PART IFoundational Concepts
for Public Health Nursing Practice
1 Introduction to Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 Evidence-Based Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
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3
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CHAPTER
1Introduction to Public Health Nursing Practice
n PatriciaM.Schoonwith 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).
HealthDeterminants: 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.
HealthStatus: 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)
HolisticNursing: 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).
LevelsofPrevention: 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 risk exposure, or experiencing an emerging health threat or risk” (American Nurses Association [ANA], 2013, p. 3).
Population-BasedPractice: Population-based practice focuses on the population as a whole to determine its priority needs (Minnesota Department of Health [MDH], 2001).
PublicHealth: 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.).
PublicHealthNursing: 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).
SocialDeterminantsofHealth: 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 LivePublic 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 .
PublicHealthThe 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 .
PublicHealthNursingPublic 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
DefinitionofPublicHealthNursingPractice
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 compassionn Holistic and relationship-centered practicen Sensitivity to vulnerable populationsn 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 justicen Population focusn Reliance on epidemiologyn Health promotion and preventionn The greater goodn 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
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Cornerstones of Public Health NursingThe 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 communityn Take time to establish trust when visiting families in
their homesn 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 teamn 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 StatesSources: 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
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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.
ActivityKeep 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, 2007Source 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 NursingPublic 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 PracticeAll 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)
Activityn 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 NursingPublic 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 1.1HealthinAllPolicies
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 NursingThe 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 IconsSource: United Nations General Assembly, 2015
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12 PART I  n  Foundational Concepts for Public Health Nursing Practice
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‘‘
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/FamilyLevelofPracticePHNs 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 Ethicsn 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 Ethicsn 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 Ethicsn 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 NursingThe 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 SystemsIndividuals, 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 .
CommunityLevelofPracticeWe 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 .
SystemsLevelofPracticeA 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 storewith fresh fruit and vegetables;no transportation tosupermarket 5 miles away
Community—No communityaction planexists to bringsupermarketor communitymarket toinner-cityneighborhood
System—No for-profit grocery storechain wants to locate ininner-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 DeterminantsPublic 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 Leveln 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 Leveln 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 Leveln 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 Leveln 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 StatusPHNs 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 .
ActivityReview 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 STUDYHealth 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 StatusLevels of Health and/or Illness
Morbidity Rates (illness)Mortality Rates (death)Levels of Independence
Life SatisfactionComparisons 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
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’’
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
HealthyPeople
  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
KeyInterventions
HealthPromotion and
Prevention
Screening,Diagnosis, and
Treatment
Rehabilitation,Remediation,Maintenance
Level ofPrevention
Primary Secondary Tertiary
Stageof Health
Healthy Early Diseaseor Injury
ChronicDisease
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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 seatn Providing parents with information about approved car seats
PHN Postpartum home visit:n Checking the car seat to determine that it is correctly installedn 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 weightsn Identifying children who are outside established normsn 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 plansn 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 statusn 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 prioritiesn 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 Communicationn Epidemiology and biostatisticsn Community/population assessmentn Community/population planningn Policy developmentn Assurancen Health promotion and risk reductionn Illness and disease managementn Information and healthcare technologyn Environmental healthn Global healthn Human diversityn Ethics and social justicen Coordination and care managementn Emergency preparedness, response, and recovery
Activityn 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?
Activityn 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.
LeadingHealthIndicators,HealthyPeople2020
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 CompetenciesThis 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 .
HenryStreetEntry-LevelPHNCompetenciesThe 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 .
Activityn 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 .
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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
Ivanov, L . L ., & Oden, T . F . (2013) . Public health nursing, ethics and human rights . Public Health Nursing, 30(3), 231–238 . doi:10 .1111/phn .12022
Keller, L . O ., Strohschein, S ., & Schaffer, M . A . (2011) . Cornerstones of public health nursing . Public Health Nursing, 28(3), 249–260 . doi:10 .1111/j .1525-1446 .2010 .00923 .x
Kub, J ., Kulbok, P . A ., & Glick, D . (2015) . Cornerstone documents, milestones, and policies: Shaping the direction of public health nursing 1890–1950 . Online Journal of Issues in Nursing, 20(2), 3 .
Kulbok, P . A ., Thatcher, E ., Park, E ., & Meszaros, P . S . (2012) . Evolving public health nursing roles: Focus on community par-ticipatory health promotion and prevention . Online Journal of Issues in Nursing, 17(2), 1 . doi:10 .3912/OJIN .Vol17No02Man01
Leavell, H ., & Clark, E . (1958) . Preventive medicine for the doctor in his community: An epidemiologic approach. New York, NY: McGraw-Hill .
Marmot, M ., & Wilkinson, R . G . (1999) . Social determinants of health. Oxford, UK: Oxford University Press .
Martin, K . S . (2005) . The Omaha System: A key to practice, docu-mentation, and information management (2nd ed .) . Omaha, NE: Health Connections Press .
Minnesota Department of Health, Center for Public Health Nursing . (2003) . Definition of population-based practice . Retrieved from http://www .health .state .mn .us/divs/opi/cd/ phn/docs/0303phn_popbasedpractice .pdf
Minnesota Department of Health, Center for Public Health Nursing . (2007) . Cornerstones of public health nursing. Adapted from original by Center for Public Health Nursing, 2004 . St . Paul, MN: Author . Retrieved from http://www .health . state .mn .us/divs/opi/cd/phn/docs/0710phn_cornerstones .pdf
Minnesota Department of Health, Division of Community Health Services, Public Health Nursing Section . (2001) . Public health interventions: Applications for public health nursing practice. St . Paul, MN: Author . Retrieved from http://www .health .state .mn .us/divs/opi/cd/phn/docs/0301wheel_manual .pdf
Minnesota Department of Health, Public Health Nursing Section . (2000) . Public health nursing practice for the 21st century: Competency development in population-based practice. National Satellite Learning Conference . St . Paul, MN: Author . Retrieved from http://www .health .state .mn .us/divs/opi/cd/phn/docs/ 0001phnpractice_learningguide .pdf
National Center for Health Statistics . (2012) . Healthy People 2010, final review. Hyattsville, NY: U .S . Department of Health and Human Services . Retrieved from http://www .cdc .gov/nchs/data/hpdata2010/hp2010_final_review .pdf
Parker, M . E ., & Smith, M . C . (2010) . Nursing theories and nursing practice (3rd ed .) . Philadelphia, PA: F . A . Davis .
Purtilo, R . (2005) . Ethical dimensions in the health professions (4th ed .) . Philadelphia, PA: Elsevier Saunders .
Quad Council of Public Health Nursing Organizations . (2011) . The Quad Council competencies for public health nurses. Retrieved from http://www .achne .org/files/Quad%20Council/ QuadCouncilCompetenciesforPublicHealthNurses .pdf
Racher, F . E . (2007) . The evolution of ethics for community practice . Journal of Community Health Nursing, 24(1), 65–76 .
ReferencesAbrams, S . E . (2008) . The best of public health nursing, circa 1941 .
Public Health Nursing, 25(3), 285–291 . doi:10 .1111/ j .1525-1446 .2008 .00706 .x
Aiken, T . (2004) . Legal, ethical, and political issues in nursing. Philadelphia, PA: F . A . Davis .
American Nurses Association . (2003) . Nursing’s social policy statement (2nd ed .) . Silver Spring, MD: Author .
American Nurses Association . (2013) . Public health nursing: Scope and standards of practice. Silver Spring, MD: Author .
American Public Health Association, Public Health Nursing Section . (2013) . The definition and practice of public health nursing. Washington, DC: Author . Retrieved from https:// www .apha .org/~/media/files/pdf/membergroups/phn/ nursingdefinition .ashx
Beauchamp, T ., & Childress, J . (1979) . Principles of biomedical ethics. New York, NY: Oxford University Press .
Beck, D-M . (2010) . Expanding our Nightingale horizon: Seven recommendations for 21st-century nursing practice . Journal of Holistic Nursing, 28(4), 317–326 . doi:10 .1177/0898010110387780
Buhler-Wilkerson, K . (1993) . Bringing care to the people: Lillian Wald’s legacy to public health nursing . American Journal of Public Health, 83(12), 1778–1786 .
Clark, M . J . (2008) . Community health nursing. Upper Saddle River, NJ: Pearson .
Davies, R . (2012) . ‘Notes on nursing: What it is and what it is not’ (1860), by Florence Nightingale . Nurse Education Today, 32(2012), 624–626 . Retrieved from http://www . nurseeducationtoday .com/article/S0260-6917(12)00132-3/fulltext
Dossey, B . M ., & Keegan, L . (2016) . Holistic nursing—A handbook for practice (7th ed .) . Burlington, MA: Jones & Bartlett Learning .
Dreher, M ., Shapiro, D ., & Asselin, M . (2006) . Healthy places, healthy people: A handbook for culturally competent com-munity nursing practice. Indianapolis, IN .: Sigma Theta Tau International .
Education Committee of the Association of Community Health Nurse Educators . (2010) . Essentials of baccalaureate nursing education for entry-level community/public health nursing . Public Health Nursing, 27(4), 371–382 . doi:10 .1111/ j .1525-1446 .2010 .00867 .x
Friedman, M ., Bowden, V ., & Jones, E . (2003) . Family nursing: Research, theory, and practice (5th ed .) . Hoboken, NJ: Pearson Education, Inc .
Henry Street Consortium . (2017) . Entry-level, population-based public health nursing competencies. St . Paul, MN: Author . Retrieved from www .henrystreetconsortium .org
Institute of Medicine . (1988) . The future of public health. Washington, DC: National Academies Press .
Institute of Medicine . (2011) . The future of nursing—Leading change, advancing health. Washington, DC: National Academies Press .
International Council of Nurses . (2011) . Nurses and human rights [Position statement] . Retrieved from http://www .icn .ch/images/stories/documents/publications/position_statements/ E10_Nurses_Human_Rights .pdf
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23CHAPTER 1  n  Introduction to Public Health Nursing Practice
U .S . Department of Health and Human Services . (n .d .-b) . Healthy People 2020 framework. Retrieved from https://www . healthypeople .gov/sites/default/files/HP2020Framework .pdf
U .S . Department of Health and Human Services . (2017) . Healthy People 2020: Chapter 3–Overview of midcourse progress and health disparities. Retrieved from https://www .cdc .gov/nchs/data/hpdata2020/HP2020MCR-B03-Overview .pdf
Visiting Nurses Association of Western New York . (n .d .) . Our his-tory . Retrieved from https://www .vnawny .org/about/history .asp
Volbrecht, R . M . (2002) . Nursing ethics: Communities in dialogue. Upper Saddle River, NJ: Pearson Prentice Hall .
Watson, J . (2008) . Nursing: The philosophy and science of caring (Rev . ed .) . Boulder, CO: University Press of Colorado . In Watson Caring Science Institute and International Caritas Consortium . (2010) . Core concepts of Jean Watson’s theory of human caring/caring science. Retrieved from http://watsoncaringscience .org/files/Cohort%206/watsons-theory-of-human-caring-core- concepts-and-evolution-to-caritas-processes-handout .pdf
Watson, J . (2010) . Florence Nightingale and the enduring legacy of transpersonal human caring-healing . Journal of Holistic Nursing, 28(1), 107–108 .
World Health Organization . (n .d .) . Public health . Retrieved from http://www .euro .who .int/en/health-topics/Health-systems/public-health-services
World Health Organization . (2013) . About social determinants of health . Retrieved from http://www .who .int/ social_determinants/sdh_definition/en/index .html
World Health Organization . (2017) . Health in all policies: Progressing the sustainable development goals . Retrieved from http://www .who .int/phe/events/HiAP-conference- March2017/en/
Zahner, S . J ., & Block, D . E . (2006) . The road to population health: Using Healthy People 2010 in nursing education . Journal of Nursing Education, 45(3), 105–108 .
Robert Wood Johnson Foundation . (2013) . Forum on the future of public health nursing, February 8, 2012—Proceedings and feed-back: Summary report. Retrieved from http://www .rwjf .org/content/dam/farm/reports/reports/2012/rwjf404144
Schaffer, M . A ., Cross, S ., Olson, L . O ., Nelson, P ., Schoon, P . M ., & Henton, P . (2011) . The Henry Street Consortium population-based competencies for educating public health nursing students . Public Health Nursing, 28(1), 78–90 . doi:10 .1111/j .1525-1446 .2010 .00900 .x
Scoville Walker, S . (2004) . Ethical quandaries in community health nursing . In E . Anderson & J . McFarlane (Eds .), Community as partner: Theory and practice in nursing (4th ed ., pp . 83–113) . Philadelphia, PA: Lippincott, Williams & Wilkins .
Selanders, L . C ., & Crane, P . C . (2012) . The voice of Florence Nightingale on advocacy . Online Journal of Issues in Nursing, 17(1), 1 .
Skemp, L . E ., Dreher, M . C ., & Lehmann, S . P . (2016) . Healthy places, healthy people (3rd ed .) . Indianapolis, IN: Sigma Theta Tau International .
Stanhope, M ., & Lancaster, J . (2008) . Public health nursing: Population-centered health care in the community (7th ed .) . St . Louis, MO: Mosby .
United Nations . (1948) . Universal declaration of human rights. New York, NY: Author . Retrieved from http://www .ohchr .org/EN/UDHR/Documents/UDHR_Translations/eng .pdf
United Nations General Assembly . (2015) . Transforming our world: The 2030 agenda for sustainable development. New York, NY: Author . Retrieved from https://sustainabledevelopment .un .org/content/documents/21252030%20Agenda%20for %20Sustainable%20Development%20web .pdf
U .S . Department of Health and Human Services . (n .d .-a) . Healthy People 2020: About Healthy People 2020: Leading health indicators. Retrieved from https://www .healthypeople .gov/ 2020/Leading-Health-Indicators
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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 ProcessThe 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 WheelThe 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
Implem
entation
Dia
gnos
is
Evaluation 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 InterventionExamples
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
SurveillanceDisease &Health EventInvestigation
Outreach
ScreeningR
eferral &
Follow-U
p
Case
Man
agem
ent
Delegate
d
Funct
ions
Health
Teaching
Counseling
Consultation
Collaboration
Coalition
BuildingC
omm
unity
Organizing
Adv
ocac
y
Social
Mark
eting
Policy
Development &
Enforcement
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29CHAPTER 2  n  Evidence-Based Public Health Nursing Practice
PHN Intervention Definition
PHN InterventionExamples
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 InterventionExamples
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 InterventionExamples
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 2.1Public 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 PracticePublic 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 evidencen 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 Teachingn Conduct classroom teaching on the
dangers of tobacco use and strategies to avoid it.
Case Finding, Referral, and Follow-Upn 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 Collaborationn 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 Outreachn 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-Upn Hold health-behaviors screening,
including tobacco use, for teens and young adults at the county fair.
Case Management and Social Marketingn 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 Educationn 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-Upn Develop a health-behaviors screen-
ing, referral, and follow-up program for middle school and high school students.
Case Management and Collaborationn Develop a case management protocol
for the school smoking prevention and cessation interdisciplinary team.
n Applying program planning frameworksn Engaging the community in assessment and
decision-makingn Conducting sound evaluationn 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 evidencen Clinical practice guidelinesn 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 evidencen Integrative reviewsn Literature reviewsn Quality improvement, program, or financial
evaluationn Case reportsn 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 NursingSources: Based on work by Keller & Strohschein, 2009; Melnyk & Fineout-Overholt, 2014
Credible evidence
Clientpreferenceand values
Clinicalexpertise
FIGURE 2.4 JHNEBP PET ProcessSource: Used with permission: Dang & Dearholt, 2018, p. 4
PracticeQuestion
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 findingCase managementHealth teachingConsultation 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]
CounselingHealth teachingReferral 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
ConsultationScreening
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]
CollaborationOutreach
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 SearchesThe 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 PracticesPHNs 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.
AskWhen 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.
AcquireAfter 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.
AppraiseThe 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.
ApplyOnce 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.
AssessThe 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 PracticeOne 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 2.2Searching 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 partum 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.
AskA 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?
AcquireOvid 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.
AppraiseThe 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.
ApplySupporting 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.
AssessAt 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.
ACTIVITYImagine 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?
ReferencesAdams, C., Drake, D., Dang, M., & Le-Hinds, N. (2014).
Optimization of injury prevention outreach for helmet safety. Journal of Trauma Nursing, 21, 133–138. doi:10.1097/JTN.0000000000000047
American Nurses Association. (2013). Public health nursing: Scope and standards of practice. Silver Spring, MD: Author.
Anderson, L. J. W., Schaffer, M. A., Hiltz, C., O’Leary, S. A., Luehr, R. E., & Yoney, E. L. (2018). Public health interventions: School nurse practice stories. The Journal of School Nursing, 34(3), 192–202. doi:10.1177/1059840517721951
Barr-Walker, J. (2017). Evidence-based information needs of public health workers: A systematized review. Journal of the Medi-cal Library Association, 105(1), 69–79. doi:dx.doi.org/10.5195/jmla.2017.109
EBSCOhost – printed on 1/15/2023 5:35 AM via MINNESOTA STATE UNIVERSITY – MANKATO. All use subject to https://www.ebsco.com/terms-of-use

43CHAPTER 2  n  Evidence-Based Public Health Nursing Practice
Kitzman, H. J., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., . . . Holmberg, J. R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 412–418. doi:10.1001/archpediatrics.2010.76
Kvarme, L. G., Helseth, S., Sørum, R., Luth-Hansen, V., Haugland, S., & Natvig, G. K. (2010). The effect of a solution- focused approach to improve self-efficacy in socially withdrawn school children: A non-randomized controlled trial. International Journal of Nursing Studies, 47, 1389–1396. doi:10.1016/ j.ijnurstu.2010.05.001
Li, Y., Liebel, D. V., & Friedman, B. (2013). An investigation into which individual instrumental activities of daily living are affected by home visiting nurse intervention. Age and Ageing, 42, 27–33. doi:10.1093/ageing/afs151
Lovelace, R. A., Aronson, R. E., Rulison, K. L., Labban, J. D., Shah, G. H., & Smith, M. (2015). Laying the groundwork for evidence-based public health: Why some local health departments use more evidence-based decision-making than others. American Journal of Public Health, 105(S2), S189–S197. doi:10.2105.AJPH.2014.302306
McDonald, A., Frazer, K., Duignan, C., Healy, M., Irving, A., Marteinsson, P., … McNicholas, E. (2015). Validating the “ intervention wheel” in the context of Irish public health nurs-ing. British Journal of Community Nursing, 20(3), 140–145.
Meethien, N., Pothiban, L., Ostwald, S. K., Sucamvang, K., & Panuthai, S. (2011). Effectiveness of nutritional education in promoting healthy eating among elders in northeastern Thailand. Pacific Rim International Journal of Nursing Research, 15(3) 188–202.
Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2014). Evidence- based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams and Wilkins.
Minnesota Department of Health, Center for Public Health Nursing. (2001). Public health interventions: Applications for public health nursing practice. St. Paul, MN: Author. Retrieved from http://www.health.state.mn.us/divs/opi/cd/phn/docs/0301wheel_manual.pdf
Minnesota Department of Health, Center for Public Health Nurs-ing. (2003). The nursing process applied to population-based public health nursing practice. Retrieved from http:// www.health.state.mn.us/divs/opi/cd/phn/docs/0303phn_ processapplication.pdf
Olds, D. L., Kitzman, H. J., Cole, R. E., Hanks, C. A., Arcoleo, K. J., Anson, E. A., … Stevenson, A. J. (2010). Enduring effects of prenatal and infancy home visiting by nurses on mater-nal life course and government spending: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 419–424. doi:10.1001/archpediatrics.2010.49
Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., … Holmberg, J. (2004). Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114(6), 1550–1559.
Olds, D., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora- Arcoleo, K., … Bondy, J. (2007). Effects of nurse home visiting on maternal and child functioning: Age 9 follow-up of a ran-domized trial. Pediatrics, 120(4), e832–e845.
Bigbee, J. L., & Issel, L. M. (2012). Conceptual models for popula-tion-focused public health nursing interventions and outcomes: The state of the art. Public Health Nursing, 29(4), 370–379. doi:10.1111/j.1525-1446.2011.01006.x
Brownson, R. C., Baker, E. A., Leet, T. L., & Gillespie, K. N. (Eds.). (2002). Evidence-based public health. New York, NY: Oxford University Press.
Brownson, R. C., Fielding, J. E., & Maylahn, C. M. (2009). Evidence-based public health: A fundamental concept for public health practice. Annual Review of Public Health, 30(1), 75–201.
Butler, A., Hall, H., & Copnell, B. (2016). A guide to writing a qual-itative systematic review protocol to enhance evidence-based practice in nursing and health care. Worldviews on Evi-dence-Based Nursing, 13(3), 241–249. doi:10.1111/wvn.12134
Centers for Disease Control and Prevention. (2017). Immunization schedules. Retrieved from https://www.cdc.gov/vaccines/ schedules/index.html
Chapman, D. J., Young, S., Ferris, A. M., & Perez-Escamilla, R. (2001). Impact of breast pumping on lactogenesis stage II after cesarean delivery: A randomized clinical trial. Pediatrics, 107(6), 1–7.
Dang, D., & Dearholt, S. L. (2018). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Indianapolis, IN: Sigma Theta Tau International.
Felice, J. P., Cassano, P. A., & Rasmussen, K. M. (2016). Pumping human milk in the early postpartum period: Its impact on long-term practices for feeding at the breast and exclusively feeding human milk in a longitudinal survey cohort. American Journal of Clinical Nutrition, 103, 1267–1277.
Flaherman, V. J., Gay, B., Scott, C., Aby, J., Stewart, A. L., & Lee, K. A. (2013). Development of the breast milk expression expe-rience measure. Maternal & Child Nutrition, 9(3), 425–430. Retrieved from https://doi.org/10.1111/j.1740-8709.2011.00390.x
Hedberg, I. G. (2013). Barriers to breastfeeding in the WIC popula-tion. American Journal of Maternal Child Health Nursing, 38(4), 244–249. doi:10.1097/NMC.0b013e3182836ca2
Hopp, L., & Rittenmeyer, L. (2012). Introduction to evidence-based practice—A practical guide for nursing. Philadelphia, PA: F. A. Davis.
Jiang, B., Hua, J., Wang, Y., Fu, Y., Zhuang, Z., & Zhu, L. (2015). Evaluation of the impact of breast milk expression in early postpartum period on breastfeeding duration: A prospective cohort study. BMC Pregnancy & Childbirth, 15, 1–13. doi:10.1186/s12884-015-0698-6
Kelaher, M., Dunt, D., Feldman, P., Nolan, A., & Raban, B. (2009). The effect of an area-based intervention on breastfeeding rates in Victoria, Australia. Health Policy, 90, 89–93.
Keller, L. O., & Strohschein, S. (2009). E2 evidence exchange: Your public health nursing e-source. Public Health Nursing Faculty Conference, Otsego, MN.
Keller, L. O., Strohschein, S., Lia-Hoagberg, B., & Schaffer, M. (1998). Population-based public health nursing interventions: A model for practice. Public Health Nursing, 15(3), 207–215.
Keller, L. O., Strohschein, S., Lia-Hoagberg, B., & Schaffer, M. (2004). Population-based public health interventions: Practice-based and evidence-supported. Part I. Public Health Nursing, 21(5), 453–468.
EBSCOhost – printed on 1/15/2023 5:35 AM via MINNESOTA STATE UNIVERSITY – MANKATO. All use subject to https://www.ebsco.com/terms-of-use

44 PART I  n  Foundational Concepts for Public Health Nursing Practice
Swider, S. M., Levin, P. F., & Reising, V. (2017). Evidence of public health nursing effectiveness: A realistic review. Public Health Nursing, 34(4), 324–334. doi:10.1111/phn.12320
Taft, A. J., Hooker, L., Humphreys, C., Hegarty, K., Walter, R., Adams, C., … Small, R. (2015). Maternal and child health nurse screening and care for mothers experiencing domestic violence (MOVE): A cluster randomised trial. BMC Medicine, 13, 1–10. doi:10.1186/s12916-015-0375-7
Thorland, W., Currie, D., Wiegand, E. R., Walsh, J., & Mader, N. (2017). Status of breastfeeding and child immunization out-comes in clients of the Nurse–Family Partnership. Maternal and Child Health Journal, 21(3), 439–445. doi:10.1007/s10995-016-2231-6
U.S. Department of Health and Human Services. (n.d.). Home visiting evidence of effectiveness. Retrieved from https:// homvee.acf.hhs.gov/default.aspx
Vari, P., Vogeltanz-Holm, N., Olsen, G., Anderson, C., Holm, J., Peterson, H., & Henly, S. (2013). Community breastfeeding attitudes and beliefs. Healthcare for Women International, 34(7), 592–606. doi:10.1080/07399332.2012.655391
Poe, S. S., & White, K. K. (2010). Johns Hopkins nursing evidence- based practice: Implementation and translation. Indianapolis, IN: Sigma Theta Tau International.
Population Health Interest Group. (2013). Public health nursing in Ireland: Demonstrating interventions from practice. Dublin, IE: Institute of Community Health Nursing.
Quad Council of Public Health Nursing Organizations. (2011). The Quad Council competencies for public health nurses. Retrieved from http://www.achne.org/files/Quad%20Council/ QuadCouncilCompetenciesforPublicHealthNurses.pdf
Raile Alligood, M. (2010). Family healthcare with King’s theory of goal attainment. Nursing Science Quarterly, 23(2), 99–104.
Schaffer, M. A., Anderson, L. J. W., & Rising, S. (2016). Public health interventions for school nursing practice. Journal of School Nursing, 32(3), 195–208. doi:10.1177/1059840515605361
Schaffer, M. A., Keller, L. O., & Reckinger, D. (2015). Public health activities: Visible or invisible? Public Health Nursing, 32(6), 711–720. doi:10.1111/phn.12191
Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice: Step by step. American Journal of Nursing, 110(5), 41–47.
EBSCOhost – printed on 1/15/2023 5:35 AM via MINNESOTA STATE UNIVERSITY – MANKATO. All use subject to https://www.ebsco.com/terms-of-use

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