccalaureate nursing students to achieve the
expected outcomes of baccalaureate nursing education .
KEY POINTS
n Public health nursing combines the theory and practice
of nursing and public health . It is a required component
of baccalaureate nursing education .
n Public health nursing practice is guided by the national
scope of practice standards .
n The goal of public health and public health nursing is to
improve the health of the public at the local, national,
and international levels .
n The Cornerstones of Public Health explain the beliefs
and values of the clinical specialty of public health
nursing practice .
n Public health nursing practice is population-based,
focusing on the priority health needs of populations .
‘‘
’’
REFLECTIVE PRACTICE
Alberto takes a deep breath, closes his eyes as if in deep
thought, and says to Abby and Sia, “Let’s see if I have this
straight. Public health nursing is part of my professional
nursing practice. It can be practiced anywhere, because
public health nursing is shaped by its goal, not by its set-
ting, but it is most often practiced in the community. The
goal of public health nursing is to improve the health of the
public, the health of the communities in which we live. The
client in public health nursing may be an individual, a fam-
ily, the community, or a population within the community.
To improve and protect the public’s health, I need to assess
the health status and identify the health determinants that
affect the health status of individuals, families, communi-
ties, and populations. Then I need to intervene by helping
my clients build on their protective factors and reduce their
risk factors. The interventions I will use most often are
teaching and counseling, but we will learn about more inter-
ventions as we read this book and complete our community
clinical. When I practice in the community, I will probably
be partnering with other members of the healthcare team
as well as community members. I need to demonstrate a
set of entry-level public health nursing competencies to
successfully complete my baccalaureate nursing education.
The Henry Street Consortium Population-Based Public
Health Nursing Competencies focus on what I should be
learning and practicing in my public health clinical activi-
ties. Whew! Do I have that right?”
Abby and Sia respond, “Yes. You’ve got it! You get an ‘A’
for the course!”
1. Think about what Alberto, Abby, and Sia have learned
about public health nursing from their observations
and discussions with their preceptors .
2. How will you analyze what you observe about public
health nursing during your clinical experience?
3. How would you describe public health nursing prac-
tices you observe in your clinical to your classmates?
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22 PART I n Foundational Concepts for Public Health Nursing Practice
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25
‘‘
’’
CHAPTER
2Evidence-Based Public
Health Nursing Practice
n Patricia M. Schoon and Marjorie A. Schaffer
with Stephanie Rivery
Abby is talking with Jaime, an RN who has returned to school to get his baccalaureate nursing
degree. She is struggling to understand the three levels of public health nursing practice. Abby
asks, “How do you use the nursing process in your hospital work? Did you ever think you could
use it for more than the patients you are caring for?”
Jaime replies, “It still seems kind of strange to me. But I am a member of the Quality Improve-
ment Team. We just finished an audit to look at the incidence of patient falls to find out whether
our unit is meeting the goals set by the hospital to reduce the patient fall rate. Our patient fall rate
is still higher than the goal set by the hospital, so we decided that we need to hold an in-service on
assessing patients for their fall risk and the different protocols we can use to reduce the number of
patient falls. So, I guess if we think of my unit as a community, we are using the nursing process
at more than one level.”
Abby ponders, “I guess I can kind of see that you are using the nursing process to assess the
fall rate. The idea of using the nursing process at the systems level still seems very strange to me.”
Jaime thinks about the idea of nursing at the systems level and finally says, “Maybe if I think
of the nursing staff on my unit as part of the hospital system, then Quality Improvement Team
members can assess what they know about fall risk and prevention and design a program just for
our staff members to improve their skills in that area. What do you think?”
Abby sighs, “I kind of understand how I can use nursing process to assess the health needs of
individuals, families, and communities, but I can’t think how I would assess the health status of
a system. Do systems have a health status?” Abby muses, “If a system, like a public health agency,
doesn’t have enough money to provide the health services that the community needs, then I guess
it wouldn’t be very healthy.”
Jaime says thoughtfully, “Maybe we need to look at a community’s health needs and determine
whether specific community systems, such as hospitals, schools, educational systems, and public
health agencies, have the resources to meet the priority needs of their community. If they don’t
have the resources, then maybe we can plan interventions to help them get the resources or services
they need.”
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26 PART I n Foundational Concepts for Public Health Nursing Practice
’’
‘‘
The application of the nursing process to all three levels of
practice is discussed in Chapter 3.
An easy way to remember the level of practice is to ask
yourself, “Whose knowledge, beliefs, behaviors, and values
am I trying to modify?” For example, if you are teaching
a group of first grade students how to wash their hands,
even though they are in a group, your intention is to modify
the handwashing behaviors of the individual students. So,
you are intervening at the individual/family level of prac-
tice. If you taught the first-grade teachers how to monitor
the handwashing behaviors of their students, you would be
intervening at the systems level of practice. If you handed
out a flyer on the reasons for handwashing and the cor-
rect handwashing procedure at a county fair, you would be
intervening with the community level, hoping to change
community norms for handwashing, not the behaviors of
specific individuals.
Abby comments, “My PHN preceptor told me that we are
going to make a joint visit with the social worker to a family
where a baby has failure to thrive. My preceptor is going
to focus on assessing the health status of the baby, and the
social worker is going to focus on the family support system
and resources in the community for the mother. It will be
interesting to see how they work together.”
Jaime responds, “I am going to an interdisciplinary
child protection team meeting with my preceptor. It is a
county-wide team made up of police, social workers, law-
yers, and public health nurses. It seems like my preceptor is
always working with other people.”
Abby concurs, “It really does seem that PHNs work with
lots of other disciplines. My preceptor says that is the best
way to deal with community-wide health problems.”
Several years ago, a nursing student about to graduate
reflected on what she had learned. She said, “I get it. Nursing
is about critical thinking!” Nursing is a knowledge profes-
sion. That means nurses think before they do (assessment
and planning), while they do (modifying interventions),
and after they do (evaluation). This chapter explains how
to apply the nursing process to public health nursing prac-
tice and to identify and use interventions that support pub-
lic health practice goals. You will learn how to apply what
you already know about evidence-based nursing practice to
your public health nursing practice. PHNs are accountable
to their clients and to the public for practicing effectively
and efficiently to achieve the best outcomes using the least
amount of resources. This chapter discusses how PHNs use
best practice information to improve their clients’ health.
The Public Health Nursing Process
The public health nursing process integrates concepts of
nursing and public health. The steps of the nursing process
are the same: assessment, diagnosis, planning, implemen-
tation, and evaluation. However, the public health nursing
process expands the nursing process in that PHNs focus
their assessment and interventions on three different levels
of practice: individuals and families, communities, and sys-
tems (MDH, 2001). Refer to Chapter 1 for a description of the
three levels of PHN practice. Critical thinking throughout
the PHN process is essential in identifying and modifying
the complex determinants of health that influence the health
status of individuals, families, and communities. This appli-
cation of the nursing process is reflected in the American
Nurses Association’s (ANA’s) Public Health Nursing: Scope
and Standards of Practice (2013), as illustrated in Figure 2.1.
ABBY’S NOTEBOOK
USEFUL DEFINITIONS
Evidence-Based Practice: “A problem-solving approach to clinical decision-making within a healthcare orga-
nization. EBP integrates the best available scientific evidence with the best available experiential (patient and
practitioner) evidence” (Dang & Dearholt, 2018, p. 4).
Evidence-Based Public Health: Making decisions on the best information available and creating interventions
based on that evidence (Barr-Walker, 2017).
Public Health Interventions: Actions that PHNs take on behalf of individuals, families, systems, and communi-
ties to improve or protect their health status (Minnesota Department of Health [MDH Center for Public Health
Nursing], 2001); public health nurses (PHNs) commonly practice all 17 interventions.
Public Health Nursing Process: Integration of concepts of public health, community, and all three levels of the
PHN practice (i.e., individual, community, and systems) into the nursing process (Minnesota Department of
Health [MDH], Center for Public Health Nursing, 2003).
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27CHAPTER 2 n Evidence-Based Public Health Nursing Practice
These interventions are organized in the Public Health
Intervention Wheel illustrated in Figure 2.2. The Public
Health Intervention Wheel is evidence-based and represents
what PHNs do (Keller et al., 2004). PHNs often use more
than one intervention at more than one level of practice
(individual and family, community, or system) to influence
the multiple health risks affecting individuals, families, and
populations.
The 17 interventions are divided into five wedges with
three or four interventions in each wedge. Each group of
wedges reflects a cluster of interventions. The cluster of
interventions within each wedge often occurs either con-
currently or consecutively. The five wedges (also depicted in
specific colors) include the following interventions:
n Wedge 1 (pink): Surveillance, disease and health event
investigation, outreach, and screening (case finding is
the individual level for this wedge)
n Wedge 2 (green): Referral and follow-up, case manage-
ment, and delegation
n Wedge 3 (blue): Health teaching, counseling, and
consultation
n Wedge 4 (orange): Collaboration, coalition building,
and community organizing (no individual level for
coalition building and community organizing)
n Wedge 5 (yellow): Advocacy, social marketing, policy
development, and enforcement
The three inner circles, called segments, represent the
three levels of public health nursing practice (individual/
family, community, and systems). All but three interventions
are carried out at all three levels of practice. Case finding is
only carried out at the individual/family level of practice, so
it is placed inside the individual/family circle in the wheel
diagram. Community organizing and coalition formation
are practiced at the community and systems levels but not
at the individual/family level. Sixteen of the interventions
are independent nursing actions that can be practiced under
your state’s Nurse Practice Act without medical orders. The
seventeenth intervention, delegated functions, can include
medical functions delegated by a medical professional, such
as immunizations. Nursing activities that the PHN delegates
to another health team member, such as vision and hearing
screening, are part of the independent practice of nursing
and usually reflect one of the other PHN interventions.
Definitions and examples of the 17 population-based
public health interventions are outlined in Table 2.1. Inter-
ventions are organized within the five wedges on the Public
Health Intervention Wheel. Nursing students could do all
the intervention examples in the table.
The Public Health Intervention Wheel has been dissemi-
nated to public health nursing students, PHNs, other public
health professionals, and health departments nationally and
internationally. The Wheel is used as a framework for teach-
ing; a guide for planning, documentation, and evaluation in
public health practice; and a model for research on interven-
tion use and effectiveness.
PHNs often work with people in other professions as well
as community members to achieve public health goals. (See
Chapter 8 for a discussion of interprofessional collabora-
tion.) Many of the interventions that PHNs use are also used
by other professionals in the community.
Public Health Intervention Wheel
The Public Health Intervention Wheel is a major concep-
tual model in public health nursing (Keller, Strohschein,
Lia-Hoagberg, & Schaffer, 1998, 2004; Bigbee & Issel, 2012).
Concepts in the Public Health Intervention Wheel include:
population-focus, three levels of practice, three levels of pre-
vention, and 17 interventions that define the shared practice
of public health nursing. Research supporting the use and
effectiveness of many of the interventions in this model are
found in this book. This model is supported by evidence
from literature and validated by more than 200 public
health nurses from a variety of practice settings.
Public health interventions are actions that PHNs take
on behalf of individuals, families, systems, and commu-
nities to improve or protect their health status (MDH,
2001). The Public Health Intervention Wheel identifies 17
population-based interventions specific to public health
practice that are found at three levels: individual/family,
community, and systems (Keller et al., 1998, 2004; MDH,
2001). Because PHN practice occurs at three levels, interven-
tions must also be implemented at all three levels.
FIGURE 2.1 Nursing Process at Three Levels of Public Health
Nursing Practice
Community
System
Individual/
Family
Planning
Im
plem
entation
D
ia
gn
os
is
Ev
aluation Assessment
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28 PART I n Foundational Concepts for Public Health Nursing Practice
TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice
PHN Intervention
Definition
PHN Intervention
Examples
Surveillance (Wedge 1 – Pink)
Surveillance describes and monitors health events
through ongoing and systematic collection, analysis, and
interpretation of health data for the purpose of planning,
implementing, and evaluating public health interventions
(MDH, 2001, p. 13).
n Investigate and report the incidence and prevalence of sexually
transmitted infections in the local teen population (community
level).
n Work with a school nurse at an elementary school to develop a
tracking program to identify the incidence and prevalence of
student-on-student bullying before and after the implementation of
an anti-bullying curriculum (systems level).
Disease & Health Event Investigation (Wedge 1 – Pink)
Disease and other health event investigation systemati-
cally gathers and analyzes data regarding threats to the
health of populations, ascertains the source of the threat,
identifies cases and others at-risk, and determines control
measures (p. 29).
n Identify and follow up on cases of sexually transmitted infection in
a high school population to identify sources of infection and provide
treatment (individual/family level).
n Gather information about radon levels in your community and
determine high-risk geographical areas (community level).
FIGURE 2.2 Public Health Intervention Wheel
Source: MDH, Center for Public Health Nursing (2001)
Case Finding
Population-Based
Population-Based
Population-Based
Individual-Focused
Community-Focused
Systems-Focused
Surveillance
Disease &Health EventInvestigation
Outreach
Screening
R
eferral &
Follow
-U
p
Ca
se
M
an
ag
em
en
t
Dele
gate
d
Fu
nct
io
ns
Health
Teaching
Counseling
Consultation
Collaboration
Coalition
Building
C
om
m
unity
O
rganizing
A
dv
oc
ac
y
Socia
l
M
ark
etin
g
Policy
Development &
Enforcement
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29CHAPTER 2 n Evidence-Based Public Health Nursing Practice
PHN Intervention
Definition
PHN Intervention
Examples
Outreach (Wedge 1 – Pink)
Outreach locates populations of interest or populations
at risk and provides information about the nature of the
concern, what can be done about it, and how services can
be obtained (p. 41).
n Interview people at a family homeless shelter to determine who
needs information about the location of local food shelves and WIC
clinics (individual/family level).
n Develop brochures for local grocery stores to hand out about nutri-
tional needs for children and the location of local food shelves and
WIC clinics (systems level).
Case Finding (Wedge 1 – Pink)
Case finding locates individuals and families with identi-
fied risk factors and connects them to resources (p. 55).
n Identify new immigrants from southeast Asia who might be at risk
for tuberculosis (TB) (individual/family level).
n Give at-risk immigrants information on where to receive TB
screening (individual/family level).
Screening (Wedge 1 – Pink)
Screening identifies individuals with unrecognized
health risk factors or asymptomatic disease conditions in
populations (p. 63).
n Conduct blood pressure screening for African-American males
( community level)
n Organize a blood pressure screening clinic at a community center
( systems level)
Referral & Follow-up (Wedge 2 – Green)
Referral and follow-up assists individuals, families,
groups, organizations, and communities to utilize
necessary resources to prevent or resolve problems or
concerns (p. 79).
n Give an elderly person who is homebound information about how
to contact a local Meals on Wheels program and then contact the
individual a week later to see if he or she has successfully reached
the Meals on Wheels program (individual/family level).
n Work with Emergency Department (ED) nurses and home visiting
nurses to develop and use a referral process for elderly individuals
seen in the ED that need home healthcare services (systems level).
Case Management (Wedge 2 – Green)
Case management optimizes self-care capabilities of
individuals and families and the capacity of systems and
communities to coordinate and provide services (p. 93).
n Work with parents of a newborn with Down’s Syndrome to iden-
tify services in their community that they can use to help them
( individual/family level).
n Work with a PHN and school nurse to coordinate in-home and
school health services for children with severe developmental delays
(systems level).
Delegated Functions (Wedge 2 – Green)
Delegated functions are direct care tasks a registered
professional nurse carries out under the authority of
a healthcare practitioner, as allowed by law. Delegated
functions also include any direct care tasks a registered
professional nurse entrusts to other appropriate person-
nel to perform (p. 113).
n Provide immunizations at a community flu clinic under standing
orders from medical personnel (individual/family and systems
levels).
n Direct a peer counselor to work with a new diabetic to organize a
grocery list and menu plans (individual/family level).
Health Teaching (Wedge 3 – Blue)
Health teaching communicates facts, ideas, and skills
that change knowledge, attitudes, values, beliefs, behav-
iors, and practices and skills of individuals, families,
systems, and/or communities (p. 121).
n Teach a class for teen moms about how to care for new baby
( individual/family level).
n Develop a program on childcare for new moms at a local high school
(systems level).
(continues)
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30 PART I n Foundational Concepts for Public Health Nursing Practice
PHN Intervention
Definition
PHN Intervention
Examples
Counseling (Wedge 3 – Blue)
Counseling establishes an interpersonal relationship with
a community, system, family, or individual intended to
increase or enhance their capacity for self-care and cop-
ing. Counseling engages the community, system, family,
or individual at an emotional level (p. 151).
n Provide support for parents who are coping with providing care for
their dying child at home (individual/family level).
n Provide crisis management services to a community that has just
experienced a devastating tornado (community level).
Consultation (Wedge 3 – Blue)
Consultation seeks information and generates optional
solutions to perceived problems or issues through
interactive problem-solving with a community, system,
family or individual. The community, system, family or
individual selects and acts on the option best meeting the
circumstances (p. 165).
n Help a recently divorced father who has custody of his two children
to problem solve balancing parenting and work responsibilities
(individual/family level).
n Consult with a peer-counseling group for diabetes management
to help them develop strategies for working with individuals with
diabetes in their community (community level).
Collaboration (Wedge 4 – Orange)
Collaboration commits two or more persons or organiza-
tions to achieving a common goal through enhancing the
capacity of one or more of them to promote and protect
health (p. 177).
n Partner with the nurse and social worker in an adolescent correction
facility in developing a program to help inmates maintain con-
tact with caring individuals in their family or friendship network
( systems level).
n Work with the county parks and playground department and local
young parents group to develop a plan to provide more bike and
walking paths for family use (community and systems level).
Coalition Building (Wedge 4 – Orange)
Coalition building promotes and develops alliances
among organizations or constituencies for a common
purpose. It builds linkages, solves problems, and/or
enhances local leadership to address health concerns
(p. 211).
n Develop an alliance between local environmental groups, waste
management, and recycling organizations to improve community
recycling (community level).
n Establish a network of agencies to work together to develop a
community disaster plan (systems level).
Community Organizing (Wedge 4 – Orange)
Community organizing helps community groups identify
common problems or goals, mobilize resources, and
develop and implement strategies for reaching the goals
they collectively have set (p. 235).
n Organize a group of renters from several low-income housing devel-
opments to work together to improve the safety of their buildings
(community level).
n Help organize a group of low-income housing services organiza-
tions, community homeless shelters, and county human services
to develop strategies to provide a more streamlined program for
placing homeless people in affordable housing (systems level).
Advocacy (Wedge 5 – Yellow)
Advocacy pleads someone’s cause or acts on someone’s
behalf, with a focus on developing the community, sys-
tem, individual, or family’s capacity to plead their own
cause or act on their own behalf (p. 263).
n Help a client file an appeal for an insurance denial for home-care
services when the client meets eligibility criteria stated in insurance
policy (individual/family level).
n Lobby legislators for support of community mental health programs
(systems level).
Social Marketing (Wedge 5 – Yellow)
Social marketing utilizes commercial marketing princi-
ples and technologies for programs designed to influence
the knowledge, attitudes, values, beliefs, behaviors, and
practices of the population of interest (p. 285).
n Create a video for teen parents on how to help their infants and
toddlers meet developmental milestones (individual/family level).
n Participate in a televised panel discussion about the effects of drug
and alcohol use during pregnancy on the fetus (community level).
TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice (continued)
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31CHAPTER 2 n Evidence-Based Public Health Nursing Practice
PHN Intervention
Definition
PHN Intervention
Examples
Policy Development & Enforcement (Wedge 5 – Yellow)
Policy development places health issues on decision-
makers’ agendas, acquires a plan of resolution, and
determines needed resources. Policy development results
in laws, rules and regulations, ordinances, and policies.
Policy enforcement compels others to comply with the
laws, rules, regulations, ordinances, and policies created
in conjunction with policy development (p. 313).
n Participate on a county task force to revise county human services
guidelines for mandating reporting of suspected child abuse or
neglect (systems level).
n Talk to a church group about the need to support a bill for commu-
nity nutrition programs for children living in poverty (community
level).
Source: Definitions from MDH, Center for Public Health Nursing (2001)
EVIDENCE EXAMPLE 2.1
Public Health Intervention Wheel
n Over 600 school nurses (SNs), members of the National
Association of School Nurses (NASN), completed an
electronic survey on using public health interventions in
their practice as defined by the Public Health Intervention
Wheel. Most SNs (67%) were not familiar with the Wheel;
however, participants identified interventions that were
consistent with the Wheel. They used screening, referral
and follow-up, case management, and health teaching
more often than other interventions. In estimates of
time spent at specific practices levels, SN practice was
primarily at the individual level (65%). They also provided
community-level interventions 22% of their time and
systems-level interventions 14% of their time. SNs can use
the Wheel to document and explain the interventions they
provide in school nursing practice to address the health of
school populations (Schaffer, Anderson, & Rising, 2016).
n A qualitative study explored how school nurses (n = 43)
understood and used the interventions from Public Health
Intervention Wheel. Data were analyzed from six focus
groups conducted across the state of Minnesota. Ns rep-
resented urban, suburban, and rural schools. The SN prac-
tice stories included all interventions and levels of practice
except for case management and delegation at the com-
munity level. The highest number of practice examples
were for health teaching, case finding, and referral and
follow-up, all at the individual level. The practice stories
provide examples of how SNs can extend their practice to
community and systems levels and affirm school nursing
as a population-focused practice (Anderson et al., 2018).
n McDonald and colleagues (2015) replicated the process
of identifying and defining public health interventions
from the Wheel in the context of public health nursing
in Ireland. Public health nursing leaders in Ireland con-
ducted a literature review and hosted discussions on each
intervention wedge at the 2011 Institute of Community
Health Nursing conference. The aim was to promote
visibility of the PHN role and build a common language
to describe interventions. A key theme of practice stories
was the importance of building trusting relationships with
individuals and communities to support interventions.
The Population Health Interest Group (2013) pub-
lished practice stories from Irish nurses for each of the
17 interventions.
‘‘
’’
Jaime says, “I am going to a meeting with my PHN precep-
tor this afternoon about how the different county agencies
and the school district are working together as a team to try
to reduce smoking among high school students. I guess that
would be an example of collaboration, but I am not sure
which level of practice that would be.”
Abby ponders, “I think maybe when PHNs work with
agencies and school districts, they are practicing at the sys-
tems level. If they use an intervention like social market-
ing to let teens know about the availability of a smoking
cessation program at their school, then they would be prac-
ticing at the community level.”
Jaime responds, “Teens at risk for smoking are a vul-
nerable population within the community, and PHNs
work with populations within the community. If the team’s
goal is to change the smoking behaviors of individual high
school students, even if they were part of a group and PHNs
carried out some health teaching in the classroom, I guess
those actions would be at the individual/family level. This
gets kind of confusing at times.”
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32 PART I n Foundational Concepts for Public Health Nursing Practice
PHNs take a comprehensive approach to dealing with
public health problems in the community. They use mul-
tiple interventions to achieve primary, secondary, and ter-
tiary prevention goals and, when possible, work with other
members of the interdisciplinary team and members of the
community. Table 2.2 outlines how primary, secondary, and
tertiary interventions might be employed at all three levels
of practice to reduce tobacco use in teens. (See Chapter 1 for
a discussion of primary, secondary, and tertiary prevention.)
Evidence-Based Practice
Public health organizations are expected to use evidence-
based approaches in decision-making and in taking actions
based on population-based evidence (Lovelace et al., 2015).
This evidence-based public health approach means that
PHNs use the best information available to create new inter-
ventions (Barr-Walker, 2017). This evidence-based decision
process includes (Brownson, Fielding, & Maylahn, 2009,
p. 177):
n Using the best available scientific evidence
n Systematically using data and information systems
TABLE 2.2 Three Levels of PHN Practice and Three Levels of Prevention With Public Health
Interventions to Reduce Tobacco Use in Teens
Individual/Family Level of Practice
Primary Prevention Secondary Prevention Tertiary Prevention
Health Teaching
n Conduct classroom teaching on the
dangers of tobacco use and strategies
to avoid it.
Case Finding, Referral, and Follow-Up
n Assess the health behaviors, including
tobacco use, of individual students.
n Identify students at risk for tobacco
use and those already using tobacco.
n Refer students who smoke to the
school smoking prevention and
cessation team.
n Follow up with the school nurse.
Case Management and Collaboration
n The school nurse, physical education
teacher, and school psychologist team
up to work with teens using tobacco
and to monitor and implement a
smoking cessation program.
Community Level of Practice
Social Marketing and Outreach
n Staff a teen booth at the county fair
and hand out brochures on the hazards
of tobacco use and available tobacco
prevention and cessation programs.
Screening, Referral, and Follow-Up
n Hold health-behaviors screening,
including tobacco use, for teens and
young adults at the county fair.
Case Management and Social Marketing
n Create a social networking site to
empower teens and for teens to
provide peer support for smoking
cessation.
Systems Level of Practice
Health Teaching/Provider Education
n Develop and present a program to
teachers and school staff about the
hazards of tobacco use and available
smoking prevention and cessation
programs.
Screening, Referral, and Follow-Up
n Develop a health-behaviors screen-
ing, referral, and follow-up program
for middle school and high school
students.
Case Management and Collaboration
n Develop a case management protocol
for the school smoking prevention and
cessation interdisciplinary team.
n Applying program planning frameworks
n Engaging the community in assessment and
decision-making
n Conducting sound evaluation
n Disseminating findings
Public health nurses’ practice is expected to be evidence-
based. This evidence-based approach means that PHNs use
a problem-solving approach to find the best available sci-
entific evidence and the best available experiential evidence
and then integrate this evidence into their practice (Dang &
Dearholt, 2018, p. 4).
The search for credible evidence includes knowledge
gleaned from both research and nonresearch. The lev-
els of evidence at the core of the Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) include research
and nonresearch evidence. There are five levels of evidence
(see Table 2.3). You will find examples from all levels of evi-
dence in the remaining chapters of this book. Although the
levels of evidence are presented in a hierarchical manner in
Table 2.3, this table does not mean that lower levels of evi-
dence should be discounted or that randomized controlled
trials (RCTs) in experimental research should be considered
the only credible or most meaningful forms of evidence
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33CHAPTER 2 n Evidence-Based Public Health Nursing Practice
TABLE 2.3 Best Practices in Public Health Nursing by Level of Evidence
Evidence Level Definition Examples
Level I:
Experimental study, randomized controlled
trials (RCTs)
Explanatory mixed methods design
The Nurse Family Partnership involving intensive structured home visiting by
PHNs reduces repeat childbirths, improves the stability of partner relation-
ships, facilitates children’s academic adjustment to elementary school, and
reduces childhood mortality from preventable causes (Kitzman et al., 2010;
Olds et al., 2004; Olds et al., 2007; Olds et al., 2010).
Level I:
Systematic reviews of RCTs, with or without
meta-analysis
Professional organizations publish systematic reviews of medical and nursing
research
n The Cochrane Database of Systematic Reviews, published online by the
Cochrane Collaboration.
n Worldviews on Evidence-Based Nursing, a peer-reviewed journal published
by Sigma Theta Tau International.
n The Joanna Briggs Institute provides an online listing of systematic reviews
and meta-analysis specific to nursing practice. Systematic reviews of non-
RCT research may be either Level II or Level III evidence.
Level II:
Quasi-experimental study
Explanatory mixed-method design
Systematic review of a combination of RCTs and
quasi-experimental studies or quasi-experimental
studies only
A prospective cohort study evaluated the impact of breastmilk expression in
early postpartum period on breastfeeding duration (Jiang et al., 2015).
Level III:
Nonexperimental study
Systematic reviews of combination of RCTs,
quasi- experimental, and nonexperimental
studies
A descriptive study identified four significant predictors of breastfeeding
attitudes: age, gender, number of breastfeeding observations in childhood, and
breastfeeding beliefs (Vari et al., 2013).
A systematic review using CINAHL (Cumulative Index to Nursing and Allied
Health Literature), PubMed, and Cochrane Library databases identified bar-
riers to breastfeeding in the WIC population to make recommendations for
guidelines for WIC clients (Hedberg, 2013).
Level IV:
Opinion of respected authorities and nationally
recognized expert committees or consensus
panels based on scientific evidence
n Clinical practice guidelines
n Consensus panels/position statements
ANA. (2013). Public Health Nursing: Scope and Standards of Practice (2nd ed.)
Quad Council of Public Health Nursing Organizations. (2011).
The Quad Council competencies for public health nurses
Centers for Disease Control and Prevention. (2017). Immunization Schedules
Level V:
Based on experiential and nonresearch evidence
n Integrative reviews
n Literature reviews
n Quality improvement, program, or financial
evaluation
n Case reports
n Opinion of nationally recognized expert(s)
based on experiential evidence
The Best Start program supporting area-based interventions to increase breast-
feeding was evaluated. Area-based interventions and community partnerships
were found to have a positive influence on breastfeeding rates (Kelaher, Dunt,
Feldman, Nolan, & Raban, 2009).
Source: Definitions of Levels of Evidence from Dang & Dearholt, 2018, Appendix D, pp. 278–279
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34 PART I n Foundational Concepts for Public Health Nursing Practice
‘‘
in public health. It is important to thoughtfully consider
and analyze information from all levels of evidence. For
example, the use of qualitative research, particularly when
studying culture and ethnicity, has led to significant under-
standing of how diverse populations and people view them-
selves and the world around them.
Experiential evidence that may be found in IV and V
evidence levels includes clinical expertise and client’s pref-
erences and values. PHNs know that evidence-based inter-
ventions found in the scientific literature need to fit the
demographics and cultural diversity of their clients at the
individual/family and community levels of practice in order
to be consistent with ethical holistic nursing practice (see
Figure 2.3).
These three interrelated elements occur within the con-
text of the community—where public health nurses are
expected to be lifelong learners who take the initiative to
engage with their community to explore the life experi-
ences, health status, and health determinants of diverse
populations. The information PHNs gather about the indi-
viduals/families and communities they serve leads them to
question how they can positively impact the health of these
individuals/families and communities.
Public health nurses use critical thinking in applying a
deliberative process for identifying and implementing best
practices in a timely manner. The Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) includes three
essential components: inquiry, practice, and learning (Dang
& Dearholt, 2018):
n Inquiry: To question, examine, and collect information
about an issue or problem (p. 36)
n Practice: Reflects on the translation of what nurses
know to what they do (p. 36)
n Learning: A change in the way nurses think and
behave
The movement from inquiry to learning is represented
by the JHNEBP PET Process (see Figure 2.4). This process
is a group effort within or across organizations. In public
health, the team could be formed from members of a spe-
cific organization or be an interprofessional team at the
community level with key stakeholders and community
members involved. The practice team identifies the practice
issue, defines and refines the practice question, searches for
and evaluates the evidence, and determines which evidence
can and should be translated into new or revised practices
in the workplace.
Abby wonders how PHNs know what to do when they work
with their clients. She says, “The PHNs keep talking about
evidence-based practice, but I am not sure exactly what
that is.”
Jaime responds, “Today, my PHN preceptor and I made
a home visit to an elderly woman who lives alone. We did
a fall risk assessment and a home safety check. I asked the
PHN how she selected which risk assessment and home
safety assessment tools to use. She told me that a committee
of PHNs reviewed journal articles to find research reports
on which assessment tools were effective for determining
fall risks in older adults. They also looked at which home
safety tools had been developed specifically for frail older
adults living at home. Then they piloted the home safety
assessment tools themselves and picked the tool that best fit
what their PHNs needed to know about the home environ-
ment and what the elderly adults preferred. I think this is
the way you do evidence-based practice, but I need to read
more about it.”
Abby comments, “One of the PHNs at my agency went
to a fall prevention workshop given by an occupational
therapist and a physical therapist at the local hospital.
They taught the workshop participants how to screen
older adults for fall risk and which types of interventions
would help reduce fall risks, such as using assistive devices,
installing good lighting, removing slippery rugs, and wear-
ing nonskid slippers. Do you think this information could
FIGURE 2.3 Best Practice Approach to Evidence-Based
Practice in Public Health Nursing
Sources: Based on work by Keller & Strohschein, 2009; Melnyk &
Fineout-Overholt, 2014
Credible evidence
Client
preference
and values
Clinical
expertise
FIGURE 2.4 JHNEBP PET Process
Source: Used with permission: Dang & Dearholt, 2018, p. 4
Practice
Question
Evidence Translation
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35CHAPTER 2 n Evidence-Based Public Health Nursing Practice
’’
be considered evidence-based? The two therapists said they
were reporting on what they had found worked best with
their patients.”
Jaime says, “I guess we could review the material on
evidence-based practice in our textbooks and then talk
more to our PHN preceptors.”
“Good idea,” says Abby. “Let’s do it. We can also do a
search using CINAHL to see if there are any studies that
support what the PHN learned at the workshop. Do you
think this information about effective interventions will be
easy to find? What is an effective intervention anyway?”
Effective interventions fit your client’s situation and pref-
erences and result in the desired outcomes. Using inter-
ventions that are known to be effective is important. PHNs
have carried out research to demonstrate the effectiveness
of many interventions provided to individuals, families,
and communities. However, it is not always easy to find sci-
entific literature on the effectiveness of PHN interventions
(Swider, Levin, & Reising, 2017). Although research for
evidence-based practice might be limited in public health
nursing, PHNs should refer to it whenever it exists (Keller &
Strohschein, 2009, from Brownson, Baker, Leet, & Gillespie,
2002). PHNs are accountable to their clients (individuals/
families, communities, and systems) and to the public to
determine the effectiveness of an intervention and to justify
the use of resources. Your own experiences as a nursing stu-
dent can also guide your choices of which interventions you
can carry out effectively. You can use the evidence-based
public health approach—making decisions on the best
information available and creating interventions based on
that evidence (Barr-Walker, 2017). Table 2.4 includes recent
studies that demonstrate effective public health nursing
interventions.
TABLE 2.4 Effectiveness of Selected Public Health Nursing Interventions
Individual/Family Level
Intervention Results
Case management Decreased difficulty and dependence for meal preparation, telephone use, shopping, and ordinary house-
work (Instrumental Activities of Daily Living) were found for elders receiving home visiting in compari-
son with usual care (Li, Liebel, & Friedman, 2013). [Level I]
Case finding
Case management
Health teaching
Consultation
counseling
Significantly higher scores on overall healthy eating and healthy eating subdimensions (i.e., food selection,
preparation, and consumption) were found in elders 60 years and over in comparison to control group
(Meethien, Pothiban, Ostwald, Sucamvang, & Panuthai, 2011). [Level I]
Counseling Socially withdrawn students showed an increase in self-efficacy after participation in group-based coun-
seling interventions led by school nurses (Kvarme et al., 2010). [Level II]
Counseling
Health teaching
Referral and follow-up
Low-income, first-time mothers who participated in the Nurse–Family Partnership (NFP) home visiting
program had more beneficial breastfeeding and immunization outcomes compared to similar clients not
in the program (Thorland, Currie, Wiegand, Walsh, & Mader, 2017). [Level III]
Community Level
Surveillance In response to an online survey of PHNs in 29 states, PHNs reported they conducted ongoing surveillance
for tuberculosis, vaccine-preventable diseases, sexually transmitted diseases, pediculosis, foodborne dis-
eases, and elevated blood lead levels in their communities (Schaffer, Keller, & Reckinger, 2015). [Level III]
Coalition building School nurses participated in an interfaith coalition to respond to youth suicide in the community
(Anderson et al., 2017). [Level III]
Systems Level
Consultation
Screening
A maternal and child health nurse screening program for mothers experiencing domestic violence
(nurse-designed model) increased safety planning among postpartum women (Taft et al., 2015). [Level I]
Collaboration
Outreach
School nurses collaborated with a hospital and a school of nursing to develop and implement an
injury-prevention curriculum for helmet safety in elementary schools. Students from the intervention
group reported increased helmet use after intervention in comparison with the control group (Adams,
Drake, Dang, & Le-Hinds, 2014). [Level II]
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36 PART I n Foundational Concepts for Public Health Nursing Practice
‘‘
’’
Evidence-based practice (EBP)—and nursing interven-
tions—should be both effective and efficient. PHNs use the
evidence-based public health approach and consider all
evidence-based information, including the experiences of
experts. Because resources are limited in both healthcare
and public health, PHNs also need to consider the efficiency
of interventions. Efficient interventions require the least
amount of resources and achieve the desired outcomes in
the shortest period of time.
Evidence-based practice supports efficacy (the ability
to reach a desired result); efficiency (the achievement of a
desired result with minimum expense, time, and effort); and
effectiveness (the ability to produce a desired result). Addi-
tionally, EBP weighs risks, benefits, and costs against a back-
drop of patient preferences (Dang & Dearholt, 2018, p. 4).
Jaime voices his concern that if he knew from the literature
that an intervention was known to achieve a desired out-
come, he might use it even if he did not know if it would
be effective. “How do I know if it is going to work with a
specific client?”
Abby responds, “Well you can ask your preceptor what
type of interventions have worked in the past with your
client. You could also ask the client if he wants to try it.”
Before using an intervention, look at the literature or
consult with expert PHNs to identify specific interventions
that can best meet your clients’ unique needs and charac-
teristics. You also want to consider if the intervention is a
good use of your time and resources and the client’s time
and energy. Questions you can ask to determine effective-
ness and efficiency are listed in Table 2.5.
healthypeople.gov
Healthy
People
Healthy People 2020 identified 11 Leading
Health Indicators (LHIs) as priority health
concerns, including Nutrition, Physical
Activity, and Obesity. Go to the Healthy People 2020 website,
click “Leading Health Indicators,” and then click “Nutrition,
Physical Activity, and Obesity.” Read about the most recent
data and population disparities on nutrition, physical activity,
and obesity. Look for the links to the science-based Dietary
Guidelines for Americans and the Physical Activity Guidelines.
What evidence do you find that supports a healthy eating and
physical activity program for you and your family?
Just because “best practice” evidence is available does not
mean that it will be adopted and used. To create a supportive
evidence-based practice environment, three strategies are
necessary: establishing the EBP culture, building the capac-
ity for EBP, and ensuring sustainability (Dang & Dearholt,
2018, p. 19). A strategic plan and committed leadership are
necessary to develop the organizational resources and sup-
port for a sustainable evidence-based practice culture. Staff
TABLE 2.5 Analyzing Effectiveness and
Efficiency of Interventions
Determining
Intervention
Effectiveness
Determining
Intervention
Efficiency
n Is the intervention
culturally and develop-
mentally congruent with
the client’s status and
situation?
n Is the intervention
acceptable to the client?
n Does the outcome of the
intervention demonstrate
improvement of the
client’s health status?
n What are the costs of the
intervention (money, time,
people involved, and other
resources) for the PHN,
the other members of the
health team, the agencies
involved, and the client?
n Are the costs of imple-
menting the intervention
justified by the health
benefits for the client and
the community?
needs include continuing education on evidence-based
practice as well as initiatives to be implemented. Resources
such as Internet access to useful databases and journals,
evidence-based organizational mentors, and reimbursable
time facilitate integration of evidence into practice.
This chapter presents an overview of evidence-based prac-
tice relevant to public health nursing practice. The term best
practices is often used synonymously with evidence-based
practice. A few points are helpful to keep in mind as you
think about and use evidence of “best practices” in your
community health clinical:
n Experimental research using RCTs is considered uneth-
ical when placing an individual in a control group that
denies that individual treatment or interventions are
already demonstrated to be effective.
n Public health/community health nursing agencies may
be carrying out quasi- and nonexperimental research to
determine the effectiveness of their programs and inter-
ventions. These activities may be a component of their
ongoing quality improvement programs. Sometimes
students participate in these research studies. If you are
asked to participate, ask to see any informed consent or
ethical guidelines that your agency is using.
n The policies and procedures of your public health/
community agency and the professional practice stan-
dards guiding PHN practice may be considered clinical
guidelines. Progress reports and annual agency reports
may be considered organizational experiences.
n The knowledge and experiences of your preceptor and
other PHN agency staff will be reflected in the practice
you observe and the mentoring you receive. These repre-
sent expert opinions and clinical expertise.
n Clinical experiences may include both participant
and nonparticipant observation. When you reflect on
your observations of your preceptor or other public
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37CHAPTER 2 n Evidence-Based Public Health Nursing Practice
health/community health nurses interacting with clients
by using PHN interventions, you are demonstrating
nonparticipant observation. When you use these inter-
ventions yourself and reflect on your practice, you are
demonstrating participant observation. Both types of
experiences add to your clinical expertise.
n Community assessments that are carried out in collabo-
ration with community members and client satisfaction
surveys provide evidence of consumer preferences. See
Chapter 3, Competency #1, for information on commu-
nity assessments.
Database and Internet Searches
The sources of evidence must be as credible as the evidence
itself. That is why PHNs search scientific databases. The
online databases that provide the most relevant journal
articles for nursing are CINAHL and PubMed. CINAHL is
a proprietary database hosted by EBSCO, which means it
is privately owned and available to members of subscribing
institutions who pay a fee for remote access. PubMed is an
open-source database that is free to the public. Other cred-
ible sources include websites maintained by professional
organizations and service providers and governmental web-
sites, such as those run by the National Institutes of Health
(NIH), the U.S. Surgeon General, and the Centers for Disease
Control and Prevention (CDC). The Cochrane Library is an
international database of systematic reviews owned by the
Cochrane Collaboration and is an open-source database
that is free to use. The CDC Stacks, an excellent source for
public health information, is a free digital repository of pub-
lications produced by the CDC.
The NIH provides guidelines for evaluating web-based
health resources that can help you determine whether the
website resource you have found is credible. One example
of a credible website is a government program that reviews
maternal-child health home visiting program effectiveness,
called Home Visiting Evidence of Effectiveness (HOMVEE).
This website includes discussion of models and programs,
whether they meet Department of Health and Human Ser-
vices (DHHS) criteria, their target populations, and whether
research shows positive effectiveness (U.S. Department of
Health and Human Services, n.d.).
The goal of evidence-based practice is not to generate new
knowledge, but to improve practice. Baccalaureate nursing
graduates are expected to be able to find and use best prac-
tice evidence to improve their nursing practice. Hopp & Rit-
tenmeyer (2012, p. 84) identify a five-step process known as
the “5 A’s.” This process works well for students and PHNs
alike and can be used when students partner with public
health nurses during their clinical learning activities in
public health. Table 2.6 outlines a process for public health
nursing students to carry out the “5 A’s.”
TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities
The 5 A’s Students Using the 5 A’s with Community Partners
Ask: To find the right answer, you
need to ask the right question.
n Work with PHNs or other community partners to identify a public health practice issue
about a specific health concern with a specific population and a related knowledge gap
about current best practices.
n Work with PHNs or other community partners to create a specific practice question.
n Identify reasonable client outcomes that you wish to achieve with modified or new best
practice evidence.
Acquire: Search for the answer by
exploring all levels of evidence.
n Work with reference librarian, instructor, and community partners to identify credible
data sources for all five levels of evidence.
n Identify appropriate databases to search and keywords for search.
n Work with instructor and community partners to identify evidence from nonscientific
literature (e.g., credible websites, professional organizations, agency reports, etc.).
n Conduct key informant interviews.
n Conduct search, preferably for the past 5 years (or 10 years if there is little published
information for the past 5 years).
Appraise: Critically evaluate
the evidence and select the “best
practice evidence.”
n Work with fellow students, instructors, and interprofessional teams to critically review
the evidence and determine what evidence answers your practice question and is applica-
ble to the client population.
n Work with community partners to consult practice experts to determine which interven-
tions fit what the experts know about the population and health concern.
n Work with key community stakeholders to determine population preferences and values.
(continues)
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38 PART I n Foundational Concepts for Public Health Nursing Practice
Evidence of Best Practices
PHNs need to be critical consumers of public health and
nursing research. They must use a deliberative problem-
solving approach when making decisions about which
evidence in the literature is strong enough to support a
change in practice (Poe & White, 2010). However, public
health providers often do not have adequate knowledge
about evidence-based practice or the tools and resources
to research current evidence-based best practices (Barr-
Walker, 2017). In addition, published evidence in scientific
journals is limited, and many of the sources used are from
health-related statistics, government reports, and organiza-
tional or professional guidelines.
Much of the evidence for effective public health nursing
comes from Evidence-Based Practice Levels III, IV, and V. It
is often not ethical, possible, or practical to randomly place
people in an experimental or a control group, especially if
placement in either group could have a negative effect on
an individual’s health or well-being. An increasing body of
qualitative research in public health nursing exists. Under-
standing the context of the family, culture, and commu-
nity; the meaning of events; and the impact of these factors
on the clients’ health behaviors and health status is often
best achieved through the use of qualitative research meth-
ods. Public health nurses also learn a great deal from their
practice experiences and those of their colleagues. This
evidence-based information or practice-based knowledge
helps public health nurses translate evidence into practice
in specific clinical care settings (Barr-Walker, 2017). Case
study examples can be found in the literature, shared at
professional conferences, or reported on the Internet. These
anecdotal reports are also part of the practice evidence of
public health nursing.
Framing Your Evidence-Based Practice
With the “5 A’s”
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting. It is
time to return to the “5 A’s” discussed earlier in the chapter
(Hopp & Rittenmeyer, 2012): ask, acquire, appraise, apply,
and assess.
Ask
When you explore the scientific literature for best practice
evidence, it is helpful to first identify your clinical ques-
tion so that you are focused in your search. One helpful
way to frame your clinical practice question is to use the
PICOT approach by identifying the patient population (P),
the intervention of interest (I), the comparison interven-
tion (C), the outcome (O), and the timeframe (T) (Stillwell,
Fineout-Overholt, Melnyk, & Williamson, 2010). For exam-
ple, if you wanted to research the effectiveness of teaching
parents about the “Back to Sleep” program to reduce the risk
of Sudden Infant Death Syndrome (SIDS), you might frame
your PICOT question as outlined in Table 2.7.
The “T” in PICOT may not be necessary to include when
reviewing the literature, but it may be helpful to include the
time element when you plan how and when you are going to
evaluate the outcome of the intervention you have selected
to implement in your clinical setting. Once you find a set of
articles that report on the effectiveness of the intervention
you are interested in, it is time to review them to determine
their usefulness.
Acquire
After writing your PICOT question, you can identify the
keywords in the sentence. A helpful way to identify key-
words is to create a PCO Table (Population, Content, Out-
comes). Table 2.8 demonstrates that using a PCO Table helps
you to identify six keywords or phrases. If you have access
to a reference librarian, you can take your keywords to the
librarian who can then help you create your online literature
strategy and identify the databases to search (Butler, Hall, &
Copnell, 2016). Complete your search using your keywords.
Appraise
The next step is to compare and contrast the studies and
reports you have appraised. Select the best studies or reports
with the most credible evidence that fits your clinical
The 5 A’s Students Using the 5 A’s with Community Partners
Apply: Make the evidence action-
able by using the evidence to
change your practice.
n Report credible evidence from all five levels to community partners.
n Make recommendations for change in practice or new interventions.
n Collaborate with community partners on modifications of current interventions or
development of new interventions.
n Partner with your PHN preceptor to implement the intervention if possible.
Assess: Evaluate the outcomes
of the change in practice in your
clinical setting.
n Identify how and when the client outcomes will be evaluated and determine the
effectiveness and efficiency of the modified or new intervention.
TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities (continued)
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39CHAPTER 2 n Evidence-Based Public Health Nursing Practice
‘‘
’’
situation and addresses your specific question. Think about
how you would present your findings and recommendations
to the PHNs and team you are working with.
Apply
Once you have completed the first three steps and have iden-
tified a best practice intervention, begin working with your
clinical team to translate or apply the evidence into clinical
practice. Before you implement a change in your practice or
your clinical team’s practice, you need to think about how
you will evaluate the effectiveness of the change. Identify
the outcome you would like to achieve.
Assess
The timeframe for assessment of client outcomes after imple-
menting the new intervention will depend on the urgency to
determine efficacy of an intervention as well as a realistic
expectation as to when effectiveness can be evaluated. For
example, if you implemented a community-wide campaign
to increase the flu vaccine in September to decrease the inci-
dence of influenza in the fall, you would probably compare
the incidence of influenza this fall to last fall in December. If
you were evaluating the effectiveness of the “Back to Sleep”
program, you might choose a 6-month timeframe to evalu-
ate the outcome of the program.
It would be important to evaluate both the effectiveness
and the efficiency of the intervention from a cost-benefit
perspective, which would be based on the quality of life as
well as the financial and human resource costs involved.
This is not always easy to do. For example, if the “Back to
Sleep” program reduced the incidence of crib death by one
infant in a 3-month period, would any of your community
partners consider the program effective and efficient?
Jaime comments, “I think I am going to do my intervention
paper on ways to reduce smoking in high school students.
I have to start looking for evidence-based practice articles.
I wonder how I should go about that.”
Abby says, “I have been working with the college refer-
ence librarian to research my topic. She suggested that I
use three databases: CINAHL, PubMed, and the Cochrane
Database of Systematic Reviews. I have found a few good
articles in each database.”
Jaime responds, “Great! I will try those databases, too! I
know that both PubMed and the Cochrane Database are in
the public domain and free to users. CINAHL is privately
owned, and organizations have to pay for employees to
use it. I don’t think my hospital has a contract to access
CINAHL.”
Abby concludes, “Don’t forget to write your PICOT
question first!”
Translating Evidence Into Practice
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting
and to translate best practice evidence into practice, which
means that you use the best practice evidence to evaluate
and update how you practice nursing. PHNs need to make
sure that their recommendations for change in practice are
based on the best evidence and are appropriate and feasible
for their client populations, their agencies, and their com-
munities. Support and funding for PHN practice depends
on documentation and dissemination of evidence that PHN
practice makes a positive difference in the health of its com-
munities. Evidence Example 2.2 shows step-by-step how to
use an evidence-based practice approach to find best prac-
tice evidence.
TABLE 2.7 The PICOT Approach to
Clinical Problem Solving
PICOT Question
Elements Examples
P = Patient population
I = Intervention of interest
C = Comparison interven-
tion of interest
O = Outcome(s) of interest
T = Time it takes the inter-
vention to achieve outcomes
P = Infants at risk for SIDS
I = Teach parents to place
infants on backs to sleep
using “Back to Sleep”
program
C = No purposeful teaching
about safe sleeping position
of infants
O = Percentage of babies
sleeping on back
T = Evaluate at 6 weeks and
3 months
PICOT Question: Will infants (P) whose parents are taught
to place them on their backs to sleep using a “Back to
Sleep” program (I) as opposed to no purposeful teaching
about safe sleeping positions for infants (C) be sleeping on
their backs (O) at 6 weeks and 3 months after receiving the
intervention (T)?
TABLE 2.8 Finding Keywords Using PCO
PCO Elements Examples
P = Patient Population P = Infants at risk for SIDS,
parents, caretakers
C = Context C = Teaching safe sleeping positions
O = Outcome O = Sleeping on back
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40 PART I n Foundational Concepts for Public Health Nursing Practice
EVIDENCE EXAMPLE 2.2
Searching for Best Practice Evidence on Optimal Breastfeeding Initiation
and Translating the Evidence Into Practice
Breastfeeding is initiated in the setting where delivery occurs.
Often that is the hospital. Many new mothers are sent home
from the hospital within 24 hours of delivery. So, it is import-
ant for PHNs to know the best practice evidence to share with
their antepartum clients about what breastfeeding approaches
work best and then to support those practices during the
postpartum period. Public health nurses need to work with
their nursing partners in the hospital setting to prepare their
clients for breastfeeding, advocate for the preferences of the
new mothers with their acute care colleagues, and provide for
a seamless transition in the breastfeeding routine when the
mother returns home through coordination and case manage-
ment interventions. In this example, nurses in a birthing center
searched for best practice evidence for initiation of breast-
feeding immediately after birth. The following example shows
how the “5 A’s” and the PICOT process were used to identify
best practice evidence and translate it into practice. The ques-
tion was whether it was best practice to use a breast pump to
support breastfeeding in the first 72 hours postpartum.
Ask
A PICO(T) question was developed to frame the question to
guide the literature search:
P = Efficacy of use of breast pump in early postpar-
tum period to promote exclusive breastfeeding with
mother’s milk
I = Electric breast pump after breastfeeding during first
24–48 hours
C = Breastfeeding on-demand during first 24–48 hours
O = Baby fed exclusively with mother’s own breastmilk
T = 6 weeks postpartum
The question: Does use of an electric breast pump after
breastfeeding versus breastfeeding on-demand during the
first 24–48 hours postpartum increase the likelihood a baby
will be exclusively fed with a mother’s own breastmilk at
6 weeks postpartum?
Acquire
Ovid Medline, CINAHL, PubMed, and Google Scholar were
searched using a variety of search terms. Although 23 articles
were found, only 3 of these articles addressed the PICOT ques-
tion and the actual practice question.
Appraise
The literature reviewed suggested that while it remains unclear
if pumping has any immediate impact on breastfeeding initia-
tion and milk supply, using a breast pump in the first days and
weeks postpartum is associated with a shorter breastfeeding
duration (Chapman, Young, Ferris, & Perez-Escamilla, 2001;
Felice, Cassano, & Rasmussen, 2016; Jiang et al., 2015).
Other important evidence was identified:
Anticipating return to work and suboptimal long-term lac-
tation support systems increased women’s dependence on
expressing breastmilk with a pump (Chapman et al., 2001;
Felice et al., 2016; Jiang et al., 2015).
Hand expression is more effective at expressing colos-
trum (first days’ breastmilk supply) than an electric pump
( Flaherman et al., 2013).
Developing the nurse-family relationship fosters an
empowering environment where the family can experience
growth and develop the skills needed to achieve successful
infant feeding patterns, including direct breastfeeding and
expressing breastmilk (Raile Alligood, 2010).
After reviewing the scientific evidence, the nursing team at
the birthing center considered the other two evidence com-
ponents: the practice and procedures of the birthing center
and the preferences of the new mothers. The context of the
relationship between the mother and the nursing staff was
considered. The nurses’ caring interaction was considered as
necessary as the evidence-based knowledge to facilitate suc-
cessful breastfeeding initiation.
Apply
Supporting Breastfeeding Guidelines were developed and
implemented based on the evidence. The nurse in the birthing
center who initiated the quality improvement process changed
jobs and became a clinical coordinator in a public health nurs-
ing agency. She was able to share the best practice evidence
about the initiation of breastfeeding with the public health
nursing staff.
Assess
At the birthing center, the new guideline was instituted and
evaluated at both the systems and the individual/family
practice levels. Nursing staff completed a nursing practice
survey before and after implementation of the new guide-
lines. The purpose was to measure the accuracy with which
nurses were able to determine the appropriate interventions
needed to support lactation (when and when not to use an
electric pump) and their confidence levels of decision-making
regarding when to utilize the breast pump to support lactation.
The individual-level change was measured through a patient
survey completed at discharge. The survey measured the
breastfeeding mothers’ confidence levels of continuing their
breastfeeding plan of care when returning home and their per-
ception of nursing support received for their individual infant
feeding goals.
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41CHAPTER 2 n Evidence-Based Public Health Nursing Practice
‘‘
’’
Jamie is continuing to work on his evidence-based practice
search on how to reduce smoking in high school students.
Abby changed her topic. With her PHN preceptor, she
has been co-visiting a first-time mom who has postpartum
depression. The PHN is visiting the mom twice weekly, and
the PHN has asked Abby to research best practices in work-
ing with moms with postpartum depression. Abby is going
to develop her PICOT question, create her PCO Table, and
then consult with her instructor and the reference librarian
on how to go about searching for the best practice evidence.
She is excited to be able to partner with her PHN preceptor
to find the most up-to-date best practice evidence to present
to the Family Health Team.
If you follow through on the steps outlined in this chapter
for researching best practices and taking steps to translate
this evidence into your nursing practice, you will be prac-
ticing nursing from an evidence-based practice framework.
As a professional, you are accountable for your own nursing
practice, so you need to be aware of and use best practices.
You will find that this book presents many levels of evidence
to justify using specific interventions.
ACTIVITY
Imagine that you are the nurse who changed jobs from the
birthing center to the public health agency.
n How would you use this best practice breastfeeding
initiation evidence?
n What would you want to know about the public health
nurses and their antepartum and postpartum clients?
n How would you develop your PICOT question?
n How might you partner with the staff to carry out the
“5 A’s” process?
The evidence-based practice approach does not always
entail a simple, concise process. However, through the use
of various levels of evidence, clinical expertise, local con-
text, and client preference, best practice interventions can
be developed and implemented to promote and protect the
health of individuals, systems, and populations.
n All five levels of evidence are used to identify best
practices.
n Evidence-based practice is a deliberative process start-
ing with a practice question, followed by an appraisal
of the evidence, and then a change in practice based on
credible evidence.
n Using the “5 A’s” and PICOT provides a structure for
practicing from an evidence-based foundation.
KEY POINTS
n The public health nursing process guides the PHN’s
actions.
n PHNs work at all three levels of practice (individual/
family, community, and systems).
n PHNs carry out 17 interventions unique to public health
nursing; 16 of these interventions are practiced inde-
pendently as part of professional nursing practice.
n Public health nursing practice is evidence-based.
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42 PART I n Foundational Concepts for Public Health Nursing Practice
REFLECTIVE PRACTICE
1. What do you think are the major differences between
the nursing process and the public health nursing
process?
l What will you do differently when following the
public health nursing process?
l How will your knowledge about the determinants of
health guide you in your assessments and interven-
tions at the three levels of practice: individual/family,
community, and systems?
2. Which other disciplines will you work with most often
in your public health clinical?
l What additional information do you need to know
about the other health disciplines?
l How will you find out the information that you need?
3. Which public health nursing interventions have you
used in previous clinical experiences?
l How will you carry out these interventions in your
public health clinical?
l How will this experience be the same or different
from what you have done before?
4. Have you used an evidence-based practice approach in
other nursing clinical experiences?
l What have you learned in reading this chapter that
you did not know before?
l How will your past experiences and your new knowl-
edge help you practice evidence-based public health
nursing?
5. Which types of best practice evidence related to a PHN
intervention would you like to explore?
l What is your PICOT question?
l How do you frame this as a PICOT statement?
6. Refer to the Cornerstones of Public Health Nursing in
Chapter 1. Which of the Cornerstones support the use
of evidence-based practice in public health nursing?
APPLICATION OF EVIDENCE
How would you work with your PHN preceptor to identify
an intervention that the staff would like to have researched
to identify any new best practice recommendations?
When you search for best practice evidence, how would
you implement the following steps?
n Determine which databases to use in your search.
n Carry out your literature search. Obtain help from the
reference librarian if you are having difficulty with your
keyword search.
n Select three to five journal articles to review. You may
use articles that represent different levels of evidence.
How would you carry out the following steps to analyze the
evidence?
n Compare and contrast the articles you have appraised.
Are their findings and recommendations similar or
different?
n Identify the articles that have the most credible evidence
that best fits your clinical situation.
n What format would you use to report your
evidence-based finding to the PHN staff?
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http://www.achne.org/files/Quad%20Council/QuadCouncilCompetenciesforPublicHealthNurses