PART I
Foundational 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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AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model
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3

‘‘

’’

CHAPTER

1Introduction to Public
Health Nursing Practice

n Patricia M. Schoon
with Marjorie A. Schaffer and Jill Timm

Abby will soon be starting her public health nursing clinical and is struggling with the idea of practicing
nursing outside the hospital. She is talking about public health clinicals with Alberto and Sia at lunch.
“I can’t imagine myself out in someone’s home, or in a school, or in a community center or public health
agency. I’m not sure I know what I’m supposed to do. I also wonder how I will be respected without scrubs
or my uniform. Is it really true that one of the most important skills in public health is listening and that
sometimes that is all that you do? I feel like I should be doing something more.”

Alberto responds, “My friend, Zack, had public health last semester. He said that it was interesting to
consider listening as its own intervention. It was hard to not jump in and ‘teach’ immediately. He often
wanted to do more. After a while, he started to get comfortable and also started to understand the benefits
of really trying to understand the perspectives of clients in the community.”

Sia comments, “I worry about all of this too. I was talking with Jen, a friend of mine who took public
health last year. She said that on her first home visit, she went with her public health nursing preceptor.
This gave her a chance to get a sense for the family’s needs and possible interventions.”

Abby says, “I am really worried about being out alone. I wonder what the neighborhood where my
family lives will be like and whether I will be safe.”

Sia states, “I’m also curious about the various public health nursing roles that we may be able to
observe or do. It seems like the field is so broad and there are so many things to consider.”

ABBY’S NOTEBOOK

USEFUL DEFINITIONS

Client: A client (syn. patient) is the individual/family, community, population or subpopulation, or system that is
the public health nurse’s focus of care.

Community: A community can refer to (a) a group of people or a population group, (b) a physical place and time
in which the population lives and works, or (c) a cultural group that has shared beliefs, values, institutions, and
social systems (Dreher, Shapiro, & Asselin, 2006, p. 23).

Health Determinants: Health determinants are factors that influence the health of individuals, families, and
populations. Health determinants can potentially have a positive (protective factors) or negative (risk factors)
influence on health.

Health Status: Health status refers to the level of health or illness and is the outcome of the interaction of the
multiple health determinants. Health status indicators, also called global measures of population health, include
birth, longevity, and death rates (mortality); illness (morbidity) patterns; perception of wellness and life satisfac-
tion; level of independence; and functional ability.

(continues)

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4 PART I  n  Foundational Concepts for Public Health Nursing Practice

USEFUL DEFINITIONS (continued)

Holistic Nursing: Holistic nursing is defined as “all nursing practice that has healing the whole person as its goal
and honors relation-centered care and the interconnectedness of self, others, nature, and spirituality; focuses on
protecting, promoting health and wellness…” (Dossey & Keegan, 2016, p. 3).

Levels of Prevention: The levels of prevention comprise a health-intervention framework applied to the stages of
health and disease for individuals and groups (Leavell & Clark, 1958; Stanhope & Lancaster, 2008). The levels of
prevention are (a) primary—the prevention of disease and promotion of health; (b) secondary—early diagnosis
and treatment; and (c) tertiary— limiting of negative effects of disease and restoring of function.

Population: A population is defined as the “total number of people living in a specific geographic area.”
A subpopulation (syn. group or aggregate) “consist[s] of people experiencing a specific health condition;
engaging in behaviors that have potential to negatively affect health; or sharing a common risk factor or risk
exposure, or experiencing an emerging health threat or risk” (American Nurses Association [ANA], 2013, p. 3).

Population-Based Practice: Population-based practice focuses on the population as a whole to determine its
priority needs (Minnesota Department of Health [MDH], 2001).

Public Health: Public health refers to all organized measures (whether public or private) to prevent disease,
promote health, and prolong life among the population as a whole (World Health Organization [WHO], n.d.).

Public Health Nursing: Public health nursing is the practice of promoting and protecting the health of popula-
tions using knowledge from nursing, social, and public health sciences. Public health nursing is a specialty prac-
tice within nursing and public health. It focuses on improving population health by emphasizing prevention and
attending to multiple determinants of health. Often used interchangeably with community health nursing, this
nursing practice includes advocacy, policy development, and planning, which addresses issues of social justice
(American Public Health Association [APHA], Public Health Nursing Section, 2013, p. 1).

Social Determinants of Health: The social determinants of health are the conditions in which people are born,
grow, live, work, and age. The distribution of money, power, and resources at the global, national, and local levels
shape these circumstances. The social determinants of health are mostly responsible for health inequities—
the unfair and avoidable differences in health status seen within and between countries (Modified from
WHO, 2013).

System: A system is an institution or organization that exists within one or multiple communities.

ABBY’S NOTEBOOK

Practicing Nursing Where We All Live
Public health nursing care is provided to individu-
als, families, communities, and populations through a
population-based lens that enables nurses to view their cli-
ents within the context of the community in which they and
their clients live . All aspects of the client’s life are considered
as public health nurses (PHNs) carry out the nursing pro-
cess . PHNs practice in their communities, where they can
make a difference in the lives of their families, the people
they serve, and their communities on a daily basis .

As you practice nursing in a variety of clinical settings,
you will become aware that the health of people in your
families, neighborhoods, and communities affects every-
one in the community both socially and economically .
As you read this chapter, consider the concepts presented
from both your personal and professional perspectives . As
nurses, you are all citizens of the world and have civic and

professional responsibilities to promote health and provide
for a safe environment .

In the case study at the beginning of the chapter, Abby
and her friends are concerned about providing nursing
care in the community . It is difficult for nursing students
to think about practicing nursing outside the acute and
long-term care settings . Many of the skills that nursing stu-
dents learn in the acute or long-term care setting (e .g ., IV
therapy, medication administration, tube care) are part of
the delegated medical functions of nursing practice, which,
by necessity, are priorities when caring for acutely ill, frail,
and elderly individuals . In the community setting, most of
what PHNs do is part of the independent practice of nursing
(e .g ., teaching, counseling, coordinating care), as the focus
of public health nursing practice is primary prevention .
Components of public health nursing can be practiced in
any setting, although they are most often practiced in the

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5CHAPTER 1  n  Introduction to Public Health Nursing Practice

whole to determine the community’s priority health needs
(Minnesota Department of Health [MDH], Public Health
Nursing Section, 2000, 2001; MDH, Center for Public Health
Nursing, 2003) . PHNs in a variety of work settings can carry
out population-based practice . To be population based, pub-
lic health nursing practice should meet five criteria:

1. Focus on entire populations possessing similar health
concerns or characteristics

2. Be guided by an assessment of population health
status that is determined through a community
health assessment process

3. Consider the broad determinants of health
4. Consider all levels of prevention, with a preference

for primary prevention
5. Consider all levels of practice (individual/ family,

community, system) (MDH, 2001, pp . 2–3;
MDH, 2003)

PHNs work in homes, clinics, schools, jails, businesses,
religious organizations, homeless shelters, camps, hospitals,
visiting nurse associations, health departments, and Indian
reservations . Public health nursing is defined by its goals,
not by its setting . Although public health nursing is con-
sidered a specialty area of practice, its standards include
expectations for entry-level baccalaureate nursing gradu-
ates . Even at the entry level, PHNs are expected to function
as change agents and to help shape the healthcare system
to meet the public health needs of the 21st century . This
leadership expectation for public health nursing practice is
implicit in the American Nurses Association’s Public Health
Nursing: Scope and Standards of Practice (ANA, 2013) . The
American Public Health Association (APHA) definition of
public health nursing, “the practice of promoting and pro-
tecting the health of populations using knowledge from
nursing, social, and public health sciences” (APHA, 2013,
p .  2), implies the importance of the scientific knowledge
base for PHN practice .

community . Not all nursing practiced in the community
can be described as public health nursing . For example,
home care and hospice care, both very important areas of
nursing, are practiced in the community and exhibit com-
ponents of public health nursing but are not traditionally
categorized as public health nursing . As you work through
this book and engage in nursing activities, think about how
you are integrating the components of public health nursing
into your nursing practice . Also, think about how you prac-
tice nursing where you live and what your civic and pro-
fessional responsibilities are to promote the health of your
community .

Public Health
The practice of public health nursing includes components
of public health and is a part of the broader field of public
health . It is important to understand the nature and scope
of public health practice . Public health practice focuses on
protecting and promoting the health of entire populations .
This practice includes the prevention of disease and injury
and the promotion of the social conditions and lifestyles
that maintain health and prolong life .

Public health professionals monitor and diagnose the
health concerns of entire communities and promote healthy
practices and behaviors to ensure that populations stay
healthy . The World Health Organization uses the term
“global public health” to recognize that, as a result of glo-
balization, forces that affect public health can and do come
from outside state boundaries . Responding to public health
issues now requires paying attention to cross-border health
risks, including access to dangerous products and environ-
mental change (WHO, n .d .) . PHNs need to take a global
perspective about the nature of population health threats
and issues when practicing in the community .

Public Health Nursing
Public health nursing combines the theory and practice
of nursing and public health . Public health nursing, like
nursing practice everywhere, involves the interaction of the
nurse and client; the health of the client; the influence of the
home, healthcare, and community environment; and the
nursing care provided . One of the unique features of pub-
lic health nursing is that the client can be an individual or
family, a group of people, or a whole community . The client
could also be a system within the community (e .g ., a school,
church, or community health or social service agency) .
PHNs work to improve population health at the local, state,
national, and international levels (ANA, 2013; APHA, 2013) .
Public health nursing goals are to promote and preserve
the health of populations and the public, prevent disease
and disability, and protect the health of the community as
a whole .

Public health nursing practice is considered population-
based because it starts by focusing on the population as a

Definition of Public Health Nursing Practice

Up to this point in your nursing education, you have focused
on nursing care of individuals and families. Public health
nursing is population based and focuses on population
health. “Public health nursing is the practice of promoting
and protecting the health of populations using knowledge
from nursing, social, and public health sciences. Public
health nursing is a specialty practice within nursing and
public health. It focuses on improving population health by
emphasizing prevention, and attending to multiple deter-
minants of health” (APHA, 2013, p. 1). While public health
nursing practices include primary, secondary, and tertiary
prevention, the focus is on primary prevention.

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6 PART I  n  Foundational Concepts for Public Health Nursing Practice

in 1881 (Kulbok, Thatcher, Park, & Meszaros, 2012; Kub,
Kulbok, & Glick, 2015; see Figure 1 .1) . PHNs saw themselves
not only as caregivers but also as advocates for those living
in unhealthy conditions and experiencing unmet health-
care needs . Care of the ill soon expanded to care of those
at risk for poor health and to populations and entire com-
munities . Disease prevention and health promotion for vul-
nerable or at-risk populations in diverse settings became a
second focus .

Until the late 1960s, PHNs working for governmental
public health agencies generally provided services to two
at-risk populations: mothers and children, and adults living
at home with chronic diseases and disabilities . When Medi-
care legislation was enacted in 1966, home care became a
covered service, and private agencies began to offer home
care services (see Chapter 7) . Many public health agencies
renewed their commitment to the goals of health promotion,
disease prevention, and protection and risk reduction, and
they stopped providing home care to adults with chronic
diseases and disabilities . PHNs increased their efforts to
address the social determinants of health, which are dis-
cussed later in this chapter . Today, public health nurses
often work with community groups as well as individuals
and families . Community engagement, population-based
advocacy, collaboration with other community agencies
and groups, and community organizing are all part of the
scope of practice of public health nurses (see Chapters 2, 5,
and 10) . At the same time, nurses practicing in a variety of
non-traditional public health settings (e .g ., home care, hos-
pice, faith-based nursing, institutional and insurance care
coordination and care management, etc .) use public health
nursing principles and public health interventions in their
practice .

Emerging threats to public health require a dramatic shift
in the focus of healthcare, public health, and public health
nursing . ANA (2013, p . 2) has identified six 21st- century
threats that form a context for the current and future direc-
tions of public health nursing practice:

1. Reemergence of communicable disease and increas-
ing incidence of drug-resistant organisms

2. Environmental hazards
3. Physical or civic barriers to healthy lifestyles (e .g .,

food “deserts”)
4. Overall concern about the structure and function of

the healthcare system
5. Challenges imposed by the presence of modern

public health epidemics, such as pandemic influenza,
obesity, and tobacco-related diseases and deaths

6. Global and emerging crises with increased opportu-
nities for exposure to multiple health threats

Nursing continues to expand its leadership role in
healthcare in all settings, but in public health nursing, that
leadership role often takes place in the community, includ-
ing in the public policy–making arena (ANA, 2003, 2013) .

As students, you have already learned about nursing
core concepts that also shape public health nursing, which
include (Keller, Strohschein, & Schaffer, 2011):
n Care and compassion
n Holistic and relationship-centered practice
n Sensitivity to vulnerable populations
n Independent nursing practice

This book also introduces you to additional public health
core concepts that shape public health nursing, which
include (Keller et al ., 2011):
n Social justice
n Population focus
n Reliance on epidemiology
n Health promotion and prevention
n The greater good
n Long-term commitment to community

Evolution of Public Health Nursing
In this chapter, you will read about how nurses practice pub-
lic health nursing in the community, and you will consider
how important nurses are to the health of communities at
the local, national, and international levels . It is important
to mention two key founders of public health nursing . Since
the time of Florence Nightingale, the first public health
nurse, nurses have always been essential participants in
improving and maintaining the health of individuals, fami-
lies, and communities . Nightingale, who started her nursing
career in 1850, provided leadership for the health of vulner-
able populations by advocating for changes in the organiza-
tions and communities that were responsible for providing
healthcare (Selanders & Crane, 2012) . Nightingale focused
on managing the environment of those who needed care,
whether it was on the Crimean War battlefields or work-
ing with the London poor . Her concerns about the impact
environmental conditions had on health and her work to
advocate for healthful environments is as relevant today as
it was in the 1800s (Davies, 2012) . Lillian Wald, the founder
of modern-day public health nursing, founded the Henry
Street Settlement in 1893 to provide nursing services to the
indigent citizens of New York . In 1903, Wald, in collabo-
ration with Metropolitan Life, started the first insurance
reimbursement for nurse home visiting and demonstrated
its effectiveness (Abrams, 2008; Buhler-Wilkerson, 1993) .
The Henry Street Settlement House continues to provide
health and social services today .

Public health nursing in the United States developed out
of a need to provide nursing services to individuals and
families who had unmet health needs, and started with
Clara Barton, who founded the American Red Cross as a
response to the needs of injured and ill Civil War soldiers

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7CHAPTER 1  n  Introduction to Public Health Nursing Practice

‘‘

’’

Cornerstones of Public Health Nursing
The Cornerstones of Public Health Nursing (Minnesota
Department of Health [MDH], Center for Public Health
Nursing, 2007) provide the foundation for population-based
nursing practice (Keller et al ., 2011) . The Cornerstones reflect
the values and beliefs that guide public health nursing prac-
tice, and they are also closely related to the ANA Principles
of Public Health Nursing Practice (ANA, 2013), as repre-
sented in Table 1 .1 .

These Cornerstones are reflected in PHNs’ daily practice
when they:
n Organize their workload and schedule based on priority

health needs of clients and community
n Take time to establish trust when visiting families in

their homes
n Carry out holistic assessments of individuals and

families within the context of culture, ethnicity, and
communities

n Use evidence-based practice from nursing and pub-
lic health sciences to select appropriate and effective
interventions

n Collaborate with other members of the healthcare team
n Make critical decisions about the needs of their clients

and the selection, implementation, and evaluation of
interventions based on their professional knowledge and
professional licensure

A key principle to keep in mind is that PHNs must place
more importance on goals related to the public good than
goals for the benefit of individuals in the social and eco-
nomic systems (see Chapter 13 for a discussion of social jus-
tice and Chapter 14 for a discussion of public health nursing
leadership) .

“I still don’t really understand how we are going to factor in
community or environmental needs when we are working
with individuals.” Albert sighs.

Sia responds, “What I remember from our public health
theory class this morning is that even though we are meet-
ing people in their homes, we have to take into account the
home environment and the community. Our instructor
also talked about public health nurses having a responsibil-
ity to improve the health of the public at the local, national,
and international levels. She mentioned that this idea can
be overwhelming for nursing students and suggested that
we focus on what we could do to improve the health of indi-
viduals and families as a way to help improve the health of
our community. She used the term ‘glocal,’ which means to
think global, but act local.”

Abby adds, “Maybe we should read more about this in
our textbook and look at some of the websites suggested.”

“Good idea,” says Sia.

FIGURE 1.1 Public Health Nursing in the United States
Sources: Abrams, 2008; Buhler-Wilkerson, 1993; Kub, Kulbok, & Glick, 2015;

Visiting Nurses Association of Western New York, n.d.

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8 PART I  n  Foundational Concepts for Public Health Nursing Practice

‘‘

’’

and developmental delays. Abby’s PHN preceptor modifies
her home-visiting plan for the day so that she can make
an initial visit to this family at the local family homeless
shelter. The family speaks Spanish but the PHN does not, so
she arranges for an interpreter to accompany them on the
visit to this family. The PHN has Abby gather information
about local homeless shelters and food banks to take to the
visit and has her get some bus passes for the family to use
when they go to different agencies to apply for assistance.
The PHN also brings along important phone numbers so
that she can assist the family with follow-up regarding their
application for cash assistance. After her busy day with her
PHN preceptor, Abby discusses her visit to the homeless
family with Alberto and Sia that evening. Their instructor
has challenged them to identify the Cornerstones of Public
Health Nursing found in their clinical visits that day.

Activity
Keep a log of your nursing activities. Reflect on how you have 
demonstrated the cornerstones of public health nursing in your 
clinical activities.

Abby is spending the day with her PHN preceptor. Her pre-
ceptor receives a referral to visit a family who just moved
into the community and is homeless. The PHN knows
that a health priority for her community and agency is to
improve the health of homeless populations, particularly
those in the population with young children. Recent data on
the health needs of her county demonstrate that young chil-
dren in homeless families have higher rates of malnutrition

TABLE 1.1 Cornerstones of Public Health Nursing and Related ANA Principles of PHN Practice

Cornerstones of Public Health Nursing ANA Principles of Public Health Nursing Practice

Focuses on the health of entire populations The client or unit of care is the population .

Reflects community priorities and needs The primary obligation is to achieve the greatest good for the greatest
number of people or the population as a whole (also related to the
social justice cornerstone) .

Establishes caring relationships with communities,
systems, individuals, and families

NA

Is grounded in social justice, compassion, sensitivity to
diversity, and respect for the worth of all people, especially
the vulnerable

A public health nurse is obligated to actively identify and reach out to
all who might benefit from a specific activity or service .

Encompasses mental, physical, emotional, social, spiritual,
and environmental aspects of health

Public health nursing focuses on strategies that create healthy envi-
ronmental, social, and economic conditions in which populations
may thrive .

Promotes health through strategies driven by
epidemiological evidence

Optimal use of available resources and creation of new evidence-
based strategies is necessary to ensure the best overall improvement
in the health of the population .

Primary prevention is the priority in selecting appropriate activities .

Collaborates with community resources to achieve those
strategies but can and will work alone if necessary

Public health nurses collaborate with the client as an equal partner .

Collaboration with other professions, populations, organizations, and
stakeholder groups is the most effective way to promote and protect
the health of the people .

Derives its authority for independent action from the
Nurse Practice Act

NA

Sources for Cornerstones: Keller et al ., 2011; MDH, Center for Public Health Nursing, 2007
Source for ANA Principles: ANA, 2013, pp . 8–9

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9CHAPTER 1  n  Introduction to Public Health Nursing Practice

Holistic Foundations of
Public Health Nursing
Public health nursing and holistic nursing practice have
common roots . Florence Nightingale, who believed in care
that focused on unity, wellness, and the interrelationship of
human beings and their environment, is considered to be
one of the first holistic nurses . She is known for her global
vision, leadership, and advocacy (Beck, 2010; Dossey &
Keegan, 2016; Selanders & Crane, 2012) . Lillian Wald was
as concerned about the health of the indigent of New York
as she was about their social welfare, the tenement envi-
ronment in which they lived, and the cultural and political
environment that needed to change in order to improve the
health of her clients and her community (Buhler- Wilkerson,
1993) . Both Nightingale’s and Ward’s nursing practices have
informed contemporary holistic public health nursing
practice .

A contemporary nursing theory that reflects the synthe-
sis of nursing and public health and reflects holistic pub-
lic health nursing practice is Watson’s Theory of Human
Caring, in which the nurse and the client exist within a
caring-healing environment . Watson was greatly influenced
by the practice of Florence Nightingale and built upon Night-
ingale’s work in emphasizing the “curative factors” of dis-
ease and illness, embracing the wholeness of the individual .
The Theory of Human Caring reflects an expansive sharing
process that changes the self, others, the culture, and the

environment; respects the beliefs of others; and recognizes
and is open to unexpected life events (Parker & Smith, 2010;
Watson, 2008, p . 34, 2010) . Some of the public health nursing
theoretical perspectives that you will find in later chapters
reflect this synthesis of public health nursing and holistic
nursing into holistic public health nursing practice .

Scope and Standards of
Public Health Nursing Practice
All professional nurses, regardless of their clinical areas of
practice, have a scope of practice . A scope of practice refers
to the boundaries of safe and ethical practice (see Chapter 6
for a discussion of the scope of practice of public health
nursing) and depends on four components: educational
preparation, credentials, state licensure law, and clinical or
employer role description . A PHN’s job description is a good
measure of the nurse’s scope of practice .

Professional nurses are also guided by standards of prac-
tice developed by their professional nursing organizations .
One nationally accepted set of standards for public health
nursing is the American Nurses Association (ANA) publi-
cation Public Health Nursing: Scope and Standards of Prac-
tice (2013); Table 1 .2 lists these standards . Specific criteria
for operationalizing these standards and measuring perfor-
mance are included in the publication .

TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance

Standards of Public Health Nursing Practice

Standard 1. Assessment: The public health nurse collects comprehensive data pertinent to the health status of populations .

Standard 2. Population Diagnosis and Priorities: The public health nurse analyzes the assessment data to determine the diagnosis
or issues .

Standard 3. Outcomes Identification: The public health nurse identifies expected outcomes for a plan specific to the population or
issues .

Standard 4. Planning: The public health nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes .

Standard 5. Implementation: The public health nurse implements the identified plan .

Standard 5A. Coordination of Care: The public health nurse coordinates care delivery .

Standard 5B. Health Teaching and Health Promotion: The public health nurse employs multiple strategies to promote health and a
safe environment .

Standard 5C. Consultation: The public health nurse provides consultation to influence the identified plan, enhance the abilities of
others, and effect change .

Standard 5D. Prescriptive Authority: Not applicable .

Standard 5E. Regulatory Activities: The public health nurse participates in the application of public health laws, regulations,
and policies .

Standard 6. Evaluation: The public health nurse evaluates progress toward the attainment of outcomes .

Standard 7. Ethics: The public health nurse practices ethically .

(continues)

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10 PART I  n  Foundational Concepts for Public Health Nursing Practice

Standards of Professional Performance

Standard 8: Education: The public health nurse attains knowledge and competence that reflect current nursing practice .

Standard 9. Evidence-based Practice & Research: The public health nurse integrates evidence and research findings into practice .

Standard 10. Quality of Practice: The public health nurse contributes to quality nursing practice .

Standard 11. Communication: The public health nurse communicates effectively in a variety of formats in all areas of practice .

Standard 12. Leadership: The public health nurse demonstrates leadership in the professional practice setting and the profession .

Standard 13. Collaboration: The public health nurse collaborates with the population and others in the conduct of nursing practice .

Standard 14. Professional Practice Evaluation: The public health nurse evaluates her or his own nursing practice in relation to
professional practice standards and guidelines, relevant statutes, rules, and regulations .

Standard 15. Resource Utilization: The public health nurse utilizes appropriate resources to plan and provide nursing and public
health services that are safe, effective, and financially responsible .

Standard 16. Environmental Health: The public health nurse practices in an environmentally safe, fair, and just manner .

Standard 17. Advocacy: The public health nurse advocates for the protection of the health, safety, and rights of the population .

Source: American Nurses Association, 2013, pp . 28–64

TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance (continued)

Activity
n Review your preceptor’s job description with your preceptor. 

n Share the list of the ANA practice standards for public 
health nursing. 

n Discuss how your preceptor’s job description and nursing 
practice incorporate specific ANA standards. 

Global Nature of Public Health Nursing
Public health nurses are citizens of the world as well as
their own communities . Travel, communication technol-
ogy, immigration patterns, the global spread of disease, and
the universality of the social determinants of health in all
geographic areas and cultures have changed the nature of
public health nursing practice .

In 2015, the United Nations (UN) General Assembly
adopted resolution 70/1. Transforming Our World: The 2030
Agenda for Sustainable Development (2015) . This resolution
addresses the social determinants of health at a global level
and sets out an action plan for people, the planet, prosper-
ity, peace, and partnership . This action plan identifies 17
Sustainable Development Goals (SDGs) . These goals, repre-
sented by the following set of icons (see Figure 1 .2), provide
a framework for the public health nursing practice wherever
PHNs practice . Examples of how SDGs are addressed will
be highlighted throughout the chapters of this book .

EVIDENCE EXAMPLE 1.1
Health in All Policies

In 2017, an International Health in All Policies Conference
was convened in Adelaide, Australia to strategize over how
to make progress in achieving the SDGs. A major outcome
of the conference was Health in All Policies: Governance, Part-
nerships and the Sustainable Development Agenda, Adelaide
Statement II on Health in All Policies 2017.
The statement stresses that:

n “Health is a political choice, and as such any political,
economic, social and ecological decision has health and
equity impacts. Mayors play a critical role in agenda
2030 and health.

n The SDGs are indivisible and universal and should not
be addressed in silos but rather through taking into
consideration their interconnectedness.

n The transformative strategies for implementing the
SDGs require joint action and policy coherence through
the various levels of the government. Thus, health
literacy is critical to good governance” (WHO, 2017).

As nurses who care about the social environment in
which you and the populations you serve live, you need to
consider how your nursing practice fits into both the SDGs
and the Health in All Policies approach within your local,
national, and global communities .

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11CHAPTER 1  n  Introduction to Public Health Nursing Practice

Ethnic diversity in the community requires a complex ethi-
cal framework that includes the complementary approaches
of rule ethics, virtue ethics, and feminist ethics (Racher,
2007; Volbrecht, 2002) .

Rule ethics uses a framework of guiding principles
for decision-making (Racher, 2007) . Examples of rules
or principles include autonomy, beneficence (promoting
good), nonmaleficence (preventing harm), justice, loyalty,
truth-telling, and respect (Aiken, 2004; Beauchamp & Chil-
dress, 1979; Purtilo, 2005; Scoville Walker, 2004) . Rule eth-
ics is based on a biomedical model of decision-making .

In contrast, virtue ethics is based on good character
(Racher, 2007) . One’s actions are evaluated in the context
of one’s community . Examples of nursing virtues include
compassion, honesty, courage, justice, self-confidence, resil-
ience, practical reasoning, and integrity (Volbrecht, 2002) .

Feminist ethics focuses on building relationships and
reducing oppression in society (Volbrecht, 2002) . Key values
in a feminist ethics approach are inclusion, diversity, partic-
ipation, empowerment, social justice, advocacy, and inter-
dependence (Racher, 2007) . Table 1 .3 provides additional
explanations about these three ethical approaches .

This three-pronged ethical approach is used throughout
the book to highlight ethical concerns and principles related
to specific public health nursing competencies .

Ethical Framework for
Public Health Nursing
The ever-changing healthcare environment, complex health-
care systems, and technological changes require a dual
approach according to Ivanov and Oden (2013) . They recom-
mend that PHNs employ a rights-based approach consistent
with the Universal Declaration of Human Rights passed by
the United Nations (UN) in 1948 (United Nations, 1948) and
an ethical approach based on ethical standards for nursing
practice published by the American Nurses Association . The
International Council of Nurses (ICN), in its position state-
ment on Nurses and Human Rights (2011; p . 1), states that “all
human rights are interdependent and indivisible and that
individuals’ health and wellbeing can be harmed when their
human rights in any category are violated .”

Other authors propose a complementary ethical frame-
work that addresses the diversity of client populations and
settings . PHNs might experience ethical problems when
they have to consider the impact or benefits and burdens
of their decisions on multiple clients, population groups,
and communities (Racher, 2007) . Culturally diverse soci-
eties and communities might have moral standards differ-
ent from each other’s and from those of the PHNs, which
could lead to conflicts between the PHNs and clients .

FIGURE 1.2 UN Sustainable Development Goals With Icons
Source: United Nations General Assembly, 2015

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12 PART I  n  Foundational Concepts for Public Health Nursing Practice

’’

‘‘

The Cornerstones, health determinants framework, and
levels of prevention are included in this chapter . The pub-
lic health nursing process and Public Health Intervention
Wheel are discussed in Chapter 2 . In the United States,
PHNs and other public health professionals who work for
governmental public health agencies have a scope of prac-
tice that is based on identified core public health functions
and the essential services of public health (IOM, 1988) . Chap-
ter 7 discusses the responsibility and accountability of PHNs
who work in governmental agencies .

“Well, this is all very interesting. But I still don’t have a clue
how I am actually going to practice public health nursing,”
Albert sighs.

Sia responds, “I’m realizing that there are a variety of
roles in public health nursing. Some PHNs might spend
their time working with individual families, but they still
have to consider global impacts on health. Our instruc-
tor told us we would be practicing at the individual/fam-
ily level of practice during most of our clinical time. But, I
know we still need to consider how basic human rights are
impacted by public health nursing work. There are a lot of
good internet videos on human rights. I suppose we could
look at them. And there is additional information in the
textbook itself.”

Abby states, “Great! But I think I want to spend more
time actually doing something. I am going to spend a day
with my preceptor tomorrow. Maybe I can apply some of
what I have read and watched on the web.”

Practicing Public Health Nursing
As a student, you will probably be spending most of your
clinical hours working with individuals and families . How-
ever, the role of the PHN is broader; PHNs also spend time
working with community groups and other members of the
community team . Public health nursing is carried out at
different levels of practice within society: individual/family,
community, and systems (MDH, 2001, pp . 4–5) .

Individual/Family Level of Practice
PHNs work with individuals and families to promote health
and reduce risks . The family is the essential unit of all com-
munities and societies . A family is defined as a social unit
of two or more people who identify themselves as a fam-
ily, share emotional bonds, and carry out the functions of a
family, including managing healthcare (Clark, 2008; Fried-
man, Bowden, & Jones, 2003; Martin, 2005) .

PHNs work with individuals and families in many differ-
ent community settings (see Chapter 3 for information on

TABLE 1.3 Ethical Framework for
Public Health Nursing Practice

Rule Ethics
n Rule ethics defines rules or principles that are based on

perceptions of fairness .
n Ethical principles are standards of conduct that guide

behavior and specify moral duties and obligations
(Racher, 2007) .

n Community rights might be given priority over individual
rights in some situations .

n Resources are given based on need and thus might be
distributed unequally (distributive justice) .

n Those who have been unfairly burdened or harmed are
compensated (compensatory justice) .

Virtue Ethics
n Virtue ethics identifies characteristics of the individual

(moral agent) and that person’s intentions and behaviors .
n An individual is responsible for developing good character

and good community (Volbrecht, 2002) .
n This type of ethics provides the foundation for professional

ethics, which specifies professional values and virtues .

Feminist Ethics
n A core ideal is achieving social justice; feminist ethics

applies social justice and distributive justice to social struc-
tures and context .

n This ethical approach focuses on characteristics of rela-
tionships, strengthens relationships and connectedness,
eliminates oppression, and realigns power imbalances .

n Feminist ethics is committed to restructuring relation-
ships, social practices, and institutions so that people can
live freer and fuller lives (Volbrecht, 2002) .

Key Components of
Public Health Nursing
The key components of public health nursing practice dis-
cussed in this book include:
n Cornerstones of Public Health Nursing (MDH, 2007)
n Core public health functions and essential services of

public health (IOM, 1988)
n The standards of public health nursing practice

(ANA, 2013)
n Health determinants framework (U .S . Department of

Health and Human Services [U .S . DHHS], n .d .-b)
n Levels of prevention (Leavell & Clark, 1958; Stanhope

& Lancaster, 2008)
n Public health nursing process (ANA, 2013; MDH, 2001)
n Public Health Intervention Wheel (MDH, 2001)

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13CHAPTER 1  n  Introduction to Public Health Nursing Practice

PHNs practice at the systems level when they work with
providers and professionals like teachers, social workers,
nurses, doctors, government officials, and members of the
business community working for different agencies . If you
are working with members of systems to help these systems
adapt or change their values, health beliefs, or the way they
conduct their business (behaviors) so that they can improve
their capacity to meet the health needs of those they serve,
then you are working at the systems level of practice .

The Relationships Between
Individuals/Families, Communities,
and Systems
Individuals, families, and systems are best understood
within the context of the community in which you live .
Individuals and families interact with, and are influenced
by, their social and physical environments and the systems
that influence their health . For example, families living in
an inner-city neighborhood might not have access to a gro-
cery store with fresh fruits and vegetables or transportation
to the store . The neighborhood’s characteristics influence
family access to quality food and their nutritional well-
being . Figure 1 .3 shows an example of the interrelationships
among families, communities, and systems .

home visiting and family assessment) . Working with fam-
ilies in the community helps you understand the diverse
socioeconomic, cultural, and environmental factors that
influence the health, wellness, and disease of individuals
and families . If you are working with an individual or fam-
ily to help them adapt or change their values, health beliefs,
or behaviors to improve their health status, then you are
working at the individual/family level of practice .

Community Level of Practice
We tend to think of a community as a geographic place, but
a community may refer to any group of people who share
common values, culture, characteristics, and goals, whether
they live in a specific geographical locale or are separated
by distance (Skemp, Dreher, & Lehmann, 2016) . Commu-
nities are composed of people, organizations, and social
patterns of behavior . If you are working with members of
the community to help the community adapt or change its
values, health beliefs, or behaviors to improve the members’
health status, then you are working at the community level
of practice .

PHNs work with two types of populations in the commu-
nity: populations of interest and populations at risk (MDH,
2001, p . 2) . Table 1 .4 defines and provides examples of these
populations .

Systems Level of Practice
A system is an institution or organization that exists within
one or multiple communities . Key systems include health-
care systems, public health systems, schools, churches, gov-
ernment agencies, nonprofit organizations, and businesses .

TABLE 1.4 Populations Served by
Public Health Nurses

Population Examples

Population of Interest:
Population who is
essentially healthy but
could improve factors
that promote or protect
health (MDH, 2001)

n Families who live in urban
areas with little opportunity
for exercise because of lack
of parks, playgrounds, or
bike paths

n College students who have
increased stress because of
study needs and college debts
and are looking for ways to
reduce their stress level

Population at Risk:
Population with a
common identified risk
factor or risk exposure
that poses a threat to
health (MDH, 2001)

n Children who are not immu-
nized for major childhood
illnesses, such as measles and
chickenpox

n Older members of a church
congregation who live alone
and are at risk for falls

FIGURE 1.3 Interrelationships of Families, Communities,  
and Systems

Individual/Family—
No access to grocery store
with fresh fruit and vegetables;
no transportation to
supermarket 5 miles away

Community—
No community
action plan
exists to bring
supermarket
or community
market to
inner-city
neighborhood

System—
No for-profit grocery store
chain wants to locate in
inner-city neighborhood

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14 PART I  n  Foundational Concepts for Public Health Nursing Practice

To make a difference for these families and others in
their inner-city neighborhood, PHNs might carry out the
following interventions:

n Refer families who are eligible for food benefits and
nutrition services to Women, Infants, and Children
(WIC)—individual/family level of practice .

n Work with a community action council to make its
members aware of problems in their inner-city neigh-
borhood and assist them with taking action to obtain
bus service from the neighborhood to a shopping center
or supermarket—community level of practice .

n Help form a coalition of nonprofit organizations and
businesses to bring a cooperative store or other full-
service grocery store to the neighborhood—systems
level of practice .

Table 1 .5 summarizes the three levels of PHN practice
and provides examples of how public health nursing is car-
ried out at these levels . These are all actions that you as a stu-
dent or a newly practicing public health nurse can also take .

TABLE 1.5 Levels of Public Health Nursing Practice

Individual/Family Level Examples

“Population-based, individual-focused practice changes knowl-
edge, attitudes, beliefs, practices, and behaviors of individuals .
This practice level is directed at individuals, alone or as part of
a family, class, or group . Individuals receive services because
they are identified as belonging to a population at-risk” (MDH,
2001, p . 5) .

n Make home visits to newborns and their parents .
n Teach hand-washing to a first-grade class .
n Assess for the presence of lead-based paint in a home with

preschool children .
n Develop a fall-prevention plan for an elderly person living

alone .

Community Level Examples

“Population-based, community-focused practice changes com-
munity norms, community attitudes, community awareness,
community practices, and community behaviors . They [PHNs]
are directed toward entire populations within the community
or occasionally toward target groups within those populations .
Community-focused practice is measured in terms of what pro-
portion of the population actually changes” (MDH, 2001, p . 4) .

n Write a letter to the editor of a local paper to stress the
value of home visits to parents of newborns .

n Create a billboard about the hazards of lead-based paint .
n Participate in a community “town hall” meeting to make

the community aware of safety hazards for elderly people
living alone .

Systems Level Examples

“Population-based, systems-focused practice changes organiza-
tions, policies, laws, and power structures . The focus is not directly
on individuals and communities but on the systems that impact
health . Changing systems is often a more effective and long-lasting
way to impact population health than requiring change from every
single individual in a community” (MDH, 2001, pp . 4–5) .

n Meet with legislators to advocate for reimbursement for
home visits with families of newborns .

n Develop a hand-washing program at an elementary school .
n Teach real-estate agents how to recognize lead-based paint

in a home .
n Develop a fall-prevention protocol for nurses working with

the elderly in the community .

Health Determinants
Public health nurses consider the multiple factors that
determine the health of their clients . Health determinants
are factors that influence the health of individuals, families,
and populations . Health determinants can have a positive or
negative influence on health . Table 1 .6 presents examples of
protective and risk factors at all three levels of practice for
communicable disease in childhood:
n Protective factors are health determinants that pro-

tect a person from illness or assist in improving the
person’s health .

n Risk factors are health determinants that contribute
to the potential for illness to occur or to a decrease in
health or well-being .

Just as holistic nursing practice focuses on the whole,
public health nursing focuses on the whole by identifying
all of the factors that influence the health of individuals,
families, and communities . To ignore this wholeness of the
living condition is to ignore many factors that impact health
and the ability of public health nurses to promote health .
Biological, behavioral, and environmental factors interact

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15CHAPTER 1  n  Introduction to Public Health Nursing Practice

TABLE 1.6 Protective and Risk Factors for Childhood Communicable Diseases

Protective Factors by Level of Practice

Individual/Family Level
n Family has insurance that covers

immunizations .
n Children are up to date on

immunizations .
n Parents teach children proper

hand-washing and the benefits of
covering their mouths when coughing .

Community Level
n 95% of children in the community are

immunized (herd immunity) .
n Community billboards urge parents to

immunize their children .
n Low-density housing or single-

dwelling homes reduce contact
between infected and noninfected
children .

Systems
n Immunizations are available at public

health clinics, pharmacies, and medi-
cal clinics .

n Free or low-cost immunizations are
available to the uninsured .

n Childcare center has effective infection
prevention and control practices .

Risk Factors by Level of Practice

Individual/Family Level
n Family is uninsured .
n Family members are not aware of the

need for immunizations .
n Parents are not aware of how to pre-

vent the spread of infectious diseases .

Community Level
n 45% of children in the community are

immunized (no herd immunity) .
n Some community groups oppose

childhood immunizations .
n Many high-density housing and apart-

ment complexes in the community
place people living close together at
greater risk .

Systems
n Immunizations are not available at the

public health clinic .
n Funding for low-cost immunizations

for the uninsured is lacking .
n School district does not track students’

immunization records .

and contribute to the health and illness of individuals, fam-
ilies, and populations (ANA, 2013; Marmot & Wilkinson,
1999; Zahner & Block, 2006) . Individuals and families are
able to influence or control some of their biological and
many of their behavioral health determinants but are not
able to control many of the physical and social environmen-
tal determinants of health that occur at the community and
systems levels . Health determinants shaped by social, eco-
nomic, and political forces, including systems put in place to
deal with illness, are called the social determinants of health .
(See Chapter 13 for further discussion on the social determi-
nants of health .) These social determinants of health affect
population health in all nations of the world .

The social determinants of health are the conditions in
which people are born, grow, live, work, and age . These cir-
cumstances are shaped by the distribution of money, power,
and resources at global, national, and local levels . The social
determinants of health are mostly responsible for health
inequities—the unfair and avoidable differences in health
status seen within and between countries (WHO, 2013) .

Health Status
PHNs use the community assessment process and public
health nursing process (see Chapter 3) to determine the
health statuses of individuals, families, communities, and

populations . Health status refers to the level of health or ill-
ness and is the outcome of the interaction of the multiple
health determinants . Health status indicators are frequently
represented by statistical measures, such as rates and per-
centages . Some common examples of population health
status indicators are teen pregnancy rates, percentage of
low-birthweight babies, neonatal mortality rates, percentage
of malnutrition in a group, and obesity rates . Rates and per-
centages of various population groups can be compared to
determine similarities or differences in the health status of
those groups . Health status comparisons can also be applied
at an individual level, such as identifying a child with mal-
nutrition as having a lower level of health than a child who is
not malnourished . Health status comparisons allow PHNs
to determine their priorities for actions with specific indi-
viduals, families, communities, and populations . Figure 1 .4
illustrates a health determinants model .

All of the Healthy People 2020 health determinants,
including access to healthcare, are represented in Fig-
ure 1 .4 (U .S . DHHS, n .d .-b) . This model represents a holistic
approach to assessment of the protective and risk factors
that determine health status in individuals, families, and
communities . Health determinants, including protective
and risk factors, exist at individual/family, community,
and systems levels, so nursing interventions should address
health determinants at all levels as needed . PHNs can use
this holistic approach to organize and identify the complex
contributors to the health status of specific individuals,

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16 PART I  n  Foundational Concepts for Public Health Nursing Practice

families, and populations and to develop interventions
to improve health . PHNs collaborate with their clients by
building and strengthening their protective factors and
helping them reduce their risk factors . The social determi-
nants of health that play a significant role in health dispari-
ties are discussed in Chapter 13 .

Activity
Review the following Health Determinants Analysis Case Study:

n Identify the health status indicators for this community.

n Identify health determinants, including protective and 
risk factors that contribute to the health status of this 
community. 

n Determine how you would work with community members to 
build on their protective factors and reduce their risk factors.

CASE STUDY
Health Determinants Analysis

A community assessment in a small rural community determines 
that  more  than  one-third  of  the  adult  residents  are  overweight 
or obese. The assessment reveals that 40% of the adults in this 
community  report  that  they  have  high  cholesterol,  and  30% 
report that they have high blood pressure. The majority of adults 
admit  to  eating  out  at  fast-food  restaurants  at  least  five  times 
a  week.  This  community  contains  many  fast-food  restaurants, 
and the most common foods sold in them are high in fat, sodium, 
sugar, and calories. This community has few outdoor recreational 
sites, such as bike and walking paths, and the county board has 
voted  against  increasing  tax  levies  to  provide  those paths.  The 
local hospital does provide evening and weekend health educa-
tion classes on modifying diet and exercise to lead a healthier life. 
A  coalition  of  healthcare  clinics,  the  public  health  agency,  and 
local businesses  is working on a plan  to  increase healthy  living 
resources in the community.

FIGURE 1.4 A Health Determinants Model for Individuals/Families, Communities, and Populations

Health Status
Levels of Health and/or Illness

Morbidity Rates (illness)
Mortality Rates (death)
Levels of Independence

Life Satisfaction
Comparisons with Others

• biological factors
• physical characteristics
• genetic factors
• health conditions

Biology

Behaviors
• health-seeking actions
• health-limiting actions
• lifestyle patterns
• socioeconomic status
• family, work, and

community roles
• levels of coping and

resilience
• language and literacy
• health literacy

Social Environment
• culture
• government
• education
• commerce
• religion
• health systems
• media
• social & economic

patterns Access to Healthcare

Physical Environment
• geography
• climate
• weather
• natural resources
• agriculture
• urban versus rural
• natural versus

built environment

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17CHAPTER 1  n  Introduction to Public Health Nursing Practice

‘‘

’’

Levels of Prevention
The levels of prevention (primary, secondary, and tertiary)
provide a framework for health-promotion and disease-
prevention efforts in the stages of the natural history of dis-
ease (Leavell & Clark, 1958; Stanhope & Lancaster, 2008) .
The health-promotion progression from primary to sec-
ondary to tertiary prevention provides a framework for
population-based public health nursing interventions at all
levels of public health nursing practice (MDH, 2001; Skemp
et al ., 2016) . It is important to determine the health status
of individuals/families, communities, and populations and
to determine the level of prevention for specific health con-
cerns to implement the appropriate interventions . Figure 1 .5
provides an overview of the stages of health, the levels of
prevention, and intervention approaches .

Although the focus of public health nursing is primary
prevention, public health nursing practice encompasses
all three levels . In contrast, within the hospital setting,
the focus of most nursing care is on ill patients and their
family members, and nurses more often provide secondary
and tertiary prevention but may also provide some primary
prevention . Table 1 .7 shows the definition of each level with
examples .

healthypeople.gov

Healthy
People

  Healthy People, a program of the U.S.  
  Department of Health and Human Services,  
  has established science-based benchmarks 
and 10-year national objectives for improving the health of all 
Americans. Healthy People 2020 is the third set of national 
health priorities identified over the last 3 decades. Its vision is “a 
society in which all people live long healthy lives” (U.S. DHHS, 
n.d.-b, p. 1). The mission and goals are displayed in Table 1.8. 
This national program seeks to involve all Americans by encour-
aging community and organizational collaboration, empowering 
individuals to make informed health decisions, and measuring 
the outcomes of prevention activities (U.S. DHHS, n.d.-b). 

“Okay! Now I understand why public health nurses do what
they do, but I am still not clear about what I am supposed
to do!” Albert states in an exasperated tone of voice.

Sia responds, “I guess we have to assess our clients’
health status, identify their health determinants, and
develop a plan of care that builds on their protective factors
and reduces their risk factors. Now it makes sense that we
would be mostly listening, teaching, and counseling. Did
you know that the words listen and silent have the same
letters? I guess we need to use silence to listen to our clients!”

Abby states, “I really like all the secondary and tertiary
prevention interventions that I do in the hospital setting, so
I am afraid I am going to get bored working in the commu-
nity. I can only sit and listen for so long. I like action!”

Albert reflects, “Primary prevention doesn’t have to
mean you are not doing anything. Just because there isn’t
already an illness or disease doesn’t mean there isn’t work
to do. Primary prevention is the way that we can identify
health determinants and make an impact. Our instructor
says we can apply public health nursing in any nursing
practice setting. Maybe I will think about how I can use
everything I learn in my community clinical in my hospital
practice. But, who knows, maybe I will decide to become a
public health nurse!”

Sia asks, “I understand what we are supposed to focus
on when we work with individuals and families, but I am
not sure how identifying their health statuses and health
needs fits in with the concept of population-based practice.
I guess I need to talk to my preceptor about how our home
visits fit in with the priority health needs of our community.
How do I know whether what we are doing reflects what the
community really wants public health nurses to do?”

FIGURE 1.5 Stages of Health and Disease and Levels of Prevention

Key
Interventions

Health
Promotion and

Prevention

Screening,
Diagnosis, and

Treatment

Rehabilitation,
Remediation,
Maintenance

Level of
Prevention

Primary Secondary Tertiary

Stage
of Health

Healthy Early Disease
or Injury

Chronic
Disease

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18 PART I  n  Foundational Concepts for Public Health Nursing Practice

TABLE 1.7 Prevention Continuum With Public Health Nursing Examples

Definitions Examples

Primary prevention promotes health and protects against
threats to it . It is designed to keep problems from occur-
ring in the first place . It promotes resiliency and protective
factors or reduces susceptibility and exposure to risk factors .
Primary prevention occurs before a problem develops . It
targets populations that are essentially well .

PHN Antepartal home visit:
n Teaching parents the importance of taking a newborn home from

the hospital in an approved car seat
n Providing parents with information about approved car seats

PHN Postpartum home visit:
n Checking the car seat to determine that it is correctly installed
n Monitoring the parents’ use of car seat

Secondary prevention detects and treats problems in their
early stages . It keeps problems from causing serious or
long-term effects or from affecting others . It identifies risks
or hazards and modifies, removes, or treats them before a
problem becomes more serious . Secondary prevention is
implemented after a problem has begun, possibly before
signs and symptoms appear . It targets populations that
share common risk factors .

PHN at WIC Clinic:
n Using a growth chart to plot children’s heights and weights
n Identifying children who are outside established norms
n Referring parents and children who are above 95th percentile or

below 5th percentile to a primary care provider for assessment
and to a nutritionist for nutritional education and counseling

Tertiary prevention limits further negative effects from a
problem and aims to keep existing problems from getting
worse . Tertiary prevention is implemented after a disease
or injury has occurred . It alleviates the effects of disease
and injury and restores individuals to their optimal levels
of functioning . It targets populations that have experienced
disease or injury .

School Nurse
Beginning of the school year:

n Identifying students with asthma and obtaining asthma plans
n Working with teaching staff to reduce environmental asthma

triggers in the school building

During the school year:
n Monitoring students with asthma for adherence to their asthma

plans and their health status
n Providing nebulizer treatments in the health office

Source: Modified from MDH, 2001, p . 4

TABLE 1.8 Healthy People 2020 Mission and Goals

Mission—Healthy People 2020 strives to: Overarching Goals

n Identify nationwide health-improvement priorities
n Increase public awareness and understanding of the

determinants of health, disease, and disability and
opportunities for progress

n Provide measurable objectives and goals that are
applicable at the national, state, and local levels

n Engage multiple sectors to take action to strengthen
policies and improve practices that are driven by the best
available evidence and knowledge

n Identify critical research, evaluation, and data- collection
needs

n Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death

n Achieve health equity, eliminate disparities, and improve the
health of groups

n Create social and physical environments that promote good
health for all

n Promote quality of life, healthy development, and healthy
behaviors across all life stages

Source: U .S . DHHS, n .d .-b

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19CHAPTER 1  n  Introduction to Public Health Nursing Practice

BSN Preparation
The need for nurses to be prepared to both work in the
community and have the ability to practice entry-level pub-
lic health nursing has become more urgent as healthcare
moves from the acute care setting to the community and
new models of healthcare and nursing practice emerge . The
challenge of practicing in the community is influenced by
the persistence of health disparities among all age groups
and diverse populations, the aging of the population, and
the continuous increase in healthcare costs . In addition,
healthcare needs and diseases are not isolated by geographic
boundaries but evolve within a global environment . Recog-
nition of the need for nurses to have the ability to improve
the health of populations by taking leadership roles within
the healthcare system and in their communities and by
partnering with other health professionals and community
leaders has resulted in a renewed commitment to increase
the proportion of nurses with baccalaureate degrees and
to enrich the baccalaureate nursing curriculum to prepare
nurses for the challenges that face them (Education Com-
mittee of the Association of Community Health Nurse
Educators [ACHNE], 2010; Institute of Medicine [IOM],
2011; Robert Wood Johnson Foundation, 2013) . ACHNE has
identified 15 basic core knowledge competencies for bacca-
laureate nursing graduates that should be included in the
baccalaureate nursing curriculum (2010):
n Communication
n Epidemiology and biostatistics
n Community/population assessment
n Community/population planning
n Policy development
n Assurance
n Health promotion and risk reduction
n Illness and disease management
n Information and healthcare technology
n Environmental health
n Global health
n Human diversity
n Ethics and social justice
n Coordination and care management
n Emergency preparedness, response, and recovery

Activity
n Which knowledge areas have you already studied?

n What are your knowledge and competency goals for your 
public health nursing clinical?

A set of national health priorities titled Leading Health
Indicators (LHIs) is included in Healthy People 2020 (U .S .
DHHS, n .d . -a) . They include 42 health outcomes orga-
nized into 12 health topics . These priorities reflect the great-
est unmet national health needs based on an analysis of
Healthy People 2010 health outcome data . The 12 health top-
ics are listed in the following “Leading Health Indicators”
box . A mid-course review of progress toward achieving the
42 health indicators shows that 21% of the targets have been
achieved and 19% are improving while 11% are getting worse
(U .S . DHHS, 2017) .

OnlineActivity
    Go to the Healthy People webpage (http:// 
www.healthypeople.gov) and search for the LHIs. 

n Read about one of the LHI health outcomes that 
interests you. 

n Find the Healthy People 2010 statistical data that measured 
the achievement of that outcome.

n What is the goal for the Healthy People 2020 outcome? 
Which statistic would demonstrate improvement of that 
outcome?

Activity
n Explore the community health priorities of your state or local 

health department. Compare them with the LHIs.

n Identify programs or activities in your clinical agency that are 
related to the LHIs. 

n Discuss with your preceptor how nurses are involved in these 
programs or activities.

n Consider how you might become involved as a citizen or 
as a nurse in working on one of the LHI priorities in your 
community.

Leading Health Indicators, Healthy People 2020

n Access to Health Services

n Clinical Preventive Services

n Environmental Quality

n Injury and Violence

n Maternal, Infant, and Child Health

n Mental Health

n Nutrition, Physical Activity, and Obesity

n Oral Health

n Reproductive and Sexual Health

n Social Determinants

n Substance Abuse

n Tobacco

Sources: National Center for Health Statistics, 2012; U .S . DHHS, n .d .-a

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20 PART I  n  Foundational Concepts for Public Health Nursing Practice

Entry-Level Population-Based Public
Health Nursing Competencies
This chapter has given you a lot to think about . Now it is
time to focus on the entry-level public health nursing com-
petencies that you can work to develop in your community
clinical . This book is going to help you focus on the entry-
level competencies expected of baccalaureate nursing grad-
uates and novice nurses entering public health nursing .

Henry Street Entry-Level PHN Competencies
The Henry Street Consortium (HSC) entry-level population-
based public health nursing competencies, initially pub-
lished in 2003 and updated in 2017, are intended for
baccalaureate nursing graduates and novice public health
nurses (Henry Street Consortium, 2017; Schaffer et al ., 2011) .
These 12 competencies are consistent with national bench-
mark standards for entry-level public health nursing (ANA,
2013; Quad Council of Public Health Nursing Organiza-
tions, 2011) . (See Table 1 .9 .) A consortium of practicing pub-
lic health nurses and educators developed these simplified
entry-level standards to facilitate the teaching and learning
of public health nursing knowledge and skills in the clinical
setting (Schaffer et al ., 2011) .

This list presents each competency in broad statements
that are not measurable by themselves . A more complete
outline of each of the HSC competencies, which provides
measures of how to evaluate PHN achievement of each
competency, is found in Appendix A . Chapters 3 to 14 each
cover one of the 12 competencies and provide specific evi-
dence about best practices for each competency . As you read
this book, you will learn how you might meet these entry-
level competencies in your public health clinical learning
activities .

Activity
n Review the competencies and their related activities in 

Appendix A. Make a list of activities within each compe-
tency that you would like to practice during your community 
clinical. 

n Talk with your preceptor about how you might practice these 
public health nursing activities. 

TABLE 1.9 Henry Street Consortium
Entry-Level Population-Based Public Health
Nursing Competencies

Entry-Level Population-Based Public Health Nursing
Competencies

For the New Graduate or Novice Public Health Nurse

1 . Applies the public health nursing process to communities,
systems, individuals, and families

2 . Utilizes basic epidemiological (the incidence, distribution,
and control of disease in a population) principles in public
health nursing practice

3 . Utilizes the principles and science of environmental
health to promote safe and sustainable environments for
individuals/families, systems, and communities

4 . Practices within the auspices of the Nurse Practice Act

5 . Works within the responsibility and authority of the
governmental public health system

6 . Utilizes collaboration to achieve public health goals

7 . Effectively communicates with communities, systems,
individuals, families, and colleagues

8 . Establishes and maintains caring relationships with
communities, systems, individuals, and families

9 . Incorporates mental, physical, emotional, social, and
spiritual aspects of health into assessment, planning,
implementation, and evaluation

10 . Demonstrates nonjudgmental/unconditional acceptance
of people different from self

11 . Shows evidence of commitment to social justice, the
greater good, and the public health principles

12 . Demonstrates leadership in public health nursing with
communities, systems, individuals, and families

Source: Henry Street Consortium, 2017

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21CHAPTER 1  n  Introduction to Public Health Nursing Practice

n Primary prevention is the focus of public health nurs-
ing, but PHNs also provide secondary and tertiary
prevention interventions .

n PHNs work at all three levels of practice: individual/
family, community, and systems .

n Emerging threats and challenges in health and health-
care require changes in and leadership from public
health nursing .

n The HSC Entry-Level Public Health Nursing competen-
cies, based on accepted national standards, provide a
guide for baccalaureate nursing students to achieve the
expected outcomes of baccalaureate nursing education .

KEY POINTS

n Public health nursing combines the theory and practice
of nursing and public health . It is a required component
of baccalaureate nursing education .

n Public health nursing practice is guided by the national
scope of practice standards .

n The goal of public health and public health nursing is to
improve the health of the public at the local, national,
and international levels .

n The Cornerstones of Public Health explain the beliefs
and values of the clinical specialty of public health
nursing practice .

n Public health nursing practice is population-based,
focusing on the priority health needs of populations .

‘‘

’’

REFLECTIVE PRACTICE

Alberto takes a deep breath, closes his eyes as if in deep
thought, and says to Abby and Sia, “Let’s see if I have this
straight. Public health nursing is part of my professional
nursing practice. It can be practiced anywhere, because
public health nursing is shaped by its goal, not by its set-
ting, but it is most often practiced in the community. The
goal of public health nursing is to improve the health of the
public, the health of the communities in which we live. The
client in public health nursing may be an individual, a fam-
ily, the community, or a population within the community.
To improve and protect the public’s health, I need to assess
the health status and identify the health determinants that
affect the health status of individuals, families, communi-
ties, and populations. Then I need to intervene by helping
my clients build on their protective factors and reduce their
risk factors. The interventions I will use most often are
teaching and counseling, but we will learn about more inter-
ventions as we read this book and complete our community
clinical. When I practice in the community, I will probably

be partnering with other members of the healthcare team
as well as community members. I need to demonstrate a
set of entry-level public health nursing competencies to
successfully complete my baccalaureate nursing education.
The Henry Street Consortium Population-Based Public
Health Nursing Competencies focus on what I should be
learning and practicing in my public health clinical activi-
ties. Whew! Do I have that right?”

Abby and Sia respond, “Yes. You’ve got it! You get an ‘A’
for the course!”

1. Think about what Alberto, Abby, and Sia have learned
about public health nursing from their observations
and discussions with their preceptors .

2. How will you analyze what you observe about public
health nursing during your clinical experience?

3. How would you describe public health nursing prac-
tices you observe in your clinical to your classmates?

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22 PART I  n  Foundational Concepts for Public Health Nursing Practice

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25

‘‘

’’

CHAPTER

2Evidence-Based Public
Health Nursing Practice

n  Patricia M. Schoon and Marjorie A. Schaffer 
with Stephanie Rivery

Abby is talking with Jaime, an RN who has returned to school to get his baccalaureate nursing
degree. She is struggling to understand the three levels of public health nursing practice. Abby
asks, “How do you use the nursing process in your hospital work? Did you ever think you could
use it for more than the patients you are caring for?”

Jaime replies, “It still seems kind of strange to me. But I am a member of the Quality Improve-
ment Team. We just finished an audit to look at the incidence of patient falls to find out whether
our unit is meeting the goals set by the hospital to reduce the patient fall rate. Our patient fall rate
is still higher than the goal set by the hospital, so we decided that we need to hold an in-service on
assessing patients for their fall risk and the different protocols we can use to reduce the number of
patient falls. So, I guess if we think of my unit as a community, we are using the nursing process
at more than one level.”

Abby ponders, “I guess I can kind of see that you are using the nursing process to assess the
fall rate. The idea of using the nursing process at the systems level still seems very strange to me.”

Jaime thinks about the idea of nursing at the systems level and finally says, “Maybe if I think
of the nursing staff on my unit as part of the hospital system, then Quality Improvement Team
members can assess what they know about fall risk and prevention and design a program just for
our staff members to improve their skills in that area. What do you think?”

Abby sighs, “I kind of understand how I can use nursing process to assess the health needs of
individuals, families, and communities, but I can’t think how I would assess the health status of
a system. Do systems have a health status?” Abby muses, “If a system, like a public health agency,
doesn’t have enough money to provide the health services that the community needs, then I guess
it wouldn’t be very healthy.”

Jaime says thoughtfully, “Maybe we need to look at a community’s health needs and determine
whether specific community systems, such as hospitals, schools, educational systems, and public
health agencies, have the resources to meet the priority needs of their community. If they don’t
have the resources, then maybe we can plan interventions to help them get the resources or services
they need.”

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26 PART I  n  Foundational Concepts for Public Health Nursing Practice

’’

‘‘

The application of the nursing process to all three levels of
practice is discussed in Chapter 3.

An easy way to remember the level of practice is to ask
yourself, “Whose knowledge, beliefs, behaviors, and values
am I trying to modify?” For example, if you are teaching
a group of first grade students how to wash their hands,
even though they are in a group, your intention is to modify
the handwashing behaviors of the individual students. So,
you are intervening at the individual/family level of prac-
tice. If you taught the first-grade teachers how to monitor
the handwashing behaviors of their students, you would be
intervening at the systems level of practice. If you handed
out a flyer on the reasons for handwashing and the cor-
rect handwashing procedure at a county fair, you would be
intervening with the community level, hoping to change
community norms for handwashing, not the behaviors of
specific individuals.

Abby comments, “My PHN preceptor told me that we are
going to make a joint visit with the social worker to a family
where a baby has failure to thrive. My preceptor is going
to focus on assessing the health status of the baby, and the
social worker is going to focus on the family support system
and resources in the community for the mother. It will be
interesting to see how they work together.”

Jaime responds, “I am going to an interdisciplinary
child protection team meeting with my preceptor. It is a
county-wide team made up of police, social workers, law-
yers, and public health nurses. It seems like my preceptor is
always working with other people.”

Abby concurs, “It really does seem that PHNs work with
lots of other disciplines. My preceptor says that is the best
way to deal with community-wide health problems.”

Several years ago, a nursing student about to graduate
reflected on what she had learned. She said, “I get it. Nursing
is about critical thinking!” Nursing is a knowledge profes-
sion. That means nurses think before they do (assessment
and planning), while they do (modifying interventions),
and after they do (evaluation). This chapter explains how
to apply the nursing process to public health nursing prac-
tice and to identify and use interventions that support pub-
lic health practice goals. You will learn how to apply what
you already know about evidence-based nursing practice to
your public health nursing practice. PHNs are accountable
to their clients and to the public for practicing effectively
and efficiently to achieve the best outcomes using the least
amount of resources. This chapter discusses how PHNs use
best practice information to improve their clients’ health.

The Public Health Nursing Process
The public health nursing process integrates concepts of
nursing and public health. The steps of the nursing process
are the same: assessment, diagnosis, planning, implemen-
tation, and evaluation. However, the public health nursing
process expands the nursing process in that PHNs focus
their assessment and interventions on three different levels
of practice: individuals and families, communities, and sys-
tems (MDH, 2001). Refer to Chapter 1 for a description of the
three levels of PHN practice. Critical thinking throughout
the PHN process is essential in identifying and modifying
the complex determinants of health that influence the health
status of individuals, families, and communities. This appli-
cation of the nursing process is reflected in the American
Nurses Association’s (ANA’s) Public Health Nursing: Scope
and Standards of Practice (2013), as illustrated in Figure 2.1.

ABBY’S NOTEBOOK

USEFUL DEFINITIONS

Evidence-Based Practice: “A problem-solving approach to clinical decision-making within a healthcare orga-
nization. EBP integrates the best available scientific evidence with the best available experiential (patient and
practitioner) evidence” (Dang & Dearholt, 2018, p. 4).

Evidence-Based Public Health: Making decisions on the best information available and creating interventions
based on that evidence (Barr-Walker, 2017).

Public Health Interventions: Actions that PHNs take on behalf of individuals, families, systems, and communi-
ties to improve or protect their health status (Minnesota Department of Health [MDH Center for Public Health
Nursing], 2001); public health nurses (PHNs) commonly practice all 17 interventions.

Public Health Nursing Process: Integration of concepts of public health, community, and all three levels of the
PHN practice (i.e., individual, community, and systems) into the nursing process (Minnesota Department of
Health [MDH], Center for Public Health Nursing, 2003).

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27CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

These interventions are organized in the Public Health
Intervention Wheel illustrated in Figure 2.2. The Public
Health Intervention Wheel is evidence-based and represents
what PHNs do (Keller et al., 2004). PHNs often use more
than one intervention at more than one level of practice
(individual and family, community, or system) to influence
the multiple health risks affecting individuals, families, and
populations.

The 17 interventions are divided into five wedges with
three or four interventions in each wedge. Each group of
wedges reflects a cluster of interventions. The cluster of
interventions within each wedge often occurs either con-
currently or consecutively. The five wedges (also depicted in
specific colors) include the following interventions:

n Wedge 1 (pink): Surveillance, disease and health event
investigation, outreach, and screening (case finding is
the individual level for this wedge)

n Wedge 2 (green): Referral and follow-up, case manage-
ment, and delegation

n Wedge 3 (blue): Health teaching, counseling, and
consultation

n Wedge 4 (orange): Collaboration, coalition building,
and community organizing (no individual level for
coalition building and community organizing)

n Wedge 5 (yellow): Advocacy, social marketing, policy
development, and enforcement

The three inner circles, called segments, represent the
three levels of public health nursing practice (individual/
family, community, and systems). All but three interventions
are carried out at all three levels of practice. Case finding is
only carried out at the individual/family level of practice, so
it is placed inside the individual/family circle in the wheel
diagram. Community organizing and coalition formation
are practiced at the community and systems levels but not
at the individual/family level. Sixteen of the interventions
are independent nursing actions that can be practiced under
your state’s Nurse Practice Act without medical orders. The
seventeenth intervention, delegated functions, can include
medical functions delegated by a medical professional, such
as immunizations. Nursing activities that the PHN delegates
to another health team member, such as vision and hearing
screening, are part of the independent practice of nursing
and usually reflect one of the other PHN interventions.

Definitions and examples of the 17 population-based
public health interventions are outlined in Table 2.1. Inter-
ventions are organized within the five wedges on the Public
Health Intervention Wheel. Nursing students could do all
the intervention examples in the table.

The Public Health Intervention Wheel has been dissemi-
nated to public health nursing students, PHNs, other public
health professionals, and health departments nationally and
internationally. The Wheel is used as a framework for teach-
ing; a guide for planning, documentation, and evaluation in
public health practice; and a model for research on interven-
tion use and effectiveness.

PHNs often work with people in other professions as well
as community members to achieve public health goals. (See
Chapter 8 for a discussion of interprofessional collabora-
tion.) Many of the interventions that PHNs use are also used
by other professionals in the community.

Public Health Intervention Wheel
The Public Health Intervention Wheel is a major concep-
tual model in public health nursing (Keller, Strohschein,
Lia-Hoagberg, & Schaffer, 1998, 2004; Bigbee & Issel, 2012).
Concepts in the Public Health Intervention Wheel include:
population-focus, three levels of practice, three levels of pre-
vention, and 17 interventions that define the shared practice
of public health nursing. Research supporting the use and
effectiveness of many of the interventions in this model are
found in this book. This model is supported by evidence
from literature and validated by more than 200 public
health nurses from a variety of practice settings.

Public health interventions are actions that PHNs take
on behalf of individuals, families, systems, and commu-
nities to improve or protect their health status (MDH,
2001). The Public Health Intervention Wheel identifies 17
population-based interventions specific to public health
practice that are found at three levels: individual/family,
community, and systems (Keller et al., 1998, 2004; MDH,
2001). Because PHN practice occurs at three levels, interven-
tions must also be implemented at all three levels.

FIGURE 2.1 Nursing Process at Three Levels of Public Health 
Nursing Practice

Community

System

Individual/
Family

Planning

Im
plem

entation

D
ia

gn
os

is

Ev
aluation Assessment

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28 PART I  n  Foundational Concepts for Public Health Nursing Practice

TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice

PHN Intervention
Definition

PHN Intervention
Examples

Surveillance (Wedge 1 – Pink)
Surveillance describes and monitors health events
through ongoing and systematic collection, analysis, and
interpretation of health data for the purpose of planning,
implementing, and evaluating public health interventions
(MDH, 2001, p. 13).

n Investigate and report the incidence and prevalence of sexually
transmitted infections in the local teen population (community
level).

n Work with a school nurse at an elementary school to develop a
tracking program to identify the incidence and prevalence of
student-on-student bullying before and after the implementation of
an anti-bullying curriculum (systems level).

Disease & Health Event Investigation (Wedge 1 – Pink)
Disease and other health event investigation systemati-
cally gathers and analyzes data regarding threats to the
health of populations, ascertains the source of the threat,
identifies cases and others at-risk, and determines control
measures (p. 29).

n Identify and follow up on cases of sexually transmitted infection in
a high school population to identify sources of infection and provide
treatment (individual/family level).

n Gather information about radon levels in your community and
determine high-risk geographical areas (community level).

FIGURE 2.2 Public Health Intervention Wheel 
Source: MDH, Center for Public Health Nursing (2001)

Case Finding

Population-Based

Population-Based

Population-Based

Individual-Focused

Community-Focused

Systems-Focused

Surveillance
Disease &Health EventInvestigation

Outreach

Screening
R

eferral &

Follow
-U

p

Ca
se

M
an

ag
em

en
t

Dele
gate

d

Fu
nct

io
ns

Health

Teaching

Counseling

Consultation

Collaboration

Coalition

Building
C

om
m

unity

O
rganizing

A
dv

oc
ac

y

Socia
l

M
ark

etin
g

Policy

Development &

Enforcement

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29CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Outreach (Wedge 1 – Pink)
Outreach locates populations of interest or populations
at risk and provides information about the nature of the
concern, what can be done about it, and how services can
be obtained (p. 41).

n Interview people at a family homeless shelter to determine who
needs information about the location of local food shelves and WIC
clinics (individual/family level).

n Develop brochures for local grocery stores to hand out about nutri-
tional needs for children and the location of local food shelves and
WIC clinics (systems level).

Case Finding (Wedge 1 – Pink)
Case finding locates individuals and families with identi-
fied risk factors and connects them to resources (p. 55).

n Identify new immigrants from southeast Asia who might be at risk
for tuberculosis (TB) (individual/family level).

n Give at-risk immigrants information on where to receive TB
screening (individual/family level).

Screening (Wedge 1 – Pink)
Screening identifies individuals with unrecognized
health risk factors or asymptomatic disease conditions in
populations (p. 63).

n Conduct blood pressure screening for African-American males
( community level)

n Organize a blood pressure screening clinic at a community center
( systems level)

Referral & Follow-up (Wedge 2 – Green)
Referral and follow-up assists individuals, families,
groups, organizations, and communities to utilize
necessary resources to prevent or resolve problems or
concerns (p. 79).

n Give an elderly person who is homebound information about how
to contact a local Meals on Wheels program and then contact the
individual a week later to see if he or she has successfully reached
the Meals on Wheels program (individual/family level).

n Work with Emergency Department (ED) nurses and home visiting
nurses to develop and use a referral process for elderly individuals
seen in the ED that need home healthcare services (systems level).

Case Management (Wedge 2 – Green)
Case management optimizes self-care capabilities of
individuals and families and the capacity of systems and
communities to coordinate and provide services (p. 93).

n Work with parents of a newborn with Down’s Syndrome to iden-
tify services in their community that they can use to help them
( individual/family level).

n Work with a PHN and school nurse to coordinate in-home and
school health services for children with severe developmental delays
(systems level).

Delegated Functions (Wedge 2 – Green)
Delegated functions are direct care tasks a registered
professional nurse carries out under the authority of
a healthcare practitioner, as allowed by law. Delegated
functions also include any direct care tasks a registered
professional nurse entrusts to other appropriate person-
nel to perform (p. 113).

n Provide immunizations at a community flu clinic under standing
orders from medical personnel (individual/family and systems
levels).

n Direct a peer counselor to work with a new diabetic to organize a
grocery list and menu plans (individual/family level).

Health Teaching (Wedge 3 – Blue)
Health teaching communicates facts, ideas, and skills
that change knowledge, attitudes, values, beliefs, behav-
iors, and practices and skills of individuals, families,
systems, and/or communities (p. 121).

n Teach a class for teen moms about how to care for new baby
( individual/family level).

n Develop a program on childcare for new moms at a local high school
(systems level).

(continues)

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30 PART I  n  Foundational Concepts for Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Counseling (Wedge 3 – Blue)
Counseling establishes an interpersonal relationship with
a community, system, family, or individual intended to
increase or enhance their capacity for self-care and cop-
ing. Counseling engages the community, system, family,
or individual at an emotional level (p. 151).

n Provide support for parents who are coping with providing care for
their dying child at home (individual/family level).

n Provide crisis management services to a community that has just
experienced a devastating tornado (community level).

Consultation (Wedge 3 – Blue)
Consultation seeks information and generates optional
solutions to perceived problems or issues through
interactive problem-solving with a community, system,
family or individual. The community, system, family or
individual selects and acts on the option best meeting the
circumstances (p. 165).

n Help a recently divorced father who has custody of his two children
to problem solve balancing parenting and work responsibilities
(individual/family level).

n Consult with a peer-counseling group for diabetes management
to help them develop strategies for working with individuals with
diabetes in their community (community level).

Collaboration (Wedge 4 – Orange)
Collaboration commits two or more persons or organiza-
tions to achieving a common goal through enhancing the
capacity of one or more of them to promote and protect
health (p. 177).

n Partner with the nurse and social worker in an adolescent correction
facility in developing a program to help inmates maintain con-
tact with caring individuals in their family or friendship network
( systems level).

n Work with the county parks and playground department and local
young parents group to develop a plan to provide more bike and
walking paths for family use (community and systems level).

Coalition Building (Wedge 4 – Orange)
Coalition building promotes and develops alliances
among organizations or constituencies for a common
purpose. It builds linkages, solves problems, and/or
enhances local leadership to address health concerns
(p. 211).

n Develop an alliance between local environmental groups, waste
management, and recycling organizations to improve community
recycling (community level).

n Establish a network of agencies to work together to develop a
community disaster plan (systems level).

Community Organizing (Wedge 4 – Orange)
Community organizing helps community groups identify
common problems or goals, mobilize resources, and
develop and implement strategies for reaching the goals
they collectively have set (p. 235).

n Organize a group of renters from several low-income housing devel-
opments to work together to improve the safety of their buildings
(community level).

n Help organize a group of low-income housing services organiza-
tions, community homeless shelters, and county human services
to develop strategies to provide a more streamlined program for
placing homeless people in affordable housing (systems level).

Advocacy (Wedge 5 – Yellow)
Advocacy pleads someone’s cause or acts on someone’s
behalf, with a focus on developing the community, sys-
tem, individual, or family’s capacity to plead their own
cause or act on their own behalf (p. 263).

n Help a client file an appeal for an insurance denial for home-care
services when the client meets eligibility criteria stated in insurance
policy (individual/family level).

n Lobby legislators for support of community mental health programs
(systems level).

Social Marketing (Wedge 5 – Yellow)
Social marketing utilizes commercial marketing princi-
ples and technologies for programs designed to influence
the knowledge, attitudes, values, beliefs, behaviors, and
practices of the population of interest (p. 285).

n Create a video for teen parents on how to help their infants and
toddlers meet developmental milestones (individual/family level).

n Participate in a televised panel discussion about the effects of drug
and alcohol use during pregnancy on the fetus (community level).

TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice (continued)

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31CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Policy Development & Enforcement (Wedge 5 – Yellow)
Policy development places health issues on decision-
makers’ agendas, acquires a plan of resolution, and
determines needed resources. Policy development results
in laws, rules and regulations, ordinances, and policies.
Policy enforcement compels others to comply with the
laws, rules, regulations, ordinances, and policies created
in conjunction with policy development (p. 313).

n Participate on a county task force to revise county human services
guidelines for mandating reporting of suspected child abuse or
neglect (systems level).

n Talk to a church group about the need to support a bill for commu-
nity nutrition programs for children living in poverty (community
level).

Source: Definitions from MDH, Center for Public Health Nursing (2001)

EVIDENCE EXAMPLE 2.1
Public Health Intervention Wheel

n Over 600 school nurses (SNs), members of the National
Association of School Nurses (NASN), completed an
electronic survey on using public health interventions in
their practice as defined by the Public Health Intervention
Wheel. Most SNs (67%) were not familiar with the Wheel;
however, participants identified interventions that were
consistent with the Wheel. They used screening, referral
and follow-up, case management, and health teaching
more often than other interventions. In estimates of
time spent at specific practices levels, SN practice was
primarily at the individual level (65%). They also provided
community-level interventions 22% of their time and
systems-level interventions 14% of their time. SNs can use
the Wheel to document and explain the interventions they
provide in school nursing practice to address the health of
school populations (Schaffer, Anderson, & Rising, 2016).

n A qualitative study explored how school nurses (n = 43)
understood and used the interventions from Public Health
Intervention Wheel. Data were analyzed from six focus
groups conducted across the state of Minnesota. Ns rep-
resented urban, suburban, and rural schools. The SN prac-
tice stories included all interventions and levels of practice

except for case management and delegation at the com-
munity level. The highest number of practice examples
were for health teaching, case finding, and referral and
follow-up, all at the individual level. The practice stories
provide examples of how SNs can extend their practice to
community and systems levels and affirm school nursing
as a population-focused practice (Anderson et al., 2018).

n McDonald and colleagues (2015) replicated the process
of identifying and defining public health interventions
from the Wheel in the context of public health nursing
in Ireland. Public health nursing leaders in Ireland con-
ducted a literature review and hosted discussions on each
intervention wedge at the 2011 Institute of Community
Health Nursing conference. The aim was to promote
visibility of the PHN role and build a common language
to describe interventions. A key theme of practice stories
was the importance of building trusting relationships with
individuals and communities to support interventions.
The Population Health Interest Group (2013) pub-
lished practice stories from Irish nurses for each of the
17 interventions.

‘‘

’’

Jaime says, “I am going to a meeting with my PHN precep-
tor this afternoon about how the different county agencies
and the school district are working together as a team to try
to reduce smoking among high school students. I guess that
would be an example of collaboration, but I am not sure
which level of practice that would be.”

Abby ponders, “I think maybe when PHNs work with
agencies and school districts, they are practicing at the sys-
tems level. If they use an intervention like social market-
ing to let teens know about the availability of a smoking

cessation program at their school, then they would be prac-
ticing at the community level.”

Jaime responds, “Teens at risk for smoking are a vul-
nerable population within the community, and PHNs
work with populations within the community. If the team’s
goal is to change the smoking behaviors of individual high
school students, even if they were part of a group and PHNs
carried out some health teaching in the classroom, I guess
those actions would be at the individual/family level. This
gets kind of confusing at times.”

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32 PART I  n  Foundational Concepts for Public Health Nursing Practice

PHNs take a comprehensive approach to dealing with
public health problems in the community. They use mul-
tiple interventions to achieve primary, secondary, and ter-
tiary prevention goals and, when possible, work with other
members of the interdisciplinary team and members of the
community. Table 2.2 outlines how primary, secondary, and
tertiary interventions might be employed at all three levels
of practice to reduce tobacco use in teens. (See Chapter 1 for
a discussion of primary, secondary, and tertiary prevention.)

Evidence-Based Practice
Public health organizations are expected to use evidence-
based approaches in decision-making and in taking actions
based on population-based evidence (Lovelace et al., 2015).
This evidence-based public health approach means that
PHNs use the best information available to create new inter-
ventions (Barr-Walker, 2017). This evidence-based decision
process includes (Brownson, Fielding, & Maylahn, 2009,
p. 177):
n Using the best available scientific evidence
n Systematically using data and information systems

TABLE 2.2 Three Levels of PHN Practice and Three Levels of Prevention With Public Health
Interventions to Reduce Tobacco Use in Teens

Individual/Family Level of Practice

Primary Prevention Secondary Prevention Tertiary Prevention

Health Teaching
n Conduct classroom teaching on the

dangers of tobacco use and strategies
to avoid it.

Case Finding, Referral, and Follow-Up
n Assess the health behaviors, including

tobacco use, of individual students.
n Identify students at risk for tobacco

use and those already using tobacco.
n Refer students who smoke to the

school smoking prevention and
cessation team.

n Follow up with the school nurse.

Case Management and Collaboration
n The school nurse, physical education

teacher, and school psychologist team
up to work with teens using tobacco
and to monitor and implement a
smoking cessation program.

Community Level of Practice

Social Marketing and Outreach
n Staff a teen booth at the county fair

and hand out brochures on the hazards
of tobacco use and available tobacco
prevention and cessation programs.

Screening, Referral, and Follow-Up
n Hold health-behaviors screening,

including tobacco use, for teens and
young adults at the county fair.

Case Management and Social Marketing
n Create a social networking site to

empower teens and for teens to
provide peer support for smoking
cessation.

Systems Level of Practice

Health Teaching/Provider Education
n Develop and present a program to

teachers and school staff about the
hazards of tobacco use and available
smoking prevention and cessation
programs.

Screening, Referral, and Follow-Up
n Develop a health-behaviors screen-

ing, referral, and follow-up program
for middle school and high school
students.

Case Management and Collaboration
n Develop a case management protocol

for the school smoking prevention and
cessation interdisciplinary team.

n Applying program planning frameworks
n Engaging the community in assessment and

decision-making
n Conducting sound evaluation
n Disseminating findings

Public health nurses’ practice is expected to be evidence-
based. This evidence-based approach means that PHNs use
a problem-solving approach to find the best available sci-
entific evidence and the best available experiential evidence
and then integrate this evidence into their practice (Dang &
Dearholt, 2018, p. 4).

The search for credible evidence includes knowledge
gleaned from both research and nonresearch. The lev-
els of evidence at the core of the Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) include research
and nonresearch evidence. There are five levels of evidence
(see Table 2.3). You will find examples from all levels of evi-
dence in the remaining chapters of this book. Although the
levels of evidence are presented in a hierarchical manner in
Table 2.3, this table does not mean that lower levels of evi-
dence should be discounted or that randomized controlled
trials (RCTs) in experimental research should be considered
the only credible or most meaningful forms of evidence

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33CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

TABLE 2.3 Best Practices in Public Health Nursing by Level of Evidence

Evidence Level Definition Examples

Level I:

Experimental study, randomized controlled
trials (RCTs)

Explanatory mixed methods design

The Nurse Family Partnership involving intensive structured home visiting by
PHNs reduces repeat childbirths, improves the stability of partner relation-
ships, facilitates children’s academic adjustment to elementary school, and
reduces childhood mortality from preventable causes (Kitzman et al., 2010;
Olds et al., 2004; Olds et al., 2007; Olds et al., 2010).

Level I:

Systematic reviews of RCTs, with or without
meta-analysis

Professional organizations publish systematic reviews of medical and nursing
research
n The Cochrane Database of Systematic Reviews, published online by the

Cochrane Collaboration.
n Worldviews on Evidence-Based Nursing, a peer-reviewed journal published

by Sigma Theta Tau International.
n The Joanna Briggs Institute provides an online listing of systematic reviews

and meta-analysis specific to nursing practice. Systematic reviews of non-
RCT research may be either Level II or Level III evidence.

Level II:

Quasi-experimental study

Explanatory mixed-method design

Systematic review of a combination of RCTs and
quasi-experimental studies or quasi-experimental
studies only

A prospective cohort study evaluated the impact of breastmilk expression in
early postpartum period on breastfeeding duration (Jiang et al., 2015).

Level III:

Nonexperimental study

Systematic reviews of combination of RCTs,
quasi- experimental, and nonexperimental
studies

A descriptive study identified four significant predictors of breastfeeding
attitudes: age, gender, number of breastfeeding observations in childhood, and
breastfeeding beliefs (Vari et al., 2013).

A systematic review using CINAHL (Cumulative Index to Nursing and Allied
Health Literature), PubMed, and Cochrane Library databases identified bar-
riers to breastfeeding in the WIC population to make recommendations for
guidelines for WIC clients (Hedberg, 2013).

Level IV:

Opinion of respected authorities and nationally
recognized expert committees or consensus
panels based on scientific evidence
n Clinical practice guidelines
n Consensus panels/position statements

ANA. (2013). Public Health Nursing: Scope and Standards of Practice (2nd ed.)

Quad Council of Public Health Nursing Organizations. (2011).
The Quad Council competencies for public health nurses

Centers for Disease Control and Prevention. (2017). Immunization Schedules

Level V:

Based on experiential and nonresearch evidence
n Integrative reviews
n Literature reviews
n Quality improvement, program, or financial

evaluation
n Case reports
n Opinion of nationally recognized expert(s)

based on experiential evidence

The Best Start program supporting area-based interventions to increase breast-
feeding was evaluated. Area-based interventions and community partnerships
were found to have a positive influence on breastfeeding rates (Kelaher, Dunt,
Feldman, Nolan, & Raban, 2009).

Source: Definitions of Levels of Evidence from Dang & Dearholt, 2018, Appendix D, pp. 278–279

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34 PART I  n  Foundational Concepts for Public Health Nursing Practice

‘‘
in public health. It is important to thoughtfully consider
and analyze information from all levels of evidence. For
example, the use of qualitative research, particularly when
studying culture and ethnicity, has led to significant under-
standing of how diverse populations and people view them-
selves and the world around them.

Experiential evidence that may be found in IV and V
evidence levels includes clinical expertise and client’s pref-
erences and values. PHNs know that evidence-based inter-
ventions found in the scientific literature need to fit the
demographics and cultural diversity of their clients at the
individual/family and community levels of practice in order
to be consistent with ethical holistic nursing practice (see
Figure 2.3).

These three interrelated elements occur within the con-
text of the community—where public health nurses are
expected to be lifelong learners who take the initiative to
engage with their community to explore the life experi-
ences, health status, and health determinants of diverse
populations. The information PHNs gather about the indi-
viduals/families and communities they serve leads them to

question how they can positively impact the health of these
individuals/families and communities.

Public health nurses use critical thinking in applying a
deliberative process for identifying and implementing best
practices in a timely manner. The Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) includes three
essential components: inquiry, practice, and learning (Dang
& Dearholt, 2018):
n Inquiry: To question, examine, and collect information

about an issue or problem (p. 36)
n Practice: Reflects on the translation of what nurses

know to what they do (p. 36)
n Learning: A change in the way nurses think and

behave

The movement from inquiry to learning is represented
by the JHNEBP PET Process (see Figure 2.4). This process
is a group effort within or across organizations. In public
health, the team could be formed from members of a spe-
cific organization or be an interprofessional team at the
community level with key stakeholders and community
members involved. The practice team identifies the practice
issue, defines and refines the practice question, searches for
and evaluates the evidence, and determines which evidence
can and should be translated into new or revised practices
in the workplace.

Abby wonders how PHNs know what to do when they work
with their clients. She says, “The PHNs keep talking about
evidence-based practice, but I am not sure exactly what
that is.”

Jaime responds, “Today, my PHN preceptor and I made
a home visit to an elderly woman who lives alone. We did
a fall risk assessment and a home safety check. I asked the
PHN how she selected which risk assessment and home
safety assessment tools to use. She told me that a committee
of PHNs reviewed journal articles to find research reports
on which assessment tools were effective for determining
fall risks in older adults. They also looked at which home
safety tools had been developed specifically for frail older
adults living at home. Then they piloted the home safety
assessment tools themselves and picked the tool that best fit
what their PHNs needed to know about the home environ-
ment and what the elderly adults preferred. I think this is
the way you do evidence-based practice, but I need to read
more about it.”

Abby comments, “One of the PHNs at my agency went
to a fall prevention workshop given by an occupational
therapist and a physical therapist at the local hospital.
They taught the workshop participants how to screen
older adults for fall risk and which types of interventions
would help reduce fall risks, such as using assistive devices,
installing good lighting, removing slippery rugs, and wear-
ing nonskid slippers. Do you think this information could

FIGURE 2.3 Best Practice Approach to Evidence-Based 
Practice in Public Health Nursing
Sources: Based on work by Keller & Strohschein, 2009; Melnyk &
Fineout-Overholt, 2014

Credible evidence

Client
preference
and values

Clinical
expertise

FIGURE 2.4 JHNEBP PET Process
Source: Used with permission: Dang & Dearholt, 2018, p. 4

Practice
Question

Evidence Translation

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35CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

’’

be considered evidence-based? The two therapists said they
were reporting on what they had found worked best with
their patients.”

Jaime says, “I guess we could review the material on
evidence-based practice in our textbooks and then talk
more to our PHN preceptors.”

“Good idea,” says Abby. “Let’s do it. We can also do a
search using CINAHL to see if there are any studies that
support what the PHN learned at the workshop. Do you
think this information about effective interventions will be
easy to find? What is an effective intervention anyway?”

Effective interventions fit your client’s situation and pref-
erences and result in the desired outcomes. Using inter-
ventions that are known to be effective is important. PHNs
have carried out research to demonstrate the effectiveness

of many interventions provided to individuals, families,
and communities. However, it is not always easy to find sci-
entific literature on the effectiveness of PHN interventions
(Swider, Levin, & Reising, 2017). Although research for
evidence-based practice might be limited in public health
nursing, PHNs should refer to it whenever it exists (Keller &
Strohschein, 2009, from Brownson, Baker, Leet, & Gillespie,
2002). PHNs are accountable to their clients (individuals/
families, communities, and systems) and to the public to
determine the effectiveness of an intervention and to justify
the use of resources. Your own experiences as a nursing stu-
dent can also guide your choices of which interventions you
can carry out effectively. You can use the evidence-based
public health approach—making decisions on the best
information available and creating interventions based on
that evidence (Barr-Walker, 2017). Table 2.4 includes recent
studies that demonstrate effective public health nursing
interventions.

TABLE 2.4 Effectiveness of Selected Public Health Nursing Interventions

Individual/Family Level

Intervention Results

Case management Decreased difficulty and dependence for meal preparation, telephone use, shopping, and ordinary house-
work (Instrumental Activities of Daily Living) were found for elders receiving home visiting in compari-
son with usual care (Li, Liebel, & Friedman, 2013). [Level I]

Case finding
Case management
Health teaching
Consultation
counseling

Significantly higher scores on overall healthy eating and healthy eating subdimensions (i.e., food selection,
preparation, and consumption) were found in elders 60 years and over in comparison to control group
(Meethien, Pothiban, Ostwald, Sucamvang, & Panuthai, 2011). [Level I]

Counseling Socially withdrawn students showed an increase in self-efficacy after participation in group-based coun-
seling interventions led by school nurses (Kvarme et al., 2010). [Level II]

Counseling
Health teaching
Referral and follow-up

Low-income, first-time mothers who participated in the Nurse–Family Partnership (NFP) home visiting
program had more beneficial breastfeeding and immunization outcomes compared to similar clients not
in the program (Thorland, Currie, Wiegand, Walsh, & Mader, 2017). [Level III]

Community Level

Surveillance In response to an online survey of PHNs in 29 states, PHNs reported they conducted ongoing surveillance
for tuberculosis, vaccine-preventable diseases, sexually transmitted diseases, pediculosis, foodborne dis-
eases, and elevated blood lead levels in their communities (Schaffer, Keller, & Reckinger, 2015). [Level III]

Coalition building School nurses participated in an interfaith coalition to respond to youth suicide in the community
(Anderson et al., 2017). [Level III]

Systems Level

Consultation
Screening

A maternal and child health nurse screening program for mothers experiencing domestic violence
(nurse-designed model) increased safety planning among postpartum women (Taft et al., 2015). [Level I]

Collaboration
Outreach

School nurses collaborated with a hospital and a school of nursing to develop and implement an
injury-prevention curriculum for helmet safety in elementary schools. Students from the intervention
group reported increased helmet use after intervention in comparison with the control group (Adams,
Drake, Dang, & Le-Hinds, 2014). [Level II]

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36 PART I  n  Foundational Concepts for Public Health Nursing Practice

‘‘
’’

Evidence-based practice (EBP)—and nursing interven-
tions—should be both effective and efficient. PHNs use the
evidence-based public health approach and consider all
evidence-based information, including the experiences of
experts. Because resources are limited in both healthcare
and public health, PHNs also need to consider the efficiency
of interventions. Efficient interventions require the least
amount of resources and achieve the desired outcomes in
the shortest period of time.

Evidence-based practice supports efficacy (the ability
to reach a desired result); efficiency (the achievement of a
desired result with minimum expense, time, and effort); and
effectiveness (the ability to produce a desired result). Addi-
tionally, EBP weighs risks, benefits, and costs against a back-
drop of patient preferences (Dang & Dearholt, 2018, p. 4).

Jaime voices his concern that if he knew from the literature
that an intervention was known to achieve a desired out-
come, he might use it even if he did not know if it would
be effective. “How do I know if it is going to work with a
specific client?”

Abby responds, “Well you can ask your preceptor what
type of interventions have worked in the past with your
client. You could also ask the client if he wants to try it.”

Before using an intervention, look at the literature or
consult with expert PHNs to identify specific interventions
that can best meet your clients’ unique needs and charac-
teristics. You also want to consider if the intervention is a
good use of your time and resources and the client’s time
and energy. Questions you can ask to determine effective-
ness and efficiency are listed in Table 2.5.

healthypeople.gov

Healthy 
People

   Healthy People 2020 identified 11 Leading  
  Health Indicators (LHIs) as priority health  
  concerns, including Nutrition, Physical 
Activity, and Obesity. Go to the Healthy People 2020 website, 
click “Leading Health Indicators,” and then click “Nutrition, 
Physical Activity, and Obesity.” Read about the most recent 
data and population disparities on nutrition, physical activity, 
and obesity. Look for the links to the science-based Dietary
Guidelines for Americans and the Physical Activity Guidelines. 
What evidence do you find that supports a healthy eating and 
physical activity program for you and your family? 

Just because “best practice” evidence is available does not
mean that it will be adopted and used. To create a supportive
evidence-based practice environment, three strategies are
necessary: establishing the EBP culture, building the capac-
ity for EBP, and ensuring sustainability (Dang & Dearholt,
2018, p. 19). A strategic plan and committed leadership are
necessary to develop the organizational resources and sup-
port for a sustainable evidence-based practice culture. Staff

TABLE 2.5 Analyzing Effectiveness and
Efficiency of Interventions

Determining
Intervention
Effectiveness

Determining
Intervention
Efficiency

n Is the intervention
culturally and develop-
mentally congruent with
the client’s status and
situation?

n Is the intervention
acceptable to the client?

n Does the outcome of the
intervention demonstrate
improvement of the
client’s health status?

n What are the costs of the
intervention (money, time,
people involved, and other
resources) for the PHN,
the other members of the
health team, the agencies
involved, and the client?

n Are the costs of imple-
menting the intervention
justified by the health
benefits for the client and
the community?

needs include continuing education on evidence-based
practice as well as initiatives to be implemented. Resources
such as Internet access to useful databases and journals,
evidence-based organizational mentors, and reimbursable
time facilitate integration of evidence into practice.

This chapter presents an overview of evidence-based prac-
tice relevant to public health nursing practice. The term best
practices is often used synonymously with evidence-based
practice. A few points are helpful to keep in mind as you
think about and use evidence of “best practices” in your
community health clinical:
n Experimental research using RCTs is considered uneth-

ical when placing an individual in a control group that
denies that individual treatment or interventions are
already demonstrated to be effective.

n Public health/community health nursing agencies may
be carrying out quasi- and nonexperimental research to
determine the effectiveness of their programs and inter-
ventions. These activities may be a component of their
ongoing quality improvement programs. Sometimes
students participate in these research studies. If you are
asked to participate, ask to see any informed consent or
ethical guidelines that your agency is using.

n The policies and procedures of your public health/
community agency and the professional practice stan-
dards guiding PHN practice may be considered clinical
guidelines. Progress reports and annual agency reports
may be considered organizational experiences.

n The knowledge and experiences of your preceptor and
other PHN agency staff will be reflected in the practice
you observe and the mentoring you receive. These repre-
sent expert opinions and clinical expertise.

n Clinical experiences may include both participant
and nonparticipant observation. When you reflect on
your observations of your preceptor or other public

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37CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

health/community health nurses interacting with clients
by using PHN interventions, you are demonstrating
nonparticipant observation. When you use these inter-
ventions yourself and reflect on your practice, you are
demonstrating participant observation. Both types of
experiences add to your clinical expertise.

n Community assessments that are carried out in collabo-
ration with community members and client satisfaction
surveys provide evidence of consumer preferences. See
Chapter 3, Competency #1, for information on commu-
nity assessments.

Database and Internet Searches
The sources of evidence must be as credible as the evidence
itself. That is why PHNs search scientific databases. The
online databases that provide the most relevant journal
articles for nursing are CINAHL and PubMed. CINAHL is
a proprietary database hosted by EBSCO, which means it
is privately owned and available to members of subscribing
institutions who pay a fee for remote access. PubMed is an
open-source database that is free to the public. Other cred-
ible sources include websites maintained by professional
organizations and service providers and governmental web-
sites, such as those run by the National Institutes of Health
(NIH), the U.S. Surgeon General, and the Centers for Disease

Control and Prevention (CDC). The Cochrane Library is an
international database of systematic reviews owned by the
Cochrane Collaboration and is an open-source database
that is free to use. The CDC Stacks, an excellent source for
public health information, is a free digital repository of pub-
lications produced by the CDC.

The NIH provides guidelines for evaluating web-based
health resources that can help you determine whether the
website resource you have found is credible. One example
of a credible website is a government program that reviews
maternal-child health home visiting program effectiveness,
called Home Visiting Evidence of Effectiveness (HOMVEE).
This website includes discussion of models and programs,
whether they meet Department of Health and Human Ser-
vices (DHHS) criteria, their target populations, and whether
research shows positive effectiveness (U.S. Department of
Health and Human Services, n.d.).

The goal of evidence-based practice is not to generate new
knowledge, but to improve practice. Baccalaureate nursing
graduates are expected to be able to find and use best prac-
tice evidence to improve their nursing practice. Hopp & Rit-
tenmeyer (2012, p. 84) identify a five-step process known as
the “5 A’s.” This process works well for students and PHNs
alike and can be used when students partner with public
health nurses during their clinical learning activities in
public health. Table 2.6 outlines a process for public health
nursing students to carry out the “5 A’s.”

TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities

The 5 A’s Students Using the 5 A’s with Community Partners

Ask: To find the right answer, you
need to ask the right question.

n Work with PHNs or other community partners to identify a public health practice issue
about a specific health concern with a specific population and a related knowledge gap
about current best practices.

n Work with PHNs or other community partners to create a specific practice question.
n Identify reasonable client outcomes that you wish to achieve with modified or new best

practice evidence.

Acquire: Search for the answer by
exploring all levels of evidence.

n Work with reference librarian, instructor, and community partners to identify credible
data sources for all five levels of evidence.

n Identify appropriate databases to search and keywords for search.
n Work with instructor and community partners to identify evidence from nonscientific

literature (e.g., credible websites, professional organizations, agency reports, etc.).
n Conduct key informant interviews.
n Conduct search, preferably for the past 5 years (or 10 years if there is little published

information for the past 5 years).

Appraise: Critically evaluate
the evidence and select the “best
practice evidence.”

n Work with fellow students, instructors, and interprofessional teams to critically review
the evidence and determine what evidence answers your practice question and is applica-
ble to the client population.

n Work with community partners to consult practice experts to determine which interven-
tions fit what the experts know about the population and health concern.

n Work with key community stakeholders to determine population preferences and values.

(continues)

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38 PART I  n  Foundational Concepts for Public Health Nursing Practice

Evidence of Best Practices
PHNs need to be critical consumers of public health and
nursing research. They must use a deliberative problem-
solving approach when making decisions about which
evidence in the literature is strong enough to support a
change in practice (Poe & White, 2010). However, public
health providers often do not have adequate knowledge
about evidence-based practice or the tools and resources
to research current evidence-based best practices (Barr-
Walker, 2017). In addition, published evidence in scientific
journals is limited, and many of the sources used are from
health-related statistics, government reports, and organiza-
tional or professional guidelines.

Much of the evidence for effective public health nursing
comes from Evidence-Based Practice Levels III, IV, and V. It
is often not ethical, possible, or practical to randomly place
people in an experimental or a control group, especially if
placement in either group could have a negative effect on
an individual’s health or well-being. An increasing body of
qualitative research in public health nursing exists. Under-
standing the context of the family, culture, and commu-
nity; the meaning of events; and the impact of these factors
on the clients’ health behaviors and health status is often
best achieved through the use of qualitative research meth-
ods. Public health nurses also learn a great deal from their
practice experiences and those of their colleagues. This
evidence-based information or practice-based knowledge
helps public health nurses translate evidence into practice
in specific clinical care settings (Barr-Walker, 2017). Case
study examples can be found in the literature, shared at
professional conferences, or reported on the Internet. These
anecdotal reports are also part of the practice evidence of
public health nursing.

Framing Your Evidence-Based Practice  
With the “5 A’s”
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting. It is
time to return to the “5 A’s” discussed earlier in the chapter

(Hopp & Rittenmeyer, 2012): ask, acquire, appraise, apply,
and assess.

Ask
When you explore the scientific literature for best practice
evidence, it is helpful to first identify your clinical ques-
tion so that you are focused in your search. One helpful
way to frame your clinical practice question is to use the
PICOT approach by identifying the patient population (P),
the intervention of interest (I), the comparison interven-
tion (C), the outcome (O), and the timeframe (T) (Stillwell,
Fineout-Overholt, Melnyk, & Williamson, 2010). For exam-
ple, if you wanted to research the effectiveness of teaching
parents about the “Back to Sleep” program to reduce the risk
of Sudden Infant Death Syndrome (SIDS), you might frame
your PICOT question as outlined in Table 2.7.

The “T” in PICOT may not be necessary to include when
reviewing the literature, but it may be helpful to include the
time element when you plan how and when you are going to
evaluate the outcome of the intervention you have selected
to implement in your clinical setting. Once you find a set of
articles that report on the effectiveness of the intervention
you are interested in, it is time to review them to determine
their usefulness.

Acquire
After writing your PICOT question, you can identify the
keywords in the sentence. A helpful way to identify key-
words is to create a PCO Table (Population, Content, Out-
comes). Table 2.8 demonstrates that using a PCO Table helps
you to identify six keywords or phrases. If you have access
to a reference librarian, you can take your keywords to the
librarian who can then help you create your online literature
strategy and identify the databases to search (Butler, Hall, &
Copnell, 2016). Complete your search using your keywords.

Appraise
The next step is to compare and contrast the studies and
reports you have appraised. Select the best studies or reports
with the most credible evidence that fits your clinical

The 5 A’s Students Using the 5 A’s with Community Partners

Apply: Make the evidence action-
able by using the evidence to
change your practice.

n Report credible evidence from all five levels to community partners.
n Make recommendations for change in practice or new interventions.
n Collaborate with community partners on modifications of current interventions or

development of new interventions.
n Partner with your PHN preceptor to implement the intervention if possible.

Assess: Evaluate the outcomes
of the change in practice in your
clinical setting.

n Identify how and when the client outcomes will be evaluated and determine the
effectiveness and efficiency of the modified or new intervention.

TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities (continued)

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39CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

‘‘

’’
situation and addresses your specific question. Think about
how you would present your findings and recommendations
to the PHNs and team you are working with.

Apply
Once you have completed the first three steps and have iden-
tified a best practice intervention, begin working with your
clinical team to translate or apply the evidence into clinical
practice. Before you implement a change in your practice or
your clinical team’s practice, you need to think about how
you will evaluate the effectiveness of the change. Identify
the outcome you would like to achieve.

Assess
The timeframe for assessment of client outcomes after imple-
menting the new intervention will depend on the urgency to

determine efficacy of an intervention as well as a realistic
expectation as to when effectiveness can be evaluated. For
example, if you implemented a community-wide campaign
to increase the flu vaccine in September to decrease the inci-
dence of influenza in the fall, you would probably compare
the incidence of influenza this fall to last fall in December. If
you were evaluating the effectiveness of the “Back to Sleep”
program, you might choose a 6-month timeframe to evalu-
ate the outcome of the program.

It would be important to evaluate both the effectiveness
and the efficiency of the intervention from a cost-benefit
perspective, which would be based on the quality of life as
well as the financial and human resource costs involved.
This is not always easy to do. For example, if the “Back to
Sleep” program reduced the incidence of crib death by one
infant in a 3-month period, would any of your community
partners consider the program effective and efficient?

Jaime comments, “I think I am going to do my intervention
paper on ways to reduce smoking in high school students.
I have to start looking for evidence-based practice articles.
I wonder how I should go about that.”

Abby says, “I have been working with the college refer-
ence librarian to research my topic. She suggested that I
use three databases: CINAHL, PubMed, and the Cochrane
Database of Systematic Reviews. I have found a few good
articles in each database.”

Jaime responds, “Great! I will try those databases, too! I
know that both PubMed and the Cochrane Database are in
the public domain and free to users. CINAHL is privately
owned, and organizations have to pay for employees to
use it. I don’t think my hospital has a contract to access
CINAHL.”

Abby concludes, “Don’t forget to write your PICOT
question first!”

Translating Evidence Into Practice
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting
and to translate best practice evidence into practice, which
means that you use the best practice evidence to evaluate
and update how you practice nursing. PHNs need to make
sure that their recommendations for change in practice are
based on the best evidence and are appropriate and feasible
for their client populations, their agencies, and their com-
munities. Support and funding for PHN practice depends
on documentation and dissemination of evidence that PHN
practice makes a positive difference in the health of its com-
munities. Evidence Example 2.2 shows step-by-step how to
use an evidence-based practice approach to find best prac-
tice evidence.

TABLE 2.7 The PICOT Approach to
Clinical Problem Solving

PICOT Question
Elements Examples

P = Patient population

I = Intervention of interest

C = Comparison interven-
tion of interest

O = Outcome(s) of interest

T = Time it takes the inter-
vention to achieve outcomes

P = Infants at risk for SIDS

I = Teach parents to place
infants on backs to sleep
using “Back to Sleep”
program

C = No purposeful teaching
about safe sleeping position
of infants

O = Percentage of babies
sleeping on back

T = Evaluate at 6 weeks and
3 months

PICOT Question: Will infants (P) whose parents are taught
to place them on their backs to sleep using a “Back to
Sleep” program (I) as opposed to no purposeful teaching
about safe sleeping positions for infants (C) be sleeping on
their backs (O) at 6 weeks and 3 months after receiving the
intervention (T)?

TABLE 2.8 Finding Keywords Using PCO

PCO Elements Examples

P = Patient Population P = Infants at risk for SIDS,
parents, caretakers

C = Context C = Teaching safe sleeping positions

O = Outcome O = Sleeping on back

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40 PART I  n  Foundational Concepts for Public Health Nursing Practice

EVIDENCE EXAMPLE 2.2
Searching for Best Practice Evidence on Optimal Breastfeeding Initiation  
and Translating the Evidence Into Practice

Breastfeeding is initiated in the setting where delivery occurs.
Often that is the hospital. Many new mothers are sent home
from the hospital within 24 hours of delivery. So, it is import-
ant for PHNs to know the best practice evidence to share with
their antepartum clients about what breastfeeding approaches
work best and then to support those practices during the
postpartum period. Public health nurses need to work with
their nursing partners in the hospital setting to prepare their
clients for breastfeeding, advocate for the preferences of the
new mothers with their acute care colleagues, and provide for
a seamless transition in the breastfeeding routine when the
mother returns home through coordination and case manage-
ment interventions. In this example, nurses in a birthing center
searched for best practice evidence for initiation of breast-
feeding immediately after birth. The following example shows
how the “5 A’s” and the PICOT process were used to identify
best practice evidence and translate it into practice. The ques-
tion was whether it was best practice to use a breast pump to
support breastfeeding in the first 72 hours postpartum.

Ask
A PICO(T) question was developed to frame the question to
guide the literature search:

P = Efficacy of use of breast pump in early postpar-
tum period to promote exclusive breastfeeding with
mother’s milk

I = Electric breast pump after breastfeeding during first
24–48 hours

C = Breastfeeding on-demand during first 24–48 hours

O = Baby fed exclusively with mother’s own breastmilk

T = 6 weeks postpartum

The question: Does use of an electric breast pump after
breastfeeding versus breastfeeding on-demand during the
first 24–48 hours postpartum increase the likelihood a baby
will be exclusively fed with a mother’s own breastmilk at
6 weeks postpartum?

Acquire
Ovid Medline, CINAHL, PubMed, and Google Scholar were
searched using a variety of search terms. Although 23 articles
were found, only 3 of these articles addressed the PICOT ques-
tion and the actual practice question.

Appraise
The literature reviewed suggested that while it remains unclear
if pumping has any immediate impact on breastfeeding initia-
tion and milk supply, using a breast pump in the first days and
weeks postpartum is associated with a shorter breastfeeding

duration (Chapman, Young, Ferris, & Perez-Escamilla, 2001;
Felice, Cassano, & Rasmussen, 2016; Jiang et al., 2015).
Other important evidence was identified:

Anticipating return to work and suboptimal long-term lac-
tation support systems increased women’s dependence on
expressing breastmilk with a pump (Chapman et al., 2001;
Felice et al., 2016; Jiang et al., 2015).

Hand expression is more effective at expressing colos-
trum (first days’ breastmilk supply) than an electric pump
( Flaherman et al., 2013).

Developing the nurse-family relationship fosters an
empowering environment where the family can experience
growth and develop the skills needed to achieve successful
infant feeding patterns, including direct breastfeeding and
expressing breastmilk (Raile Alligood, 2010).

After reviewing the scientific evidence, the nursing team at
the birthing center considered the other two evidence com-
ponents: the practice and procedures of the birthing center
and the preferences of the new mothers. The context of the
relationship between the mother and the nursing staff was
considered. The nurses’ caring interaction was considered as
necessary as the evidence-based knowledge to facilitate suc-
cessful breastfeeding initiation.

Apply
Supporting Breastfeeding Guidelines were developed and
implemented based on the evidence. The nurse in the birthing
center who initiated the quality improvement process changed
jobs and became a clinical coordinator in a public health nurs-
ing agency. She was able to share the best practice evidence
about the initiation of breastfeeding with the public health
nursing staff.

Assess
At the birthing center, the new guideline was instituted and
evaluated at both the systems and the individual/family
practice levels. Nursing staff completed a nursing practice
survey before and after implementation of the new guide-
lines. The purpose was to measure the accuracy with which
nurses were able to determine the appropriate interventions
needed to support lactation (when and when not to use an
electric pump) and their confidence levels of decision-making
regarding when to utilize the breast pump to support lactation.
The individual-level change was measured through a patient
survey completed at discharge. The survey measured the
breastfeeding mothers’ confidence levels of continuing their
breastfeeding plan of care when returning home and their per-
ception of nursing support received for their individual infant
feeding goals.

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41CHAPTER 2  n  Evidence-Based Public Health Nursing Practice

‘‘

’’

Jamie is continuing to work on his evidence-based practice
search on how to reduce smoking in high school students.

Abby changed her topic. With her PHN preceptor, she
has been co-visiting a first-time mom who has postpartum
depression. The PHN is visiting the mom twice weekly, and
the PHN has asked Abby to research best practices in work-
ing with moms with postpartum depression. Abby is going
to develop her PICOT question, create her PCO Table, and
then consult with her instructor and the reference librarian
on how to go about searching for the best practice evidence.
She is excited to be able to partner with her PHN preceptor
to find the most up-to-date best practice evidence to present
to the Family Health Team.

If you follow through on the steps outlined in this chapter
for researching best practices and taking steps to translate
this evidence into your nursing practice, you will be prac-
ticing nursing from an evidence-based practice framework.
As a professional, you are accountable for your own nursing
practice, so you need to be aware of and use best practices.
You will find that this book presents many levels of evidence
to justify using specific interventions.

ACTIVITY
Imagine that you are the nurse who changed jobs from the  
birthing center to the public health agency.

n How would you use this best practice breastfeeding  
initiation evidence?

n What would you want to know about the public health  
nurses and their antepartum and postpartum clients?

n How would you develop your PICOT question? 

n How might you partner with the staff to carry out the  
“5 A’s” process? 

The evidence-based practice approach does not always
entail a simple, concise process. However, through the use
of various levels of evidence, clinical expertise, local con-
text, and client preference, best practice interventions can
be developed and implemented to promote and protect the
health of individuals, systems, and populations.

n All five levels of evidence are used to identify best
practices.

n Evidence-based practice is a deliberative process start-
ing with a practice question, followed by an appraisal
of the evidence, and then a change in practice based on
credible evidence.

n Using the “5 A’s” and PICOT provides a structure for
practicing from an evidence-based foundation.

KEY POINTS

n The public health nursing process guides the PHN’s
actions.

n PHNs work at all three levels of practice (individual/
family, community, and systems).

n PHNs carry out 17 interventions unique to public health
nursing; 16 of these interventions are practiced inde-
pendently as part of professional nursing practice.

n Public health nursing practice is evidence-based.

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42 PART I  n  Foundational Concepts for Public Health Nursing Practice

REFLECTIVE PRACTICE

 1.  What do you think are the major differences between
the nursing process and the public health nursing
process?

l What will you do differently when following the
public health nursing process?

l How will your knowledge about the determinants of
health guide you in your assessments and interven-
tions at the three levels of practice: individual/family,
community, and systems?

 2.  Which other disciplines will you work with most often
in your public health clinical?

l What additional information do you need to know
about the other health disciplines?

l How will you find out the information that you need?
 3.  Which public health nursing interventions have you

used in previous clinical experiences?
l How will you carry out these interventions in your

public health clinical?
l How will this experience be the same or different

from what you have done before?

 4.  Have you used an evidence-based practice approach in
other nursing clinical experiences?

l What have you learned in reading this chapter that
you did not know before?

l How will your past experiences and your new knowl-
edge help you practice evidence-based public health
nursing?

 5.  Which types of best practice evidence related to a PHN
intervention would you like to explore?

l What is your PICOT question?
l How do you frame this as a PICOT statement?
 6.  Refer to the Cornerstones of Public Health Nursing in

Chapter 1. Which of the Cornerstones support the use
of evidence-based practice in public health nursing?

APPLICATION OF EVIDENCE

How would you work with your PHN preceptor to identify
an intervention that the staff would like to have researched
to identify any new best practice recommendations?

When you search for best practice evidence, how would
you implement the following steps?
n Determine which databases to use in your search.
n Carry out your literature search. Obtain help from the

reference librarian if you are having difficulty with your
keyword search.

n Select three to five journal articles to review. You may
use articles that represent different levels of evidence.

How would you carry out the following steps to analyze the
evidence?
n Compare and contrast the articles you have appraised.

Are their findings and recommendations similar or
different?

n Identify the articles that have the most credible evidence
that best fits your clinical situation.

n What format would you use to report your
evidence-based finding to the PHN staff?

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PART II
Entry-Level Population-Based

Public Health Nursing
Competencies

3 COMPETENCY 1: Applies the Public Health Nursing Process to Communities, Systems,
Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

4 COMPETENCY 2: Utilizes Basic Epidemiological (The Incidence, Distribution, and
Control of Disease in a Population) Principles in Public Health Nursing Practice . . . . . . . . . . . . . . . 75

5 COMPETENCY 3: Utilizes the Principles and Science of Environmental Health to Promote
Safe and Sustainable Environments for Individuals/Families, Systems, and Communities . . . . . . . 95

6 COMPETENCY 4: Practices Within the Auspices of the Nurse Practice Act . . . . . . . . . . . . . . . . . . . . 127
7 COMPETENCY 5: Works Within the Responsibility and Authority of the Governmental

Public Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
8 COMPETENCY 6: Utilizes Collaboration to Achieve Public Health Goals . . . . . . . . . . . . . . . . . . . . . 167
9 COMPETENCY 7: Effectively Communicates With Communities, Systems, Individuals,

Families, and Colleagues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
10 COMPETENCY 8: Establishes and Maintains Caring Relationships With Communities,

Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
11 COMPETENCY 9: Incorporates Mental, Physical, Emotional, Social, and Spiritual Aspects

of Health Into Assessment, Planning, Implementation, and Evaluation . . . . . . . . . . . . . . . . . . . . . . . 221
12 COMPETENCY 10: Demonstrates Nonjudgmental/ Unconditional Acceptance of People

Different From Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
13 COMPETENCY 11: Shows Evidence of Commitment to Social Justice, the Greater Good,

and the Public Health Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
14 COMPETENCY 12: Demonstrates Leadership in Public Health Nursing With Communities,

Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
15 Putting It All Together: What It Means to Be a Public Health Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . 301

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AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model
for Nurses
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47

‘‘

’’

CHAPTER

3
COMPETENCY #1
Applies the Public Health Nursing
Process to Communities, Systems,
Individuals, and Families

n Patricia M. Schoon
with Karen S. Martin, Kelly Krumwiede, and Noreen Kleinfehn-Wald

Kristi is listening to Beth, her public health nurse (PHN) preceptor, tell her about the client they are about
to visit for the first time. The local public health agency received a maternal child health visit referral
from a local OB/GYN for a 16-year-old, 20-weeks-gestation primipara. The client, Sara, has been diag-
nosed with anemia and is underweight with poor weight gain. Sara is single and living with her mother,
mother’s boyfriend, and two younger siblings. Sara and her family are uncomfortable with the idea of a
public health nurse who works for the government visiting them in their home.

Beth says, “Well, I think the first thing we do is go and visit them. We need to get them to trust us if we
are to help them.”

Kristi responds, “I have never visited a pregnant teenager or her family in their home. I don’t think I
will feel comfortable. Will the family be okay with me there?”

Beth responds, “I asked Sara’s mother if you could covisit with me and she was okay with that. We
will ask Sara and her mother what their health concerns and goals are and talk with them about how to
arrange our visits and what we can do to help Sara. We will open a case file on Sara and begin to do a
family assessment. You can observe and listen on this visit and take a more active part in future visits.”

Kristi says, “That sounds good to me!”
As they walk to Beth’s car she mentions, “We can start to do a windshield survey on our way to Sara’s

home as part of the community assessment that you and your student work group are going to do of the
local community.”

Kristi responds, “Great. I just happen to have my camera with me.”

KRISTI’S NOTEBOOK
COMPETENCY #1 Applies the Public Health Nursing Process to Communities, Systems, Individuals, and Families

(continues)

A. Identifies the population(s) for which the PHN is accountable

B. Assesses the health status of communities, systems, individuals, and families

1) Uses a health and social determinants framework to determine risk factors and protective factors that
lead to health and illness in communities, systems, individuals, and families

2) Identifies relevant and appropriate data and information sources for the populations to which the PHN is
accountable

a. Familiar with data used in the health department

b. Familiar with data in the programs in which the PHN works

3) Works in partnership with communities, systems, individuals, or families to attach meaning to collected
quantitative and qualitative data

4) Works in partnership with communities, systems, individuals, and families to establish priorities

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48 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

KRISTI’S NOTEBOOK
COMPETENCY #1 (continued)

C. Creates public health strength, risk and asset-based diagnoses for communities, systems, individuals,
and families

D. In partnership with communities, systems, individuals, and families, develops a plan based on priorities
(including nursing care plans for individuals/families)

1) Selects desired outcomes that are measurable, meaningful, and manageable

2) Selects public health interventions that

a. Are supported by current literature as evidence-based

b. Reduce health determinant risk factors and strengthen health determinant protective factors

c. Have the greatest potential for improving the health of the population

d. Respect and are consistent with the culture and ethnic beliefs of the community

e. Are consistent with professional standards, the Nurse Practice Act, existing laws, ordinances, and
policies

3) Selects level(s) of intervention (community, systems, individuals, and families)

4) Selects level(s) of prevention (primary, secondary, tertiary)

E. Implements the plan with communities, systems, individuals, and families

1) Works in partnership with communities, systems, individuals, and families to implement public health
interventions

2) Utilizes best practices when implementing the public health nursing intervention

F. Evaluates

1) Measures outcomes of public health nursing interventions using evidence-based methods and tools

2) Documents public health nursing process by completing forms, records, and charts for communities,
systems, individuals, and families

3) Uses information technology to collect, document, analyze, store, and retrieve the health status of
communities, systems, individuals, and families

Source: Henry Street Consortium, 2017

USEFUL DEFINITIONS

Community: Refers to (a) a group of people or 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
(Skemp, Dreher, & Asselin, 2006, p. 23).

Community Assessment: The process of systematically collecting information about a community’s structure,
processes, and dynamics, its physical and social environment, its populations, and its level of health and wellness
to determine its strengths, its resources, its populations of interest and populations at risk, its health needs, and
its health priorities.

Electronic Health Records (EHRs): “Longitudinal collection of clinical and demographic client-specific data that
are stored in a computer-readable format” (Martin, 2005, p. 461).

Family: A family is defined as a social unit of two or more people who identify themselves as a family, share
emotional bonds, and carry out the functions of a family including managing healthcare (Clark, 2008; Friedman,
Bowden, & Jones, 2003; Martin, 2005), and family is “a group of individuals who are bound by strong emotional
ties, a sense of belonging, and a passion for being involved in one another’s lives” (Wright & Bell, 2009, p. 46).

Family Assessment: The process of systematically collecting information about clients’ family structure, pro-
cesses, and dynamics; their physical and social environments; and their levels of health and illness to determine
their strengths, resources, health needs, and health priorities.

Health Status Indicators: Measures of the level of health or illness of an individual/family, community, or popu-
lation, such as incidence or prevalence of disease, birth and death rates, level of independence, life satisfaction,
and quality of life.

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49CHAPTER 3  n  Competency #1

of the students, a recent immigrant, said she thought these
families were fairly well off—they had housing, food, and
were safe in their homes . The country she had emigrated
from was in turmoil . She had seen family members mur-
dered, their cattle slaughtered, homes burned, and people
without food or clothing . These people, she thought, had
truly stressful lives . The other students reflected on her com-
ments and came to realize that people view the world from
their own experiences . Understanding and appreciating the
lived experiences of people is important . Knowing about
and understanding each other helps promote the oppor-
tunity for people to work together in a mutually respectful
manner that can build on each other’s strengths .

PHNs work in partnership with individuals, families,
and communities . Partnerships are mutual relationships
based on trust . PHNs establish trust with individuals, fam-
ilies, and communities by respecting their rights to make
their own health decisions and by adapting the nursing
practice to fit the lived experiences and daily lives of those
individuals, families, and communities . PHNs direct their
efforts to meet the priority health needs their clients iden-
tify . Public health nursing practice includes the “3 E’s”:

n Egalitarian (equal) relationships with individuals,
families, and communities

n Enhancement of individual, family, and community
strengths, resilience, and resources

n Empowerment of individuals, families, and com-
munities to advocate for and manage their own
healthcare needs

Thinking and Doing Population Health—
Nursing Process Leads the Way
PHNs work with individuals and families wherever they
find them in the community and in whatever condition
they find them . The priority for public health nursing is
health promotion and disease prevention, but PHNs also
work with individuals and families who have chronic health
conditions to help them achieve their health potential and,
whenever possible, manage their own lives and healthcare
needs . They need to discover their clients’ potential for self-
care and wellness to help them reach that potential . PHNs
use a strengths-based approach when using the public health
nursing process . Because their clients live in the commu-
nity, PHNs need to find out as much as they can about the
community’s support systems, resources, and resource gaps .

Partnering With Individuals,
Families, and Communities
PHNs need to understand the story, the context of the lives
of the people in the community in which they work . PHNs
must know and understand the history, culture, and life-
style of individuals, families, populations, and the entire
community . For example, in a post-clinical seminar, stu-
dents were discussing the stresses and crises of the families
they were visiting . They stated that they did not understand
how these families could function with so much stress . One

Omaha System: “Research-based approach to practice, documentation, and information management that
incorporates the Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes”
(Martin, 2005, p. 463).

Population: The “total number of people living in a specific geographic area”; subpopulations (syn. groups or
aggregates) “consisting of people experiencing a specific health condition, engaging in behaviors that have
potential to negatively affect health, sharing a common risk factor or risk exposure, or experiencing an emerging
health threat or risk” (American Nurses Association [ANA], 2013, p. 3).

Priority Setting: Organizing health concerns by hazard level so that health risks that place individuals/families,
communities, or populations at greater risk are dealt with first.

Public Health Informatics: Public health informatics is the systematic application of information, computer
science, and technology to public health practice, research, and learning (Centers for Disease Control and
Prevention [CDC], n.d.-b).

Public Health Nursing Process: Integrates concepts of public health, community, and all three levels of PHN
practice (i.e., individual/family, community, system) into the nursing process (i.e., assessment, diagnosis,
planning, implementation, and evaluation) (Minnesota Department of Health [MDH], Center for Public Health
Nursing Practice, 2003).

System: An organization or institution that is part of the social environmental determinant of health
(i.e., healthcare, education, commerce, religion, government).

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50 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

third-party payers and accreditors require health depart-
ments to provide evidence that their programs result in
improved client outcomes . Aggregate data are a powerful
tool to demonstrate the value of agency programs and can
be shared with the public, be used to obtain grants and other
funds, and be incorporated into quality improvement and
program evaluation reports . Examples of reports generated
by various agencies are found at www .omahasystem .org/
links .html .

Data Collection, Data Management,
and the Public Health Nursing Process
Data compose the engine that drives the problem-solving
process in nursing practice . Data are used to determine
the health of populations and sub-populations in order to
influence health priorities, health policy, and programs that
promote the health and safety of communities and their pop-
ulations (Allen, Soderberg, Laventure, 2017; Nelson & Stag-
gers, 2018) . A continuum of population data is used by public
health agencies to improve the health of their communities
(see Figure 3 .1) . Accurate and consistent population data can
be transformed to information, which leads to population
health knowledge, and then to wisdom in order to design
public health interventions to create healthier communities .

Therefore, you need to have a system and process for
data collection and management in place at the beginning
of the nursing process . For this reason, we discuss data in
this chapter before we discuss the components of the public
health nursing process . Many public health and community
agencies use electronic health records (EHRs) and auto-
mated health information systems (HIS) . EHRs and HISs
provide ways to collect, store, analyze, and share informa-
tion . Community and population data can be gathered from
a variety of primary (data collected by individuals carrying
out assessment) and secondary (data collected and published
by others) sources .

Although more than one HIS exists, a system created for
public health nursing is useful as an example . The Omaha
System, a standardized terminology initially developed for
use in the community, provides a problem-solving approach
based on the nursing process (see Figure 3 .2) . The Omaha
System is the foundation of the HIS that interprofessional
team members at many health departments and other
community provider sites regularly use to collect, docu-
ment, and analyze individual, family, and population clin-
ical data . The Omaha System allows PHNs to collect and
record their own evidence-based practice data, analyze the
data, and generate meaningful information that can be used
to improve the quality of the care they provide . By using
this approach, PHNs operationalize the data-information-
knowledge- wisdom continuum (Allen et al ., 2017; Martin,
2005; Nelson & Staggers, 2018) . They can tell their data- and
evidence-driven stories about the individuals, families, and
communities they serve . More than 22,000 interprofes-
sional clinicians use the Omaha System globally (Omaha
System, 2017) .

The adoption of EHRs by healthcare providers, includ-
ing health departments, is increasing very rapidly (Amer-
ican Nurses Association [ANA], 2015; Martin, Monsen, &
Bowles, 2011; Office of the National Coordinator for Health
Information Technology, 2017; Omaha System, 2017) .

When health departments use EHRs based on the
Omaha System accurately and consistently, they can aggre-
gate individual and family data into larger data sets so that
patterns can be identified within populations . Increasingly,

FIGURE 3.1 Transforming Data to Practice
Source: Allen et al., 2017; adapted by LaVenture, 2008

PUBLIC HEALTH PRACTICE

HEALTHIER C MMUNITIES

LE
V

EL
O

F
V

A
LU

E

DATA

INFORMATION

KNOWLEDGE

WISDOM

PRACTICE

FIGURE 3.2 Omaha System Model of the Problem-Solving 
Process
Source: Martin, 2005, p. 7, used with permission

INDIVIDUAL,
FAMILY, OR

COMMUNITY

Evaluate
problem
outcome

Collect
and assess

data

Plan
and

intervene

Identify
admission
problem

rating

Identify
interim/
dismissal
problem

rating

State
problem

PRACTITIONER–CLIENT RELATIONSHIP

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51CHAPTER 3  n  Competency #1

‘‘

’’

communities)—The Problem Classification Scheme is a
hierarchy of terms that includes domains; individual-,
family-, and community-centered problems; modifiers;
and signs/symptoms .

n Intervention Scheme (plans, pathways, care activities,
and service delivery terms to improve safety, qual-
ity, and effectiveness)—The Intervention Scheme is a
hierarchy of terms that includes categories, targets, and
client-specific information .

n Problem Rating Scale for Outcomes (evaluation that pro-
vides usable information for measuring and reporting
client progress and change across time)—The Problem
Rating Scale for Outcomes consists of Knowledge,
Behavior, and Status concepts and Likert-type rating
scales . Evidence Example 3 .2 showcases a case study of
the Omaha System used to tell the story of a nurse-client
interaction .

See Appendix B for additional Omaha System resources .

Kristi has just finished reading about the Omaha System.
Her PHN preceptor, Beth, tells her that the public health
nursing agency uses the Omaha System, and Beth wants
Kristi to have a basic understanding of the Omaha System
before she and Beth chart on any of the clients they visit.
Beth gives Kristi the case study about Anna to read to help
her understand the system. Beth asks Kristi if what she
read made sense.

Kristi reflects: “I expected to be confused about the
Omaha System, but the case study helped a lot. I could see the
how the nurse assessed Anna and provided nursing services
to her. She could use the Problem Rating Scale for Outcomes
to evaluate Anna’s progress when she returns for another
visit. I can see that using this system helps nurses measure
the impact of their care and report how nursing care makes
a difference. The one concern I have is that my instructor
stresses the importance of using a strengths-based approach
and the Omaha System always uses the term ‘problems.’”

Beth comments: “I had the same concern when I started
using the Omaha System, but my supervisor pointed me to
the literature on how ‘problem’ is actually defined in the
Omaha System. Here is the definition of problem that I
found: ‘Unique client concerns, needs, strengths, issues, foci,
or conditions that affect any aspect of the client’s well- being;
nursing diagnosis stated from the client’s perspective’* Also,
I found that the term ‘problem’ can be considered neutral,
not negative, so a problem in the Omaha System can also be
used as part of a strengths-based approach.**

Kristi responds: “That makes me more comfortable.
I am going to share with my classmates that the Omaha
System term ‘problem’ can be used from a strengths-based
perspective.”
* Source: Martin, 2005, p . 465
** Source: Monsen, Vanderboom et al ., 2017

Omaha System terms are used in documentation at
the point of care (i .e ., the time and place that care occurs) .
Because the terms of the Omaha System are not complex
and the structure is relatively simple, nonhealthcare pro-
fessionals can understand it . Clinicians see and use point-
of-care terminologies in their EHRs . In 2014, Minnesota
became the first state to recommend that American Nurses
Association recognized point-of-care terminologies be
included in all EHRs (ANA, 2015; Minnesota Department of
Health [MDH], 2015) . Prior to that, Minnesota Department
of Health staff conducted a survey and found that 96 .5% of
community agencies in all counties used the Omaha System
(Omaha System, 2017) .

The Omaha System enables healthcare providers to ana-
lyze and exchange client-centered coded data that can be
transformed to information, the first two stages of the data-
to-wisdom continuum . The Omaha System was designed to
be used by interprofessional clinicians to guide their prac-
tice and document and communicate information about
clients from admission to discharge . It exists in the public
domain (no fee or license) and is intended for use across
the continuum of care nationally and globally . It is based
on a conceptual model that reflects the pivotal position of
the individual, family, and community as client; interpro-
fessional partnerships; and the value of the problem-solving
approach . The Omaha System encourages critical thinking,
enhances communication, and operationalizes the nursing
process . The problem-solving approach complements the
strengths-based approach that focuses on building devel-
opmental assets and increasing the health of youth and
communities (Martin, 2005; Monsen, Vanderboom, Olson,
Larson, & Holland, 2017; Omaha System, 2017) . The Omaha
System consists of three components:
n Problem Classification Scheme (client-centered

assessment that engages individuals, families, and

EVIDENCE EXAMPLE 3.1
The Omaha System

The Omaha System was developed by the Visiting Nurse
Association of Omaha (Nebraska) and seven test sites to
enhance practice, documentation, and information man-
agement. Four federally funded research studies were
conducted between 1975 and 1993 that validated appro-
priateness and effectiveness of the terminology. DeLanne
Simmons, chief executive officer, envisioned a computer-
ized management information system that incorporated an
integrated, valid, and reliable clinical information system
focused on clients who received services, not on the nurses
and other interprofessional team members who provided
the services (Martin, 2005; Martin et al., 2011; Omaha Sys-
tem, 2017). More than 400 articles, chapters, and books
have been published about the Omaha System; the Listserv
has more than 3,000 members located in the U.S. and 22
other countries (Omaha System, 2017).

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52 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

EVIDENCE EXAMPLE 3.2
Omaha System Case Study

Anna K.: Older woman who had a chronic cardiac condition
and attended a screening clinic

First Visit/Encounter Data
Public health nurses at the Dakota County Public Health
Department (Minnesota) developed health clinics for senior
citizens. The clinics offered screening for health concerns, par-
ticularly hypertension, heart disease, and depression; accurate
health information for prevention and treatment; and outreach
and referral coordination for home care, equipment, medical
assistance, and other community services. Because inter-
action time was limited, the nurses developed standardized
protocols and forms based on the Omaha System to increase
the efficiency and effectiveness of assessment, interventions,
and documentation. When new clients visited the clinics, the
nurses considered four problems, Communication with com-
munity resources, Mental health, Circulation, and Medication
regimen. If those problems did not reflect clients’ presenting
data, the nurses selected and documented other pertinent
problems, interventions, and outcome ratings.
When Anna K. came to the senior clinic for the first time,
she reported that she had a history of dizziness and high blood
pressure, but could not recall previous readings. When the
nurse checked her vital signs, her blood pressure was 152/86
sitting and 154/82 standing; her pulse was 60 and regular. Her
weight was 138 pounds, appropriate for her reported height.
They talked about hypertension, blood pressure guidelines,
the Circulation protocol, and Anna’s data. The nurse suggested
strategies to increase Anna’s safety when she was dizzy. The
nurse recorded Anna’s vital signs on a health card, gave the
card to her, and suggested that she have her blood pressure
re-checked monthly and recorded on the card. She asked her
to show the card to her doctor during future appointments.
Anna said she took two “heart” pills fairly regularly. She
agreed to bring them with her when she returned to the Senior
Clinic the following week so she and the nurse could discuss
them. The nurse planned to use the Medication regimen pro-
tocol if appropriate, and record them on Anna’s health card.

Anna’s Answers: Transforming the Story into the Omaha
System assessment, services, and evaluation terms

Domain: Physiological

Problem: Circulation (high priority problem)

Problem Classification Scheme
Modifiers: Individual and Actual
Signs/Symptoms of Actual:

n syncopal-fainting episodes/dizziness

n abnormal blood pressure reading

Intervention Scheme
Category: Teaching, Guidance, and Counseling
Targets and client specific information:

n anatomy/physiology (circulatory system)

n mobility/transfers (avoid falls)

n signs/symptoms-physical (importance of vital signs,
when to notify physician, dizziness)

Category: Case Management
Targets and client specific information:

n continuity of care (show doctor her health card with
monthly blood pressure checks)

Category: Surveillance
Targets and client specific information:

n medical/dental care (schedule and go to appointments)

n signs/symptoms-physical (vital signs, circulatory status,
weight, blood pressure)

Problem Rating Scale for Outcomes
Knowledge: 2—minimal knowledge (some information about
normal/abnormal blood pressure readings but not impact on
health; did not know previous readings)

Behavior: 4—usually appropriate behavior (usually took
medications, has blood pressure checked periodically, seeks
healthcare)

Status: 3—moderate symptoms (blood pressure exceeded
expected range for non-diabetic client)

Elizabeth A. Vance, BSN, RN, PHN
RN Primary Care
Allina Health Clinics Division
Minneapolis, Minnesota

Carol A. Fish, MS, RN, PHN
Supervisor, Social Services Department
Dakota County Public Health Department
West St. Paul, Minnesota

Source: Vance & Fish, 2017 Omaha System case study . Personal correspondence from Karen S . Martin, Martin Associates, Omaha, NE . December 8, 2017 .

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53CHAPTER 3  n  Competency #1

Home Visiting and the Nursing Process
PHNs carry out assessments as part of the nursing process
most often in a community setting, such as a home, a school,
or a clinic . Most of the information is gathered through
observation and listening . When in the home setting, PHNs
are guests of the family members and need to follow their
lead regarding communication methods; timing, length,
and place of visit; and roles of the nurse and family mem-
bers . To assess the family, PHNs must first establish a trust-
ing relationship with family members based on mutual
respect and understanding (Eriksson & Nilsson, 2008;
Martin, 2005; McCann & Baker, 2001) . Answering ques-
tions about personal family matters and health situations
requires families to disclose information they generally do
not share with strangers, so the development of a trusting
relationship needs to precede or occur simultaneously with
the interviewing process . Andrew Gardner (2010) found
that one way to engage clients and help them feel comfort-
able was to start by being open and friendly; this approach

seems obvious but can be challenging for nurses who are
learning to be professional while maintaining boundaries
and creating an environment conducive to effective nurs-
ing practice . An appropriate level of openness certainly can
facilitate a connection and mutual understanding, but this
is sometimes a difficult balancing act, as friendship often
occurs within the professional context of the nurse-client
relationship . The initial visit to a family is critical in estab-
lishing the nurse-client trust relationship (see Evidence
Example 3 .3) .

Home visiting programs may include one or more vis-
its to a client . PHNs follow some families for months and
years, depending on their health risks and needs . So you
should not feel as though you have to get everything done
in one visit . Table 3 .1 demonstrates how a PHN would use
the nursing process in making a series of home visits . The
orientation phase takes one to three visits on average . The
working phase might require multiple visits over a period of
months or years .

EVIDENCE EXAMPLE 3.3
Public Health Nurses’ Views of a Good First Meeting

Swedish researchers used focus groups to determine what
public health nurses believed constituted a good first home
visit with parents of newborns (Jansson, Petersson, & Uden,
2001). A good first visit is considered key to developing an
effective relationship with parents. Three criteria were identi-
fied (Jansson et al., 2001):

1. Creating trust through good contact/reciprocal relation-
ships; listening; being a guest; having an equal role with
parents; and having time, privacy, and peace and quiet

2. Creating a picture of the family’s life situation by getting
a holistic impression of the family, seeing them in their
home environment, getting a picture of what the clients
are like, and taking in, consciously and unconsciously, the
mood and a variety of information about the family

3. Creating a supportive climate by confirming and affirming
parents’ feelings, abilities, and responsibilities and increas-
ing their responsibilities while providing a safety net of
services until family is able to manage on its own

TABLE 3.1 How the Nursing Process Occurs in Home Visits

Home-Visiting Components Nursing Process

Orientation Phase
n Introduction
n Determine purpose of visit and visit activities with client
n Engage in social conversation
n Assessment
n Identify and state client’s problems

Assessment and Diagnosis
n Individual/family and community assessment
n Strengths-based assessment—protective factors identified
n Resources identified
n Health risks and active health problems identified
n Unmet health needs identified

Working Phase: Identification
n Client asks questions and identifies nurse as someone who

can help .
n Client identifies problems .
n Nurse provides health teaching, support and counseling,

follow-up assessment, referral, and advocacy .

Planning and Implementation
n Mutual planning, priority-setting, goal-setting
n Interventions often used include teaching, guidance, and

counseling; treatments and procedures; case management;
surveillance, advocacy, referral, and follow-up .

(continues)

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54 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Home-Visiting Components Nursing Process

Working Phase: Mutual Relationship
n Client uses nurse as resource and accesses community

resources .
n Nurse engages client in mutual problem solving .

Implementation
n Interventions often used are teaching, guidance, and

counseling; treatments and procedures; case management;
surveillance; collaboration; and consultation .

Resolution and Termination
n Problems are solved or ongoing but stable .
n Client becomes independent of nurse or continues to

need support .
n Relationship ends when client no longer needs nurse or no

longer participates in plan (moves or refuses participation
in plan or visits) .

Evaluation
n Evaluation of Knowledge, Behavior, and Status outcomes:

outcomes met, partially met, or not met
n Replan—change in goals, outcomes, or interventions
n New priorities or emerging problems identified and nursing

process continued

Sources: Phases adapted from McNaughton, 2005; Omaha System terms from Martin, 2005; and interventions from Minnesota Department of Health, 2001

TABLE 3.1 How the Nursing Process Occurs in Home Visits (continued)

PHNs carry equipment they need to complete assess-
ments on individual family members . For example, common
equipment used on maternal/child health visits includes a
baby scale, blood pressure cuffs, a stethoscope, paper tape
measures, disposable thermometers, developmental screen-
ing tools, growth grids, and a thermometer for determining
the temperature of bath water .

PHNs carry smartphones, laptops, and other electronic
devices to stay in contact with others, access information,
and enter family data into EHRs during their home visits .
Many PHNs use automated guidelines or clinical path-
ways specific to individual client and family situations . For
example, public health agencies have screening, assessment,
and monitoring databases for newborns, infants, children,
antepartum, postpartum, and family clients . PHNs collect
admitting data on each client during their initial visits to
their clients . They monitor and record health changes at
each visit .

Public Health Nursing Assessment
Public health nursing assessment is a systematic, deliber-
ative, and holistic process of collecting data about a client
(individual, family, community, or system) that leads to an
understanding of the client’s health determinants, health
status, and priority health concerns and needs, as shown
in Figure 3 .3 . PHNs also need to carry out strengths-based
assessments so that intervention plans for health concerns
and problems are based on the clients’ abilities to manage
their own healthcare needs . Strengths-based assessments
identify clients’ abilities, resources, and resilience as well as
health needs (Monsen, Vanderboom et al ., 2017) .

FIGURE 3.3 How PHNs Collect Data About Individuals, 
Communities, and Systems

Individual/Family
• Family assessment
• Family health goals

Community
• Strength-based
assessment
• Health assessment and
intervention process

• MAP-IT
• Windshield
survey

System
• Community health priorities
• Community action plan
• Community intervention plan

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55CHAPTER 3  n  Competency #1

‘‘

’’

Individual/Family Level of Practice
The family is the focus of care when PHNs work at the
individual/family level of practice . The family is the pri-
mary unit of society and is responsible for carrying out the
functions that allow family members to survive and thrive .
In a health sense, the family is a unit of care allowing the
nurse to simultaneously focus on the individual, the family,
and the health issue (Hunt, 2013) . Families come in many
shapes and sizes and in different stages of development .
Family composition is varied and changeable in contempo-
rary society (Kaakinen, Coehlo, Steele, & Robinson, 2018) .
A family is “a group of individuals who are bound by strong
emotional ties, a sense of belonging, and a passion for being
involved in one another’s lives” (Wright & Bell, 2009, p . 46) .

The experience of illness or a health concern is felt by not
just the individual but also by larger systems including fam-
ily members and the community (Marshall, Bell, & Moules,
2010) . Family-focused care has the potential to empower
vulnerable and at-risk families (Rossiter, Fowler, Hopwood,
Lee, & Dunston, 2011) . Family assessment is a holistic pro-
cess in which all the factors that influence a family’s level
of health and wellness are considered . Specifically, a family
unit assessment includes collecting data on the individual,
family, household, and community to identify resources,
strengths, and risks (Meiers, 2016; Meiers, Krumwiede,
Denham, & Bell, 2016) . In addition to considering individ-
ual human development stages, PHNs consider the family’s
stage of development . Transitions between the stages involve
rearrangement of relationships . Although it is important to
note that this is a very traditional model for married fam-
ilies with children and would need to be adapted to a vari-
ety of diverse family structures, Carter and McGoldrick’s
(2005) Family Life Cycle model highlights the development
of the family system over time:
n Leaving home as single young adults
n Joining of families through marriage: the new couple
n Families with young children
n Families with adolescents
n Launching children and moving on
n Families in later life

Each stage is associated with tasks that will foster each
member’s development . Sara’s family falls in the “families
with adolescents” stage . One unique aspect to this stage is
that the parents face a transition with both the adolescent in
terms of growing independence and the adolescent’s aging
grandparents . This stage requires the family to alter its
parent-child relationship to accommodate the adolescent’s
growing independence and autonomy . This awareness of the
family’s stage of development can be helpful for PHNs in
understanding potential family conflict as they are work-
ing through the stages . Table 3 .2 outlines the components
of family assessment typically included in a comprehensive
family assessment using the Healthy People 2020 Health
Determinants Framework .

Beth and Kristi make their first visit to Sara. Her mother,
Patricia, introduces herself at the beginning of the visit and
states that she hopes the public health nurse can straighten
out her daughter and help her daughter understand the
poor choice she made in getting pregnant at such a young
age. She is concerned because Sara is missing so much
school. Sara has poor eye contact with Beth and her mother.
Beth focuses on Sara and asks her what she would like help
with for the rest of her pregnancy. Sara responds that she
is very tired and feels uncomfortable with all of her body
changes that are now becoming visible. She is afraid of how
the other students at school will treat her.

Beth tells Sara and Patricia that she would like to get a
good sense of the family before she begins any work with
Sara. Beth asks if she can visit again next week to finish the
family assessment she was able to start today. Before Beth
and Kristi leave, Beth collects information from Sara so a
case file can be opened. Beth then asks Sara if Kristi can
check her height and weight to get some basic information.
Sara agrees. Kristi finds that Sara weighs 100 lb. and her
height is 5’3″.

After the visit, Kristi writes in her public health nursing
clinical journal. She thinks about what phases of the home
visiting occurred during this first visit. She also analyzes
the visit and asks herself the question, “Was this a good
first visit?” Kristi also reviews the holistic family assess-
ment framework that she and Sara will be using during the
second home visit.

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56 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

‘‘During the second home visit, Kristi works with Beth to
complete the family assessment. She constructs a genogram
with Sara and her mother and they notice that Patricia
and Sara’s grandmother have a history of preterm labor.
During the visit, Jimmy, Patricia’s boyfriend, comes home
early from work and Sara’s sisters, Tara and Kara, 9-year
old twins, come home from school. The home becomes loud
and there are lots of interruptions during the early part of

the visit. Beth asks Patricia if they can continue the visit in
the kitchen and asks the twins to stay in the living room.
Jimmy decides he will take a nap. The visit continues unin-
terrupted. By the end of the visit, information about the
family health determinants of biology and behaviors have
been collected. When Kristi completes her weekly clinical
journal, she organizes the family data by health determi-
nant categories.

Table 3 .3 is what Kristi recorded .

TABLE 3.2 Holistic Family Assessment Framework

Framework Factors

Family Biological and
Genetic Factors

n Age
n Sex or gender identify
n Three-generation genogram
n Family-identified ethnicity
n Health status

Family Behavioral Factors n Lifestyle and daily patterns including nutrition, sleep, exercise, and recreation
n Housing and living arrangements
n Social support/ecomap
n Family and community roles
n Education, employment
n Socioeconomic status (income, poverty)
n Cultural patterns, religious affiliations
n Language and health literacy
n Health-seeking and health-limiting behaviors
n Patterns of coping and resilience
n Patterns of conformity and nonconformity

Physical Environment
Factors

n Home environment (use a home safety checklist appropriate to family members’ age,
development, and physical and cognitive abilities)

n Immediate neighborhood (observations, walkability, windshield surveys)
n Natural physical environment and weather
n Built environment, including safety
n Maintenance of sidewalks, roads, pedestrian crossing
n Transportation
n Adequate recreational resources
n Access to shopping centers
n Accessible healthcare—see the 5 A’s of accessible healthcare in the community-assessment guide
n Potential or actual environmental hazards such as pollution of air, water, food, or soil

Social Environment
Factors (i.e., social
actions, patterns, systems,
healthcare access)

n Availability of health and social services resources
n Availability of quality schools and daycare
n Availability of fire and police
n Employment opportunities
n Mass media and library availability
n Cultural and social patterns of community, including potential exposure to violence
n Governmental services
n Business community and working conditions

Data Analysis Summary of the family assessment including:
n Major family protective factors, major family risk factors
n Statement of family resilience and ability to manage own healthcare
n Family’s priority health problems or concerns and health goals

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57CHAPTER 3  n  Competency #1

TABLE 3.3 Sara’s Family Assessment: Individual/Family Health Determinants

Biological and Genetic Health Determinant Factors

Sara: is 16 years old, 20 weeks gestation, primipara, on a prenatal vitamin, diagnosed with anemia, and underweight with poor
weight gain . She and her family are Caucasian .

Patricia: mother, is 34 years old taking hydrochlorothiazide 12 .5 mg daily for hypertension .

Jimmy: mother’s live-in boyfriend, is 37 years old and has no health conditions .

Siblings: Tara and Kara are 9-year-old twins; both females have attention deficit hyperactivity disorder (ADHD) and take
Adderall XR 1 .25 mg daily . Immunizations are up to date .

Extended family: Sara’s grandparents, Patricia’s parents, live on a farm house 30 miles away . Grandmother, 55 years old, has
hypertension . Grandfather, 57 years old, has type II diabetes .

Samuel: Sara’s boyfriend, is 17 years old, Hispanic, and has no known health conditions .

Behavioral Factors

Socioeconomic Status: Sara is a full-time high school student in 10th grade, unemployed, and with no income . Patricia is a full-time
factory worker and Jimmy is a full-time welder . Both have high school diplomas . Tara and Kara are full-time elementary school
students . Samuel, Sara’s boyfriend, is a full-time 11th-grade student and works part time at a restaurant . Although the family does
not live in poverty, their income is low and they struggle to pay their monthly bills . Patricia has family health insurance and Jimmy
has his own insurance .

Cultural and Religious Affiliation: All family members were born in the United States and are Catholic . The family attends church
most Sundays .

Family Developmental Stage: families with adolescents’ developmental stage (Carter & McGoldrick, 2005)

Family Roles and Function: Patricia takes on leadership and organizer role in the home and schedules Sara’s prenatal check-
ups . Patricia makes the decisions and Jimmy pays the bills and fixes the house . Sara babysits the twins but lacks knowledge of the
difference between being an older sibling and being a parent . Patricia is tired, stressed, guilty for not being available for the family,
and upset that Jimmy is not helping more at home . Samuel doesn’t come over much anymore because Patricia and Jimmy are not
very welcoming .

Family Lifestyle Patterns (disrupted by health concerns): The family is struggling to manage schedules . Sara has been missing
school due to fatigue and does not want anyone to know she is pregnant . Patricia and Jimmy leave for work at 6:00 a .m ., so Sara
routinely takes care of the twins in the morning . Lately, Sara hasn’t been helping the twins get ready for school or to the bus on time .
Patricia has been contacted by both schools due to Sara’s multiple absences and Tara and Kara’s tardiness . Patricia has been working
overtime to pay for Sara’s prenatal care costs . Due to the stress of Sara’s pregnancy and working overtime, the house is messy, meals
are not being made or eaten together, and the twins are not taking their ADHD medication as prescribed .

Ecomap Summary: The family has close relationships with their neighbors and church . The twins’ relationship with their school is
strained due to tardiness . Sara also has a strained relationship with her school and misses Samuel and her friends . She would like to
find a peer support group for pregnant and parenting teens but cannot find one .

Health seeking behaviors: Prior to the recent family disruptions, the family had healthy eating patterns, including eating supper
together . They enjoyed weekly family bike riding . The twins and sometimes Sara got at least 8 hours of sleep most nights . No one in
the family smokes; Sara does not use alcohol or other drugs .

Health Limiting Behaviors: The family lacks time to prepare and share meals and to go bike-riding . The twins often miss their daily
ADHD medications . Sara feels like she is getting fat due to pregnancy, so she eats only one meal a day, typically a peanut butter and
jelly sandwich, chips, and a soda and ice cream as a bedtime snack .

Family Resilience and Coping Patterns: Patricia stated she and her girls are strong and that Jimmy makes the family even stron-
ger . Patricia went through a difficult divorce and feels her family is stronger because of the experience . Patricia and the girls talked
through the experience; they “stuck together .” They have a positive outlook and pray together . Sara’s pregnancy has been stressful
for the family . Sara is scared to give birth and depends on her mom being strong . “She has always been my rock and now I am scared
because my mom is so disappointed in me . We don’t talk anymore; she just yells at me all the time .”

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58 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

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’’

‘‘

’’

Beth and Kristi decide that Kristi could return for a third
family visit to complete the home and neighborhood por-
tions of the family assessment if Sara and her mother are
okay with this. Beth phones Patricia and gets permission
for Kristi to visit. After the visit, Kristi records the data on
the physical and social environmental health determinants
in her clinical journal. Kristi believes that she and Beth
have now completed the Orientation Phase of family visit-
ing. She will confirm this with Beth.

Table 3 .4 shows the notes that Kristi wrote after her visit .

Kristi goes to meet with Beth at the office before their next
scheduled home visit with Sara and her family. Beth and
Kristi review the data analysis of the family assessment and
the summary of the family strengths and risk factors and
identifies what she thinks are the family’s health problems
and priorities.

Beth comments, “It is difficult to focus on the family as
a whole when we opened the case on Sara and now we are
assessing and planning on intervening with the family as a
whole. You did a good job focusing on the family as a unit
and putting Sara in the center of that family.”

Establishing Family Health Goals
The PHN continues the nursing process by moving into iden-
tification of the individual’s or family’s health priorities and
mutual goal-setting . PHNs employ mutual problem-solving
strategies with clients to foster self- efficacy . When working
with families in the community, the PHN partners with the
families in determining priorities, establishing goals, and
developing an intervention plan . The plan should be con-
gruent with and integrated into the family’s culture, life-
style, and daily routine and be within the family’s potential
to achieve . The plan should enhance the family’s potential
for self-care and autonomy . The family care plan should be
realistic, understandable, measurable, behavioral, achiev-
able, and time-limited so that the effectiveness of the plan
and the nursing interventions can be determined . It is pos-
sible to develop and measure Knowledge, Behavior, and
Status outcomes for a family using the Omaha System Prob-
lem Classification Scheme .

TABLE 3.4 Sara’s Family Assessment: Physical and Social Environmental Health Determinants

Physical Environment Health Determinant Factors (Natural and Built Environment)

The family lives together in a 3-bedroom, 1-bath rambler in need of repairs in a low-income neighborhood . The twins share a room .
The home safety checklist findings included: presence of smoke detectors, carbon monoxide detectors, and good lighting through-
out . Cleaning products are in an unlocked cupboard under the sink . This will present a safety hazard for the new baby . Their
neighborhood has sidewalks and is well lit . Traffic is light . There is a grocery store, a farmer’s market, and a park nearby . The family
medical clinic is 5 miles from their home .

Social Environment Health Determinant Factors

The family feels that they live in a good neighborhood and good community . The neighborhood has a neighborhood watch commit-
tee and a few retired neighbors have a Safe Home sign in their window, which means that any child who needs help can go to those
homes . The local schools have good teachers and are safe . Patricia and Sara are relieved that a PHN can come to see Sara at home .
The PHN is working with the school nurse and social worker to plan for Sara’s return to school once she has the baby . There is no
peer support program for pregnant and parenting teens at the school . The City Council has recently started a marketing program to
attract new businesses, which will give Patricia and Jimmy opportunities for better jobs .

Data Analysis—Summary of Family Assessment

Family Strengths (Protective Factors): The family has a good history of resilience and healthy family roles and functions . The
family has good community support systems . Patricia and Jimmy expressed the desire to support Sara in her pregnancy . Sara plans
to complete high school and go to college; she does not use substances such as tobacco, drugs, or alcohol . The family is working with
the PHN, school nurse, and social worker to help Sara achieve her goals .

Family Risk Factors: Sara’s unexpected pregnancy has placed a stress on the family functions that has resulted in interruptions in
some family processes . Key areas for improvement are meal preparation, Sara’s difficulty with caretaking the twins in the morning,
and Sara’s poor eating habits . The family history of preterm labor is an added risk factor for Sara’s pregnancy . Sara has experience
caring for her younger siblings and has a desire to learn about prenatal care; however, she has a lack of knowledge about pregnancy
and caring for an infant . The relationship between Patricia and Sara is strained, and Sara does not feel she is receiving the support
she needs from her mother . The relationship between Samuel and the family is strained . The twins are not receiving their daily
ADHD medications and are often tardy at school, while Sara has frequent absences from her school .

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59CHAPTER 3  n  Competency #1

TABLE 3.5 Sara’s Pregnancy and Family Stress in the Omaha System

DOMAIN: Physiological DOMAIN: Psychosocial

PROBLEM: Pregnancy (high-priority problem)
Modifiers: Individual and Actual

Signs/Symptoms of Actual
n Difficulty with prenatal exercise/rest/diet/behaviors
n Difficulty coping with body changes
n Inadequate social support

Problem Rating Scale for Outcomes

Knowledge: 2—Minimal knowledge (interested in information
about appropriate rest, exercise, and diet patterns)
Behavior: 1—Not appropriate behavior (no prenatal care; high-
risk behaviors)
Status: 1—Extreme signs/symptoms (anemia and is underweight
with poor weight gain)

PROBLEM: Interpersonal Relationship
Modifiers: Family and Actual

Signs/Symptoms of Actual:
n Difficulty establishing/maintaining relationships
n Incongruent values/goals/expectations/schedules
n Prolonged, unrelieved tension

Knowledge: 3—Basic knowledge (describes importance of
positive communication but not methods)
Behavior: 3—Inconsistently appropriate behavior (great
decrease in number and increase in length of relationships,
increase in repairing relationship)
Status: 2—Severe symptoms (limited, brief communication
and interaction, often tense)

’’‘‘

‘‘

’’

Kristi and Beth carry out a home visit with Sara and her
family to identify the family’s priority health goals. During
the visit, they work collaboratively with the family to iden-
tify two family health goals and then translate them into
the Omaha System Problems.

• Goal One: Have a healthy baby to add to the
family → Problem: Pregnancy.

• Goal Two: Work on supporting each other by
improving their relationships and communications
and get back into a scheduled routine → Problem:
Interpersonal Relationship.

Kristi and Beth return to the office to input the family
data for their family health goals using the Omaha System
Problem Classification Scheme. In order to measure health
outcome improvements over the time of the home visiting,
Beth assigns a Knowledge, Behavior, and Status (KBS) rat-
ing starting for the primary family health problems.

Kristi’s KBS rating for Sara and her family is shown in
Table 3 .5 .

Beth says, “The next step will be to develop care plans.”
Kristi states, “I just reviewed Anna’s case study and the
Intervention Scheme. Was that a care plan?”

Beth suggests, “The Omaha System Intervention Scheme
is used to describe care plans and services. For simplic-
ity, Anna’s case study documents services so readers can
‘match’ the services to the text in Anna’s story. Why don’t
you take the next half hour and go online to the Omaha Sys-
tem Community of Practice (http://omahasystemmn.org/
data.php)? Watch ‘An Introduction to the Omaha System’

and ‘How to Read an Omaha System Pathway.’ You will see
that the term ‘pathway’ is used to suggest various Interven-
tion Scheme categories, targets, and client-specific infor-
mation for specific problems. Then we can work together
to develop pathways for the Pregnancy and Interpersonal
relationship problems.”

Kristi responds, “That sounds like a great idea. I am
concerned though that Sara has a lot of other health prob-
lems related to her pregnancy: her eating habits and not
gaining any weight, anxiety, isolation from her friends and
her boyfriend, Samuel. The list goes on and on! When will
we deal with those issues?”

Beth responds, “With home visiting, we take things
one small step at a time. We are still in the Identification
Phase of the Home Visiting Process. As we work with Sara
and her family, we will deal with all of these issues using
many interventions. Once we have developed a working
relationship with the family we will move into the Mutual
Relationship Phase. Then we will be able to have more of a
consultative relationship and help them connect with com-
munity resources and decide how they want to manage the
challenges of the birth of Sara’s baby.”

Health teaching, counseling, consultation, and case
management are interventions commonly used to build on
and enhance the families’ strengths and encourage them to
manage their healthcare . PHNs use advocacy to facilitate
the individual’s and family’s ability to access health and
social resources . They also use advocacy when populations
are found to be at risk for a specific health hazard .

Whether individuals live alone or with others, the same
family functions are relevant . If you are working with an
individual who lives alone or whose extended family lives

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60 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

elsewhere, you still need to use the same family assess-
ment approach . Sometimes a complete family assessment is
not needed or impossible to collect . In that case, the PHN
would select the assessment components that relate to the
specific family health problem or priority concern . It would
be important to include the following components in this
focused family assessment: the health problem or issue and
the related risk factors and protective factors, the family goal
related to the health problem or concern, necessary access to
health and social services, and the family’s ability to manage
healthcare needs and resources .

Community Level of Practice
PHNs assess communities to determine their levels of health
and wellness . These assessments are carried out in partner-
ship with the community . Many geographic communities,
such as cities, counties, and states, conduct a community
assessment on a periodic basis . They do this to monitor
changing health conditions of the populations in their com-
munities and to establish community priorities for health
goals, funding, and actions . The governmental agencies
conducting the assessment partner with other community
organizations and members to ensure that the diversity of
the community and all points of view are reflected in the
assessment . PHNs are part of the team that collects and
analyzes the community data .

It is important to conduct a strengths-based assessment
as part of the community-assessment process . PHNs work
to enhance community strengths so that communities can
be as independent as possible in solving their own health-
care problems and managing their own healthcare needs .
See Chapter 8 for a discussion of the formation of com-
munity partnerships and building on community assets
to strengthen the community’s ability to manage its own
healthcare needs .

The population data collected in public health includes
population health status, health differences or health status
gaps between populations (health disparities), and health
determinants (causes of health and illness within the popu-
lation) . Population health status data, also known as global
health status measures, are the “vital signs” of the popula-
tion . These global health measures include:
n Mortality (death rates) data
n Life Expectancy (average years lived for someone born

in a specific year)
n Years of Potential Life Lost (life expectancy–age of

death = YPLL)

n Morbidity (illness rates) data
n Health behaviors data (e .g ., smoking, exercise, obesity,

use of seatbelts)
n Health and life satisfaction data (how satisfied one is

with current health and lifestyle)
n Functional health data (ability to live independently

and manage own healthcare needs)

Kristi is just starting her community-assessment proj-
ect with three of her classmates. They are conducting an
aggregate assessment (focusing on a specific portion of the
population). Because of the home visits to Sara and her
family, Kristi is interested in looking at the needs of preg-
nant and parenting teens and identifying existing resources
and resource gaps. She finds out that Sara’s mother’s church
is considering starting an outreach program for pregnant
and parenting teens. She asks Beth what information the
health department might have to help her and the church
members decide what to do. Did the PHNs have any data
that would help?

Beth responds, “The public health department carries
out a community assessment every five years to determine
the priority health problems of the people living in the com-
munity. We want to know what the major health needs are
and which needs are met and which are unmet. We also
look at the assets or resources of the community to deter-
mine the community’s capacity to manage its own health-
care needs and solve its own problems. Then we prioritize
and decide which services to offer, what the funding should
be, and how to allocate resources to our different programs.
During the last community-assessment process, we found
out that while our teen pregnancy rate had decreased,
we still did not have the outreach and health promotion
services to meet their needs. One area we identified as a
priority was peer support groups for pregnant and parent-
ing teens. Many of our public health nurses provide health
teaching and case management interventions for pregnant
and parenting teens in the home, and they found that
until the teens return to school, they are quite isolated. We
aren’t sure if this is affecting their ability to parent their
newborns. So, we are in the process of using Omaha System
data to see if there are services we need to provide. When
you organize your aggregate assessment, you should con-
sider looking at what other churches and community orga-
nizations are doing or if they have the resources to develop
new programs.”

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61CHAPTER 3  n  Competency #1

Community Health Assessment
and Intervention Process
Community assessment and intervention is an inclusive
process that involves all relevant stakeholders such as health
and social services providers, spokespeople for the commu-
nity and its sub-populations, and key decision-makers in the
community . The MAP-IT 5-step process (see Figure 3 .4) is a
Healthy People 2020 tool that helps people unite to improve
the health of their communities (CDC, n .d .-a) . It may be

used as a community-assessment tool and as a commu-
nity planning process tool . MAP-IT resources are found at
http://www .healthypeople .gov/2020/implement/MapIt .aspx .

Before starting the data-collection process, an assess-
ment tool must be selected or developed . The community-
assessment tool presented in Table 3 .6 is based on the
determinants of health (see Chapter 1) . The community-
assessment project you participate in as a student may
include many of these components . Remember that all data
sources, both primary and secondary, must be documented .

TABLE 3.6 Community-Assessment Guide

Part I: Defining Target Population

n Entire Population of a Geographic Area: Population by census track, community, county, state, country
n Sub-Population or Aggregate: Population who share common character (i .e ., ethnic, cultural or religious group, age or

developmental stage, common health risk [potential or actual])
n Population of Interest: Population who is essentially healthy but could improve factors that promote or protect health

(MDH, 2001)
n Population at Risk: Population with a common identified risk factor or risk exposure that poses a threat to health (MDH, 2001)

Part II: Identifying Population Health Status

Levels of Health and Illness
n Birth and Death (Mortality) Rates
n Accidents and Injuries: accidental, intentional, homicide, and suicide
n Communicable and Infectious Disease Incidence and Prevalence Rates
n Acute and Chronic Disease Rates (physical, mental)

Health Risk Behaviors (may also be listed under Behavioral Health Determinants)
n Rates of smoking or chewing, drinking, drug use, obesity, drinking and driving, sexual behaviors and unprotected sex, use of

seatbelts and helmets, interpersonal abuse, participation in antisocial or illegal behaviors

Levels of Independence by age, gender, health status, socioeconomic status

Levels of Life Satisfaction by age, gender, health status, socioeconomic status

(continues)

FIGURE 3.4 Community Planning Process: MAP-IT
Source: Adapted from MAP-IT (CDC, n.d.-a)

Mobilize key people
& organizations

Identify roles
& responsibilities

Form coalition

MOBILIZE

Assess needs
and assets

Start collecting
community data

Work together
as coalition to
set priorities

ASSESS

Develop goals
and objectives

Decide how to
measure progress

& success

Consider
intervention points

where & when
change can occur

PLAN

Create detailed
work plan

Develop a
communication

plan

Identify a single
point of contact to

manage project

IMPLEMENT

Plan regular
evaluations to
measure and

track progress
over time

Share progress
and success

TRACK

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62 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Part III: Assessing Population Determinants of Health

Population Biological and Genetic Factors
n Population at last census and population changes in last decade
n Demographics: Age, gender, race, and ethnicity (may use population pyramids)
n Physical characteristics
n Genetic factors
n Health conditions: Acute and chronic

Physical Environment Factors
n Natural Environment: Geography, climate, weather, air and water and other natural resources, agriculture, animal life, urban,

rural, suburban
n Built Environment: Infrastructure of community (roads, bridges, transportation, public spaces, and recreational areas), public,

and governmental buildings; housing stock and density; industries and workplaces; educational and religious facilities; health-
care facilities; shopping and entertainment; accessibility; and environmental adaptation

Social Environmental Factors: Social Actions and Social Patterns

Population Behavioral Patterns
n History of the community
n Social, economic, and political

patterns
n Socioeconomic status (income,

poverty), education, employment,
and work patterns

n Housing and living arrangements
n Lifestyle patterns
n Cultural patterns, diversity, and

religious affiliations
n Community roles and engagement
n Language
n Health insurance
n Health literacy
n Health-seeking behaviors
n Health-limiting behaviors
n Patterns of coping and resilience
n Patterns of conformity and

nonconformity

Community Systems (Institutions)
n Cultural and ethnic organizations
n Education (public, private, religious)
n Commerce and job opportunities
n Media and forms of communication

including mail delivery, phone, radio,
television, and Internet

n Libraries and public information
n Governmental systems and services:

public health and social services;
police and protective services;
environmental services (water, air
quality, sanitation, waste management,
recycling services, vector control);
emergency preparedness and response

n Laws, regulations, ordinances
n Community safety net programs

( public and private)
n Community support systems

(formal and informal)
n Community networks, coalitions
n Health services and health services

access (physical, mental, chemical,
dental, pharmaceutical)

Access to Healthcare

Assessing the “7 A’s of Access”

(Truglio-Londrigan & Lewenson, 2013,
p . 93)

1 . Is the individual, family, or population
aware of its needs and the services
available in the community?

2 . Can the individual, family, or pop-
ulation gain access to the services it
needs?

3 . Are services available and convenient
for the individual, family, or popu-
lation in terms of time, location, and
place for use?

4 . How affordable are the services for
the individual, family, or population?

5 . Are the services acceptable to the
individual, family, or population in
terms of choice, satisfaction, and
congruency with cultural values and
beliefs?

6 . How appropriate are the services for
the individual, family, or population?

7 . Are the services adequate in terms of
quantity or degree for the individual,
family, or population?

Part IV: Analysis of Population Health Data

n Summarize the population demographics and health status
n Summarize the physical and social environmental factors
n Identify the major protective factors for population health
n Identify the major risk factors for population health
n Identify the key health disparities within the population as a whole and between sub-groups

TABLE 3.6 Community-Assessment Guide (continued)

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63CHAPTER 3  n  Competency #1

Windshield Survey
The windshield survey is a first look at a community through
a car’s windshield . Observers are asked to use their senses
(sight, hearing, and smell) to learn about a community as
they drive, walk, or use public transportation to get around
the community . They then make observations about the
physical and social environments and the natural and built
environments . The windshield survey is sometimes referred
to as a familiarization survey because it helps establish the
community context of care for PHNs . It can also be an initial

step to a more comprehensive community assessment by
raising awareness of issues for further exploration . Table 3 .7
includes a list of questions you might ask yourself to help
guide your windshield survey and analyze your findings .

Other types of windshield surveys may also be carried
out, such as environmental hazard surveys (see Chapter 5)
and walkability surveys to assess areas not accessible by car
such as sidewalks, paths, parks, playgrounds, campuses,
and malls .

TABLE 3.7 Windshield Survey—Snapshot of Community Assessment

Windshield Survey

The first steps of a windshield survey require identifying the community boundaries and determining whether you will conduct the
survey by car, by public transportation, or partially on foot to determine feasibility of your possible travel routes . It is best to con-
duct the survey in pairs or as a group . As you drive or ride through the community, pay careful attention to as many characteristics
of the community as possible . You may wish to take photos or videotape your windshield survey . Make sure that you are only taking
photos of people in public places . Be sensitive to the privacy of others; avoid taking pictures of people where they could be identified .

n Which resources/assets do you see available in the community? Resources may include libraries, clinics, thriving local
businesses, and other features that may provide support to community members .

n Which types of services for families do you see in the community?
n Are there other organizations, such as youth centers, churches, or Head Start programs that might provide activities for

children/families?
n Where do people live in the community? Is the housing primarily single-family housing or apartments? What is the condition

of the housing?
n What types of jobs are available in the community? Would these jobs likely be held by people in the area?
n Where do people shop? Which types of stores are available: locally owned or chain stores?
n How do people get around in the community? Is public transportation available?
n What do you notice about ethnic diversity in the community? Which age range seems predominant?
n What is the geographic environment? Which types of opportunities are available for exercise? Are parks available? Is there

green space?
n Which options are available for eating out?
n What did you learn about the health status of population groups in the community that augments published population

health data?
n Where can people go for healthcare services?
n Based on your observations, what would you identify as assets in this community?
n Overall, how did you feel about being in the community (e .g ., safe, comfortable, uneasy)?

Reflection and Analysis Questions
n What is the story of each photo you have taken? What do the photos tell you about the life and health of the community?
n What are the community’s outstanding assets? Is there a relationship between these assets and the health of the community?
n What appear to be the community’s major challenges? Is there a relationship between these challenges and the health of

the community?
n What do you see as the most striking characteristic about the community? Would this characteristic influence your approach

to providing care to the community?
n What did you find to be the most unexpected? Would the unexpected be an asset or a challenge to providing care to the

community?

Source: Modified from Hargate, 2013

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64 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

PHN Assessment at the
Systems Level of Practice
Systems are part of the social environmental category of
health determinants . Systems can be assessed to determine
their ability to respond to public health priorities in the
community . Systems that PHNs interact with on an ongo-
ing basis include healthcare systems; public and govern-
mental agencies; schools and school systems; community
health and social service agencies; local and state govern-
ments, including elected and appointed officials; insurance
companies; and faith-based organizations . PHNs assess
systems to identify the extent to which they can meet com-
munity health needs and, if gaps exist, to identify the addi-
tional resources that are needed . Kristi’s discussion about
the local Catholic church, the Salvation Army, and county
public health nurses working together demonstrates how
public-private partnerships can often fill the gap when one
organization cannot meet the need alone .

Kristi and her fellow students find that two organizations
in the community are interested in developing some out-
reach services to pregnant and parenting teens: a local
Catholic church and the Salvation Army. She asks her PHN
preceptor if two such different organizations might be able
to work together.

Beth advises, “You might want to divide your group of
four students into two and ask each pair to assess one of
the organizations. You would want to look at their values,
goals, resources, and willingness to work with each other.

If you find common ground based on an interest in help-
ing pregnant and parenting teens, then you can arrange a
meeting of the two organizations. You could let them know
that the PHNs in our agency would be willing to help them.”

Kristi responds, “Wow! We might be able to do some-
thing valuable for the community while we are carrying out
our clinical assignment. I am going to call my classmates
and set up a meeting to get started. Thanks.”

Identifying Community Health Priorities
PHNs employed in governmental public health agencies
are accountable to the public for the health priorities they
select, the populations they serve, and the services they pro-
vide (see Chapter 7) . PHNs consciously make the connec-
tion between the health needs of the community as a whole
and the health needs of individuals and families within the
community . The priority health needs identified through
the community-assessment process help PHNs determine
the most vulnerable and underserved populations in their
communities and target those with greatest need for services .

PHNs also identify health priorities in the community
by determining health and illness patterns among their
individual clients and families by aggregating data on all
the families whom their agency serves . PHNs look at mul-
tiple interacting health determinants, including the social
determinants of health, to identify population health pat-
terns and causes when working with individual clients
and community partners (Monsen, Swenson, & Kerr, 2016;
Monsen, Brandt et al ., 2017; Monsen, Swenson, Klotzbach,
Mathiason, & Johnson, 2017) . PHNs also conduct research
to identify health concerns in known vulnerable popula-
tions . For example, a study of early care and education pro-
grams identified the following health needs of the centers
and enrolled children: hygiene and hand-washing; sanita-
tion and disinfection; supervision; and safety of indoor and
outdoor equipment (Alkon, Rose, Wolff, Kotch, & Aronson,
2016) . PHNs can determine community health priorities by
reviewing the community-assessment data to determine
which health problems have the greatest potential for harm
and have effective interventions . Questions to consider
when establishing health priorities are listed in Table 3 .8 .

PHNs are ever-vigilant community watchers who are
often the first to notice when a new health concern emerges
or when a service gaps exists in the community . An exam-
ple of a health concern identified by a PHN intake nurse,
explored by agency staff, and taken to a group of commu-
nity partners for a systems-level intervention is found in
Evidence Example 3 .5 .

EVIDENCE EXAMPLE 3.4
Windshield Survey

A total of 284 windshield surveys were carried out by
nursing students in Mexico, New Zealand, Norway,
Turkey, and the United States. The Omaha System Prob-
lem Classification Scheme was used to evaluate the wind-
shield survey data. The students were able to input the
community-assessment data into electronic records using
an online checklist of 11 Omaha System problems. This
framework for collecting and analyzing community data
was found to be an effective teaching-learning tool for
students.

Source: Kerr et al ., 2016

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65CHAPTER 3  n  Competency #1

TABLE 3.8 Determining Community
Health Priorities

1 . What is the incidence and prevalence of major diseases,
health risk behaviors, and health concerns in the com-
munity (e .g ., heart disease, teen pregnancy, drinking
and driving, smoking, depression, influenza)?

2 . What are the major causes of death and disability in the
community (e .g ., heart attacks, stroke, cancer, demen-
tia, car accidents, and homicide)?

3 . Which populations in the community are most affected
by these health problems (health disparities)?

4 . What are the major health risks in the community
(e .g ., obesity, air pollution, homes with lead-based
paint, seasonal flooding, homelessness, lack of health
insurance)? Consider level of risk and proportion of
population affected . What are the key social determi-
nants of health affecting vulnerable populations in the
community?

5 . Which health needs are met by community resources?

6 . Which health needs are not met?

7 . Are affordable and effective interventions available for
these health needs?

8 . Who is responsible for meeting these health needs?

9 . Rank order priorities by level of risk or hazard to
community population or sub-populations .

Decline in Child Mortality

GOAL 3 Significant progress has been made in reducing child mortality. In 2015, the mortality rate for
children under age 5 worldwide was 43 deaths per 1,000 live births—a 44% reduction since 2000. This
translates to 5.9 million under-5 deaths in 2015, down from 9.8 million in 2000. But despite progress in
every region, wide disparities persist. Sub-Saharan Africa continues to have the highest under-5 mortal-
ity rate, with 84 deaths per 1,000 live births in 2015—about twice the global average.
Children are most vulnerable in the first 28 days of life (the neonatal period). To reduce child deaths
even further, greater attention must be focused on this crucial period, where progress has not been as
rapid. In 2015, the global neonatal mortality rate was 19 deaths per 1,000 live births, a 37% reduction

since 2000. This means that, in 2015, about 2.7 million children died in the first month of life. Neonatal mortality remains highest
in Central and Southern Asia and in sub-Saharan Africa: 29 deaths per 1,000 live births in 2015 in both regions.
The share of newborn deaths in all under-5 deaths grew from 40% in 2000 to 45% in 2015, due to the slower pace of progress
among newborns. It is estimated that 40% of neonatal deaths could be prevented by providing high-quality care for both mother
and baby around the time of birth (United Nations, n.d.).

EVIDENCE EXAMPLE 3.5
Determining Population Needs in a
Rural/Suburban County

The intake nurse at the public health agency was respon-
sible for logging referrals and conversations of significant
public health concern. The agency she worked at was small
and lacked an on-site physician or walk-in clinic services.
It was a 50-mile drive to the larger metropolitan commu-
nity where low-cost clinics were available. An analysis of
the monthly logs included calls from uninsured adults with
a variety of acute and chronic healthcare conditions. The
intake nurse found a trend of increasing numbers of working
adults lacking access to care. She compiled a brief report
summarizing two months of log entries and presented it to
her public health director. At the next community partner
committee meeting with local medical clinics and hospi-
tals, the director shared the intake nurse’s report. After
consulting with other community partners, the committee
proposed establishing a nursing center. The hospital agreed
to fund the part-time center staffed by a PHN for one after-
noon a week for two years. Services focused on screening,
referrals, and health promotion. A review of client data after
several months identified a need for limited physician ser-
vices. A local medical clinic offered to see patients referred
by the nursing center free of charge. Another healthcare
provider purchased a mobile health unit to do mammog-
raphy outreach. The committee worked with this provider
to use the mobile unit to visit several community sites on
a monthly basis. These services were the direct result of
systems-level collaboration and advocacy for those lacking
access to healthcare.

Source: Kleinfehn-Wald, 2010

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66 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Public health diagnoses for populations are often written
as population risk diagnoses . The traditional risk diagno-
ses have four components: health risk, population at-risk,
modifiable risk factors, and bio-statistical data . This tradi-
tional population risk diagnosis has been modified to create
an asset-based risk diagnosis by adding the component of
modifiable protective factors (see Table 3 .9) . This approach
helps to build on existing community resources and involve
community members when creating an intervention plan .

If you wish to write an asset-based public health risk
diagnosis using the Omaha System taxonomy, you would
include Domain, Problem, and Signs/Symptoms in the
health risk area and could use the KBS ratings as a way to
measure outcomes . The category of Problem as discussed in
Chapter 2 may also be used to identify strengths .

Public Health Nursing Community Action Plan
When the PHN is working with the community, the plan-
ning process and intervention process involves an interpro-
fessional team and key community members . After the team

has established priorities and formulated clear statements
of the health priorities to be addressed, it is time to deter-
mine goals . Community goals are based on community
values, beliefs, and the willingness of community members
and elected and appointed officials to make changes; the
resources available; and a consensus of what is achievable
in the given time frame . Specific outcomes are then estab-
lished . An example of a goal and an outcome for a commu-
nity follow (sometimes the words goal and outcome are used
interchangeably):
n Goal: Reduce obesity in our community
n Outcome: Reduce obesity in adults in our community

by 10% by 2020

Population Health Goals
The United States has established population health goals
each decade since 1990 . The purpose of the goals is to
encourage communities to work together to improve the
health of their citizens and to empower individuals to make
better health decisions (U .S . Department of Health and
Human Services [U .S . DHHS], 2010) . These measurable out-
comes, called health status indicators, are determined by
reviewing existing population health outcomes, comparing
specific population outcomes with outcomes from other
populations, and analyzing evidence from the literature on
acceptable outcomes . They are time-specific and stated as a
percent . For example, scientific evidence suggests that obe-
sity is a risk factor for many diseases, so reduction of obesity
in adults within the U .S . population by 2020 would be a pos-
itive health outcome . Healthy People 2020 was based in part
on the level of achievement of Healthy People 2010 goals
(Reinberg, 2010; U .S . Department of Health and Human
Services [U .S . DHHS], 2010) . Healthy People 2030 will be
based on the population progress toward achievement of
Healthy People 2020 goals . Evidence Example 3 .6 illustrates
the ongoing monitoring of level of achievement of Healthy
People 2020 goals .

TABLE 3.9 Asset-Based Public Health
Population Risk Diagnosis

Components Example

Health risk Increased risk of infection (pertussis)

Population at risk Among nonimmunized or partially
immunized infants and children in
(specify geographic area, community,
or county)

Modifiable risk
factors

Related to contact with non-
immunized children and adults who
may have pertussis, health beliefs
opposing childhood immunizations,
knowledge deficit about benefits of
immunization, lack of access to health
resources

Modifiable
Protective Factors

Related to increased funding for
outreach and immunizations to at-risk
populations through the public health
department, coalition with local
religious organizations and safety net
organizations to immunize children .

Bio-statistical data
(for geographic
area, community,
city, county, state,
national)

As evidenced by lack of herd immu-
nity (80–90% immunization) in
preschool population (state immuni-
zation rate) in (geographic area or city,
county, state, country) with (insert
number of cases) reported cases of
pertussis in the last month in infants
and children ages (insert age range) .

EVIDENCE EXAMPLE 3.6
Healthy People 2020 Goals

A mid-decade review of progress toward Healthy People
2020 goals identified that Healthy People 2020 goals
would be more modest than the 2010 goals. Only 19% of
Healthy People 2010 goals were met, and progress was
made on only 52% of them. Some, like obesity, had become
worse since 2000. U.S. obesity rates increased from 25%
to 34% between 2000 and 2010 (Reinberg, 2010), and the
prevalence of obesity in the U.S. was 35.6% between 2011
and 2014 (CDC, 2015).

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67CHAPTER 3  n  Competency #1

n Systems Level: Consult with schools to increase the
physical activities of students within the curriculum .

n Individual/family Level: Provide health education and
counseling to children and families to empower them to
develop healthier lifestyles .

The Public Health Nursing
Community Intervention Plan
PHNs work collaboratively with multiple community part-
ners to establish population health goals and to develop
intervention plans . These plans need to be consistent with
the demography, culture, and health status of the target
population and be in language that is clear to interprofes-
sional partners and the community . It may be more appro-
priate to label the plan a population health plan rather than
a nursing care plan . However, the framework of the public
health nursing process can be used effectively with interpro-
fessional as well as lay groups . Public health interventions
for population health:
n Modify the health determinant risk factors that are

causing the population health problems or disparities by
weakening or eliminating the risk factors

n Modify health determinant protective factors that will
improve the ability of at-risk and vulnerable populations
to better manage their own healthcare

Online Activity
    Go to Healthy People 2020 and study a goal of interest  
to you. 

n Identify an objective and then click “National Snapshots”  
to see how progress has been made on that goal. 

n Go to the “Interventions & Resources” tab to find evidence  
of interventions that have been effective in working to 
achieve this goal. 

Public health nurses and other public health profession-
als use Healthy People goals as well as their community-
assessment data to establish organizational and program
goals for their communities and the clients they serve . The
focus in Public Health is primary prevention; however,
PHNs will include secondary and tertiary prevention goals
when appropriate to meet unmet community needs . PHNs
often work at more than one level of practice simultane-
ously . For example, if there is a primary prevention goal to
reduce childhood obesity, the PHNs might do the following .
n Community Level: Collaborate with local television

stations to have a media campaign to increase commu-
nity level of awareness for the need to increase children’s
activity levels and to develop more afterschool sports
and activity programs for children .

THEORY APPLICATION
Population-Based Models for PHN Interventions and Outcomes

Twelve conceptual models of population-based PHN interven-
tions and outcomes published between 1981 and 2003 were
identified and compared (Bigbee & Issel, 2012). Four of the
twelve models are very consistent with the PHN community

assessment and intervention model presented in this chapter.
The following table demonstrates how these models reflect
essential components of this book’s population-based PHN
intervention plan.

Model Major Components PHN Concepts

PHN Conceptual Model (White, 1982) Determinants of health impacted by
nursing process at individual/family,
and population levels

PHN process, levels of practice, deter-
minants of health, PHN interventions,
outcomes

Community as Partner Model
(Anderson & McFarlane, 1988, 2011)

Based on Neuman’s systems model and
includes assessment wheel and inter-
ventions based on Intervention Wheel

PHN process, levels of prevention,
PH interventions from the Intervention
Wheel, outcomes

Public Health Intervention Model
(Keller-Olson et al ., 1998)

Population-based model including 17
interventions at individual, commu-
nity, and systems levels

Population focus, levels of practice,
interventions, interprofessional aspects

LA Public Health Nursing Practice
Model–LA Model (Smith &
Bazini-Barakat, 2003)

Population-based model using nursing
process to address health indicators
using Intervention Wheel

PHN process, population focus,
levels of practice, interventions
from Intervention Wheel, outcomes,
interprofessional aspects, client
participation

Source: Abstracted from Bigbee & Issel, 2012

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68 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

The Public Health Nursing Community Intervention
Plan includes the following components:
n Public health asset-based population risk diagnosis
n Population health goal and level of prevention focus
n Client focus: individual/family, community, system
n SMART behavioral outcomes that are measurable and

attainable and understandable to the family . SMART
outcomes are:

l Specific: What needs to be accomplished?
l Measurable: How will the nurse, client, and family

know the goal has been met?
l Attainable: Can the goal be met with the resources

available?
l Realistic: Does the client (and family) have the physi-

cal, emotional, and mental capacity to meet the goal?
l Time-Bound: When will the goal be achieved?
n Evidence-Based Public Health Interventions: Pub-

lic Health Intervention Wheel (Keller, Strohschein,
Lia-Hoagberg, & Schaffer, 2004; refer to Chapter 2) or
Omaha System (Omaha System, 2017) interventions may
be used . Include the intervention, the strategy or process
to be used, and the provider(s) of the intervention

n Evidence-Based Rationale for each intervention:
Include the scientific rationale with citations as well as
population preferences

n Evaluation of Outcomes: Use quantitative measures to
determine the progress made toward achievement of the
outcome . These measures to be used should be selected
during the planning process .

EVIDENCE EXAMPLE 3.7
Evaluation of a Home Visiting Program for Pregnant and Parenting Teens

After interventions are implemented, it is necessary to assess
the effectiveness of the program and the progress of the target
population toward goal and outcome achievement.
Four commonly used public health evaluation methods
identified by Spiegelman (2016) are:

n Feasibility evaluation: Assess whether something will
work and be effective in the “real world”

n Impact evaluation: Assess the efficacy and effectiveness
of an intervention on health outcomes

n Program evaluation: Assess a program’s processes to
improve them (quality improvement approach)

n Comparative effectiveness: Assess and compare
interventions to see which work best for whom, in what
situations, and from a cost-effectiveness perspective

The Pregnant and Parenting Teen program, discussed in
Evidence Example 3.8, demonstrates the effectiveness of
using all four of these evaluation methods.

Implementing population-based interventions in a com-
munity often includes collaborative efforts of many provid-
ers, organizations, and community members . Usually, a core
team develops the implementation plan timeline and selects
or designs public health intervention strategies . For exam-
ple, if social marketing is selected for a program to encour-
age parents to have their children immunized, potential
strategies could be billboards, development of online and
printed media, and radio and television adds or other forms
of media . It would be important to know when the best time
(i .e ., window of opportunity) would be to start a social mar-
keting campaign and where (before school starts in the fall,
during spring preschool enrollment, etc .) .

Kristi and her classmates complete an assessment of the
sub-population of pregnant and parenting teens in their
community and identify an unmet need for a pregnant
and parenting peer support group. They work with a
group of local churches and the Salvation Army to plan
a community-wide outreach effort with the Salvation
Army for the meeting site. The church groups and local
high school are ready to start recruiting teen participants.
They work with Kristi’s preceptor, Beth, to identify the best
time to recruit teens and start the program. They decide to
recruit teens at the time the pregnancy is confirmed, and
decide that the beginning of the next school year is a good
time to launch the program.

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69CHAPTER 3  n  Competency #1

‘‘

’’

‘‘

’’

Kristi asks her neighbor, a county commissioner, if she
would help to find funds for the pregnant and parenting
teen peer support group that will be held at the Salvation
Army. The group needs funding for transportation for the
teens and their babies to attend a support group meeting
once a week for 6 months. The commissioner asked Kristi
if she has data to support the need for transportation ser-
vices. Kristi assures her that she does. There are 20 teens
interested in joining such a group, and only two of them
have transportation. Although the local bus service has a
stop only a block away from the Salvation Army, only five
of the girls are on a bus line. That leaves 13 teens without
transportation. In addition, the PHNs have assessed all the
teens and have data that support the need for socialization
and peer group support for these pregnant and parenting
teens. The commissioner is not sure if these teens can make
a commitment to attend the group or if attending the group
would really make a difference. Kristi tells the commis-
sioner that PHNs from the county are going to be group
facilitators and would be using the Problem Rating Scale
for Outcomes to determine if the outreach and counseling
efforts are effective. Of course, she has to explain to the
commissioner what the Problem Rating Scale for Outcomes
is! The commissioner asks Kristi and her classmates to
come to a council meeting to present their proposal. Kristi
says they can do that and she will also ask her PHN precep-
tor to come to the meeting.

EVIDENCE EXAMPLE 3.8
PHN Home Visiting Program for Pregnant and Parenting Teens

A visiting nurse association created and implemented a Preg-
nant and Parenting Teen Program to promote family and child
health and family self-sufficiency for teen moms 19 years
of age or younger. The pillars of the program are: a trusting
relationship between the PHN and the teen; outreach and
coordination with schools, clinics, and human service agen-
cies; a comprehensive and intensive maternal mental health
curriculum; and community support and caring by provision
of needed resources. A comprehensive evaluation of the pro-
gram’s effectiveness and client outcomes’s success was com-
pleted after two years (Schaffer, Goodhue, Stennes, & Lanigan,
2012). Key outcomes presented by four public health evalua-
tion methods follow.

n Feasibility evaluation: 78% of the teens referred to the
program accepted the services.

n Impact evaluation: 76% of teens with 10 or more visits
continued or graduated high school compared to 56% of
teens who received 9 visits or less; 97% were up-to-date
on well-child check-ups; 95% were up-to-date on immuni-
zations; and 96% had healthy birth weight babies.

n Program evaluation: 69% referred to community
resources; 47% received needed resources.

n Comparative effectiveness: Teens with 10 or more visits
were more successful in achieving expected outcomes
than teens who had 9 or fewer visits.

Ethical Application
Community assessment and program evaluation involves
collecting data on individuals . These data are then aggre-
gated to provide for confidentiality and anonymity . How-
ever, when the group size is small or the members of the
group are easily identified, ethical issues related to privacy
rights can arise .

Kristi is concerned because there are only 20 teens who will
be participating in the initial pregnant and parenting teen
peer support program. Most of these teens are well known
in the community. She is worried that when the program
evaluation occurs, the teens will be evaluated as individu-
als. Even though their outcome data will be aggregated, it
will be difficult to provide for anonymity if there is a need
to present program outcomes to the county commissioners.

Use the ethical framework in Table 3 .10 to determine how
you would use ethical principles to make decisions about
this ethical problem .

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70 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

TABLE 3.10 Ethical Application of the Nursing Process in Public Health Nursing

Ethical Perspective Application

Rule Ethics
(principles)

n Respect the rights of individuals related to privacy, autonomy, and self-determination .
n Critique selected actions and interventions for possible unintended harmful consequences that might

occur for diverse populations in a community .
n Select interventions that promote justice through reducing health disparities .

Virtue Ethics
(character)

n Maintain the dignity and confidentiality of individuals, families, populations, and communities when
assessing their health needs .

n Be honest in communicating the purpose of selected interventions to individuals, families,
populations, and communities .

n Be an advocate for assessing the public health needs of vulnerable populations .

Feminist Ethics
(reducing oppression)

n Include voices of vulnerable populations in community assessments and in setting priorities for action .
n Emphasize the contribution of the assets that communities and diverse populations bring to resolving

public health concerns .

Table based on work by Volbrecht (2002) and Racher (2007)

n PHNs use public health nursing interventions to provide
nursing services to individuals, families, communities,
and systems .

n PHNs use EHRs and HIS to assist them in assessing and
monitoring their clients’ health status, evaluating their
clients’ progress, and determining the effectiveness of
interventions and programs . The Omaha System is the
only ANA-recognized standardized terminology that
has integrated those components .

KEY POINTS

n PHNs are accountable to the individuals and families
they serve, and the communities in which they live
and work, to take action to maintain or improve their
health status .

n PHNs work in partnership with individuals, families,
communities, and systems .

n The public health nursing process is used to assess and
intervene with individuals, families, communities, and
systems .

n PHNs collect demographic and health determinant data
when carrying out family and community assessments .

REFLECTIVE PRACTICE

It is difficult for public health nursing students to adapt to
providing nursing care in the unstructured environment
of the home and community . When students are in family
homes, they are visitors in someone else’s personal space .
Visits often do not go as planned . It takes time to develop
trust with family members who may initially be uncom-
fortable with a nurse in their home . Think about Kristi’s co-
visits with her PHN preceptor Beth to Sara, the pregnant
teen, and her mother and then the individual visit Kristi
made to complete the home environmental assessment . If
you were making that visit alone as Kristi was, consider how
you would carry out the home environmental assessment
with Sara and her mother .
n How would you prepare for the visit? What would you

wear? Do you think you should phone Patricia or Sara
to confirm the visit?

n How would you introduce yourself to Sara and her
mother and review the purpose of the visit?

n This is your first visit alone with Sara and her mother .
Think about what makes a good first visit . What would
you want to do to make your visit a good one?

n When you carry out the home environmental assess-
ment, you will probably be going into some private areas
of the home . What can you do to make Sara, her mother,
and yourself comfortable in these private spaces?

n What will you do if you are told you cannot go into
certain rooms?

n Will you share your assessment of the family home
environment as you conduct the assessment, or will you
wait until the end of the visit?

n How will you end the visit with Sara and her mother?

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71CHAPTER 3  n  Competency #1

Centers for Disease Control and Prevention . (n .d .-a) . MAP-IT:
A guide to using Healthy People 2020 in your community.
Retrieved from http://www .healthypeople .gov/2020/
implement/MapIt .aspx

Centers for Disease Control and Prevention . (n .d .-b) . Public health
101 series: Introduction to public health informatics. Retrieved
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introduction-to-public-health-informatics .pdf

Centers for Disease Control and Prevention . (2015) . Prevalence of
obesity among adults and youth: US 2011–2014. Retrieved from
https://www .cdc .gov/nchs/data/databriefs/db219 .pdf

Clark, M . J . (2008) . Community health nursing. Upper Saddle
River, NJ: Pearson/Prentice Hall .

Eriksson, I ., & Nilsson, K . (2008) . Preconditions needed for estab-
lishing a trusting relationship during health counseling—An
interview study . Journal of Clinical Nursing, 17(17), 2352–2359 .

Friedman, M . M ., Bowden, V . R ., & Jones, E . (2003) . Family
nursing: Research, theory, and practice (5th ed .) . Hoboken, NJ:
Pearson Education, Inc .

Gardner, A . (2010) . Therapeutic friendliness and the development
of therapeutic leverage by mental health nurses in community
rehabilitation settings . Contemporary Nurse, 34(2), 140–148 .

Hargate, C . (2013) . Survey. Unpublished manuscript, Bethel
University, St . Paul, MN .

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APPLICATION OF EVIDENCE

Think about the community assessment you and your class-
mates are going to complete . You are interested in deter-
mining the need for and the resources for a teen pregnant
and parenting peer support group . Your assessment is going
to be assessing a sub-group of the community (i .e ., aggre-
gate), so you need to think about whom you will want to
work with and what data you need to collect .

Review Figure 3 .4 (Community Planning Process:
MAP-IT):

1. How would you use this tool to plan a community
assessment?

2. How would you carry out the community assessment?
3. When you develop your intervention plan, you need

to consider your “window of opportunity” for imple-
mentation . How would you find your “window of
opportunity”?

4. The implementation phase requires a detailed work
plan . What would you include in your work plan?

5. The tracking phase includes measuring the effective-
ness of your intervention plan . How would you mea-
sure the effectiveness of your plan?

6. Review Evidence Example 3 .7 . What type of evaluation
would you want to include? What measures might
you use?

Review the Community-Assessment Guide . This is an
aggregate assessment . You do not have to collect all of the
community data . Think about what you need:

1. What community demographic data would you want
to collect?

2. What biological and genetic health determinant data
would you want to collect?

3. What physical environmental health determinant data
would you need?

4. What social environmental health determinant data
would be most important?

5. How would you collect information about healthcare
access?

6. Once you have all of your data collected, how would
you analyze it?

7. What would be effective methods to communicate
your community-assessment data to others?

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72 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

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Monsen, K . A ., Brandt, J . K ., Brueshoff, B ., Chi, C . L ., Mathiason,
M . A ., Swenson, S . M ., & Thorson, D . R . (2017) . Social determi-
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Monsen, K . A ., Swenson, S . M ., Klotzbach, L ., Mathiason, M . A .,
& Johnson, K . E . (2017) . Empirical evaluation of change in
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Monsen, K . A ., Vanderboom, C . E ., Olson, K . S ., Larson, M . E .,
& Holland, D . E . (2017) . Care coordination from a strengths
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Racher, F . (2007) . The evolution of ethics for community practice .
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75

‘‘

’’

CHAPTER

4
COMPETENCY #2
Utilizes Basic Epidemiological (The
Incidence, Distribution, and Control of
Disease in a Population) Principles in
Public Health Nursing Practice

n   Carolyn M. Porta 
with Noreen Kleinfehn-Wald, Linda J. W. Anderson, and Madeleine Kerr

Elizabeth has worked as a public health nurse (PHN) doing home visits on the maternal child health
team for approximately a year. One day as she is having lunch with her co-workers, someone mentions
that an outbreak of pertussis had occurred in an adjacent county. In fact, there are 42 cases! Two days
later, Elizabeth’s supervisor asks whether she can help the Disease Prevention & Control (DP & C) team
investigate 10 probable cases of pertussis.

DP & C nurses operate the immunization clinic and work with infectious disease issues, such as tuber-
culosis. Other than these activities, Elizabeth knows very little of what their day-to-day work is like.
Her supervisor explains that disease investigation is case management work. She will most likely not be
required to do any additional home visits. (Sometimes follow-up visits are necessary when it is difficult to
locate people.) She will need to plan on a limited amount of time to place phone calls, review records, and
work with community partners, such as school nurses. Elizabeth agrees to take the additional assignment
and arranges to receive orientation from the lead nurse. During this briefing, the lead nurse explains
the state’s data-privacy laws, the state health department’s infectious disease reporting requirements for
pertussis, and the report form that needs to be completed by the healthcare provider or the lab associated
with the clinic for each suspect or confirmed case. This is a lot of new information!

ELIZABETH’S NOTEBOOK
COMPETENCY #2 Utilizes Basic Epidemiological (The Incidence, Distribution,  
and Control of Disease in a Population) Principles in Public Health Nursing Practice

A. Understands the relationship between community assessment and health promotion/disease prevention
programs, especially the populations and programs with which the PHN works

B. Understands the relationships between risk/protective factors and health issues

C. Obtains and interprets information regarding risks and benefits to the community

D. Applies an epidemiological framework when assessing and intervening with communities, systems,
individuals, and families

Source: Henry Street Consortium, 2017
(continues)

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76 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

USEFUL DEFINITIONS

Agent: The primary cause of the health-related condition. Agents are most often classified into six main types:
physical agents, chemical agents, nutritive agents, infectious agents, genetic agents, and psychological agents
(Valanis, 1999). [Note that the term infectious agent has been replaced with causative factors (Merrill,
2017, p. 11).]

Communicability: The ability of a disease to be transmitted from one person to the next; communicability is
determined by how likely a pathogen or agent is to be transmitted from a diseased or infected person who is not
immune and is susceptible (Merrill, 2017, p. 43).

Environment: Reflects the aggregate of those external conditions and influences affecting the life and develop-
ment of an organism . . . physical, chemical, biological, and social factors that affect the health status of people
(Merrill, 2017, p. 214); factors external to the human or animal that cause or allow transmission (p. 8).

Epidemic: Occurrence of cases of an illness, specific health-related behavior, or other health-related events
clearly in excess of normal expectancy in a community or region (Merrill, 2017, p. 5).

Epidemiological Triangle: Shows the interaction and interdependence of the agent, host, environment, and time
(Merrill, 2017, p. 8).

Epidemiology: The study of the distribution and determinants of health-related states or events in human
populations and the application of this study to the prevention and control of health problems (Stedman’s
Medical Dictionary for the Health Professions and Nursing (5th ed.) in Merrill, 2017, p. 2).

Herd Immunity: Resistance a population has to the invasion and spread of an infectious disease. Herd immunity
is accomplished when the number of susceptible people is reduced and the number of protected or non-
susceptible people dominates the herd (population); provides barriers to direct transmission of the disease;
occurs when 85% level of immunity exists (Merrill, 2017, p. 53).

Host: The human being affected by the particular condition under investigation. Factors that the host brings
to the triangle include intrinsic factors (age, gender, race, etc.), physical and psychological factors, and the
presence or absence of immunity (Clark, 2008). Host can be a human or animal that is susceptible to disease
(Merrill, 2017, p. 8).

Immunity: The state of nonsusceptibility to a disease or condition. Types include (a) active immunity, where the
host is exposed to the antigen through having the disease or via immunization; and (b) passive immunity, where
antibodies are provided to the host via immune globulin or mother-to-fetus transfer across the placenta—
passive immunity is short-lived (Merrill, 2017, p. 52).

Incidence: The number of individuals who develop the disease over a defined period of time (Le, 2001) or the
number of new cases of a particular health-related state or event reported over a specific period of time
(Merrill, 2017, p. 74).

Life Course Epidemiology: The study of long-term effects on later health or the risk of disease due to physi-
cal or social exposures during gestation, childhood, adolescence, young adulthood, and later adult life (Kuh,
Ben-Shlomo, Lynch, Hallqvist, & Power, 2003, p. 778).

Prevalence: The presence of a disease or health condition in a given population at a given point in time divided
by the number of persons in that population (Friis, 2018, p. 64).

Protective Factor: Health determinants that protect one from illness or assist in improving health
(see Chapter 1).

Risk Factor: A condition that is associated with the increased probability of a health-related state or event
(Merrill, 2017, p. 3). Risk factors are also health determinants (see Chapter 1).

Surveillance: The ongoing systematic collection, analysis, interpretation, and dissemination of health-related
data to improve the health of populations (Centers for Disease Control and Prevention [CDC], 2001). Public
health surveillance is the systematic ongoing collection, analysis, interpretation, and dissemination of health
data (Merrill, 2017, p. 112).

ELIZABETH’S NOTEBOOK  (continued)

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77CHAPTER 4  n  Competency #2

n Which interventions can reduce the spread of this
occurrence/disease?

n Will I be working at the individual/family, community,
or systems level?

n Do I need to consider any ethical issues?
n How will I know whether the interventions are effective?
n What could have prevented this outcome?

At its core, epidemiology is the study of solving
mysteries—of understanding where and to what extent
diseases, events, and behaviors are influencing the health
of populations. Epidemiology is more than simply under-
standing what is going on. It also involves acting on what
you learn to prevent or control problems. Similarly, a PHN
should be committed not only to understanding what is con-
tributing to a problem and the extent of the problem but also
to identifying and implementing disease prevention and
health promotion strategies. In fact, this use of core epide-
miological tools—namely, mathematics and data analysis—
contributed to advancing the role and view of nursing in
the 19th century (Earl, 2009). See Evidence Example 4.1 to
examine how Lillian Wald and Florence Nightingale used
data gathering and analysis to understand and address key
health problems. By doing so, they advanced the profession
of nursing beyond what had, up until that time, been a fairly
ill-considered occupation.

Using Data to Solve Health
and Disease Mysteries
Nurses often want to know why something happens or does
not happen. This inquisitive nature is useful when nurses
are working to prevent something from happening or to
intervene before something gets worse. In some situations,
if questions are not asked, credible solutions might be over-
looked, and health outcomes might not be optimal. In a
worst-case scenario, lives might be lost or seriously harmed
if the status quo is maintained and curious questions are
not asked and acted upon. At the foundation of effective
population-based public health nursing is the science of epi-
demiology. Epidemiology guides the questions that PHNs
ask and the steps that they take to find answers and solu-
tions. Following is a list of questions nurses ask or should
ask regularly:
n When did the problem start (end, worsen, improve)?
n What has contributed to the change? Triggered a

response?
n Why have x, y, z not improved?
n How did this occur?
n Who should be involved to contribute to the solution?
n Where are available resources to aid in addressing this

situation?

EVIDENCE EXAMPLE 4.1
Origins of Epidemiology and Nursing

Catherine Earl (2009) has written a fascinating and thorough
historical article that describes the influence of epidemiol-
ogy in the developing role of public health nursing. Beginning
in the early 19th century, Earl presents a summary of history
that reminds the reader of how far nursing and science have
come in the past 200 years. Not that long ago, diseases were
addressed solely within the individual, with little appreciation
given for trends among the group or population. Advances
in mathematical theories caused a shift, notably when Pierre
Charles Alexandre Louis, a leading 19th-century physician,
declared that the practice of bloodletting (often with the help
of leeches) was ineffective and used statistics to support his
claims. It is intriguing that, according to Earl, the use of quan-
titative methods was not well supported at that time and was
poorly understood. In the 21st century, quantitative analyses
are core to randomized controlled trials (RCTs), which are con-
sidered the gold standard for establishing evidence.
Lillian Wald used this advance in health and science to sup-
port her work with families in New York. She advocated for
nurses to live and work near and among those they were also
serving. She used numbers to support her need for resources,
including the number of nurses. Her successes are many, and
they are in part based on her foresight and wisdom in rec-
ognizing the need for data to accomplish goals and meet the

health and social needs of society. Earl summarizes well the
contribution PHNs—led by Lillian Wald—made in addressing
tuberculosis, because they collected and reported critical data:
“Nurses’ involvement in the care of TB [tuberculosis] patients
in 1914 was considered a major advancement in the use of sta-
tistical methods, because nurses became involved in improv-
ing health through their role as data collectors” (p. 262).
Florence Nightingale, considered by many to be the first
biostatistician and the first epidemiologist, also used data to
support her efforts to address health and sanitation. In her era,
it was not common for women to be educated, yet her father
encouraged her to learn varied subjects, including mathe-
matics. As a result, Nightingale had skills that enabled her to
identify causes of problems and to intervene not only to heal
or cure but also to prevent. As Earl states, “With an epidemi-
ological perspective and further discussions of mortality and
morbidity rates and the importance of sanitary conditions as
described by Florence Nightingale, the first preventorium, a
program established to save children, was designed for the
prevention, not the treatment, of TB” (p. 263). Both Lillian
Wald and Florence Nightingale contributed to a significant
shift from solely focusing on treatment to also concentrating
on prevention, which today is also a primary focus of PHNs all
over the world.

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78 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

‘‘

Although most PHNs are not epidemiologists, many
activities that PHNs engage in parallel the work of epide-
miologists. Often, epidemiologists work at the systems level
of a healthcare facility or state health department and are
responsible for the data collection, analysis, and program
development related to a particular health/medical issue.
Conversely, PHNs are frequently found in the grassroots
level of healthcare, working with local vulnerable popula-
tions and community partners, interpreting and promot-
ing the recommendations, protocols, and policies that have
been developed by an authoritative body. See Table 4.1 for a
sample list of activities that an epidemiologist often engages
in, and note the similarities to many public health nursing
activities and interventions.

Elizabeth realizes she needs to have a better understand-
ing of terms that she is reading as she investigates state
and county reports about infectious disease threats in her
community. She is getting confused by the different labels
for cases and isn’t exactly clear on the difference between
quarantine and isolation. She finds the following defini-
tions that provide clarity and adds them to her notebook:

✔ Case: Person or population identified as having a particular
disease, disorder, injury, or condition (Merrill, 2017, p. 7)

l Primary case: The first disease case in the population (p. 7)

l Index case: The first disease case brought to the attention
of the epidemiologist (p. 7)

l Secondary case: Persons who have become infected and ill
after contact with a primary case (p. 7)

✔ Incubation period: Time interval between the invasion by
an infectious agent and the appearance of the first signs or
symptoms (Friis, 2018, p. 284)

✔ Isolation: Persons who have a communicable disease are kept
away from other persons for a period of time that corre-
sponds generally to the interval when the disease is commu-
nicable (Friis, 2018, p. 284)

✔ Quarantine: Persons, animals, or objects that have been
exposed to a contagious disease are kept away from other
persons for a specified period of time (adapted from Merrill,
2017, p. 57)

Historically, nurses participated in epidemiological inves-
tigations to determine the cause of a recurring problem, such
as cholera outbreaks. As part of that process, nurses realized
very early on that numerous risk factors often contributed to
the spread of disease. This realization led to creative inter-
ventions that had multiple components to aid those already
sick or affected and to prevent others from becoming sick.
Quarantine (i.e., separation of an exposed individual from
the rest of the community) laws are a good example of a spe-
cific effort to contain the spread of disease in the absence
of other strategies. Interestingly, quarantine strategies are
still used today, because some infectious viruses can spread

TABLE 4.1 Alignment of Epidemiologist
Activities With PHN Intervention Wheel

Epidemiologist
Activities

Public Health Nursing
Activities and
Interventions

Identifying risk factors for
disease, injury, and death

Disease and Health Event
Investigation

Describing the natural
history of disease

Health Teaching

Identifying individuals and
populations at greatest risk
for disease

Outreach

Screening

Referral and Follow-Up

Advocacy

Case Management

Identifying where the public
health problem is greatest

Surveillance

Disease and Health Event
Investigation

Monitoring diseases and
other health-related events
over time

Surveillance

Evaluating the efficacy and
effectiveness of prevention
and treatment programs

A key part of the nursing
process, but not a specific
component of the interven-
tion wheel

Providing information useful
in health planning and
decision-making for estab-
lishing health programs with
appropriate boundaries

Consultation

Collaboration

Community Organizing

Policy Development and
Enforcement

Assisting in carrying out
public health programs

Most interventions on the
Public Health Intervention
Wheel

Serving as a resource Consultation

Communicating health
information

Outreach

Health Teaching

Social Marketing

Consultation

Source: Adapted from Merrill, 2017

during an incubation period before symptoms are present.
Examples of such illnesses in the 21st century include per-
tussis, chicken pox, measles, Ebola, avian influenza, and
seasonal flu. When an individual is diagnosed with pertus-
sis and other family members have been exposed, the per-
tussis case is strongly encouraged to stay isolated from the

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79CHAPTER 4  n  Competency #2

home environment remains unchanged, the child’s recov-
ery might not be maintained. In this case, the nurse might
link the family to resources such as financial heat assistance,
food banks, food stamps, etc. The nurse might begin to cre-
ate long-term solutions by helping adult family members to
explore financial management strategies as well as possi-
bilities for higher-paying employment or more affordable,
reliable housing. Finally, the nurse might advocate for leg-
islation that prohibits companies or landlords from turning
off heat sources during cold winter months. Nurses encoun-
ter numerous possible mechanisms for influence when they
face a problem that might appear to have a simple solution
but often requires complex intervention approaches to keep
that problem from recurring.

Understands the Relationship Between
Community Assessment and Health
Promotion and Disease Prevention
Programs, Especially the Populations and
Programs With Which the PHN Works
Many public health agencies and community organizations
use community assessments to prioritize their resources
and subsequent programs and services. Fundamental to the
community assessment is the understanding of the inci-
dence and distribution of disease in the community. The
PHN might begin by reviewing the birth and death (mor-
tality) data available through the state department of health.
Morbidity (illness/disease/injury not resulting in death)
data can also be reviewed to determine trends in reportable
diseases (such as tuberculosis or sexually transmitted infec-
tions) or conditions such as cancers or motor vehicle fatali-
ties. A comprehensive review of data sources generally leads
and directs the community assessment process.

A variety of other strategies (e.g., needs assessment via
focus groups or key-informant interviews, windshield
survey) can be used to expand the community assess-
ment. (See Chapter 3 for more information on community
assessment.) PHNs work collaboratively in conducting
assessments and using the resulting data for informing pri-
orities and actions. Although it might be natural to focus on
needs because the nurse is trying to address a problem, it is
extremely valuable to take an asset-based approach toward
the issue (Lind & Smith, 2008). An asset-based approach
ensures that the assessment includes documentation of
existing or potential strengths. In this way, the possible
problem-solving strategies will ideally build on identified
strengths and assets. If nurses focus only on problems, they
might reach a solution that consists of outside resources
rather than builds on what is available. Asset-based per-
spectives inherently encourage capacity building as well as
self-care among individuals and families, communities, and
populations. (See Chapter 8 for discussion of incorporating
community assets.)

broader community until five days of antibiotic treatment
have been completed. During the Sudden Acute Respira-
tory Syndrome (SARS) event in 2002 and 2003, quarantine
of exposed individuals was key to containing the epidemic.
Individuals placed under quarantine were monitored twice
daily by public health workers until the SARS incubation
period was completed. Although quarantines are not always
enforced as they were years ago and in the SARS event, they
can be effective when they are followed and when individu-
als and families adhere to the restrictions.

More broadly, Lillian Wald offers a great example of a
PHN using a variety of intervention tools to address uncon-
trolled disease and unnecessary deaths in New York City
tenements, as shown in Figure 4.1. At the individual level,
she provided direct care for sick individuals in crowded
apartments. At the community level, she organized com-
munity care for neighborhood children in need of a place
to engage in physical activity. At the systems level, she advo-
cated for programs that would meet the needs of many (e.g.,
welfare, food accessibility, child labor laws).

Today’s PHN needs a repertoire of intervention strat-
egies so that when health improves, it can be maintained
over time—which is sometimes hard to do, especially in
the presence of poor health determinants. For example, if
a child recovers from an illness that worsened as a result
of malnourishment and lack of warmth, but the family

FIGURE 4.1 How Lillian Wald Practiced the  
Individual/Community/System Approach to Healthcare

Individual/Family
Provided direct care
for sick individuals

Community
Organized community
care for neighborhood
children

System
Advocated for programs to
meet the needs of many
(welfare, food accessibility,
child labor laws)

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80 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

‘‘ because of fear, and without a known cause, they had little
confidence that the disease could be stopped or prevented.
John Snow created a map that began to identify where the
deaths from cholera were occurring across London. This
now-famous map (see Figure 4.2) yielded some clues for
Snow, because he managed to visualize the areas where
the deaths were most heavily concentrated. He suspected
a water source, so to prohibit people from accessing this
source of “risk,” he removed the water pump handle:

1854: Physician John Snow convinces a London local
council to remove the handle from a pump in Soho. A
deadly cholera epidemic in the neighborhood comes to
an end immediately, though perhaps serendipitously.
Snow maps the outbreak to prove his point… and
launches modern epidemiology (Alfred, 2009, p. 1).

In the 21st century, PHNs continue to solve mysteries in
identifying and eliminating health risks, and although con-
ditions have improved in many parts of the world, reducing
the risks from unsanitary conditions, these improvements
are not universal. Consider the following observation:

The 2010 cholera epidemic in Haiti (and the 2017 chol-
era outbreak that persists in Yemen) reminds us that
cholera remains a deadly disease, not all that differ-
ent from the time of John Snow. While Snow debated
the appropriateness of the germ theory versus the
miasmatic theory for the cause of the disease, cur-
rent scientists are focusing on different, but related,
hypotheses (University of California, Los Angeles
[UCLA], 2010, p. 1).

Elizabeth looks at the faxed pertussis report she has been
given on 11-year-old Billy Johnson. Information includes
Billy’s birth date, address, phone number, and laboratory
results, which are positive for pertussis. Next, Elizabeth
looks up Billy in the computerized state immunization
registry. She sees that he was vaccinated with five doses of
DTaP vaccine, the last of which was administered at 5 years
of age. Elizabeth recognizes that the immunity provided by
the vaccine has possibly waned.

Activity
Reflect on the following questions:

n What has Elizabeth discovered so far? 

n What are her next steps? 

Understands the Relationships
Between Risk and Protective Factors,
and Health Issues
No better classic example of understanding the relation-
ship between a risk factor and a health issue exists than
that of John Snow in mid-1800s London (Alfred, 2009). For
unknown reasons, many people in London began to suffer
and die as a result of cholera. People were fleeing the city

FIGURE 4.2 A Map Detailing Cholera Deaths in 1800s London; the Beginning of Epidemiology
Source: Alfred, 2009

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81CHAPTER 4  n  Competency #2

‘‘

Indeed, it is true that more than a century since Snow’s
solved mystery, PHNs continue to seek clear answers and
solutions regarding the risks and diseases that are present in
public health settings across the globe. In the United States,
PHNs face complex challenges in meeting the needs of indi-
viduals, families, communities, and populations. Nurses
need to identify risk and protective factors at multiple influ-
encing levels. For example, a nurse might be working with
a child recently diagnosed with asthma. The nurse needs to
identify risk factors in the family environment that might
be triggers for asthma episodes. Similarly, the nurse needs
to assess for protective factors in the family, such as parental
commitment to preventing episodes, which is an import-
ant asset the nurse can support with education and related
tools. The nurse might want to go further and explore the
neighborhood environment, including collaborating with
school personnel, for possible risks or protections influenc-
ing the child.

It can take time to carefully and thoroughly assess risk
and protective factors using a strengths-based approach.
Usually, the time is well spent because the PHN will have
a very clear picture of available assets as well as deficits
to address when intervening on a particular health issue.
Doing this proactively is a critical part of health promotion.
Conducting assessments of risk and protective factors after
a health issue has become apparent is important to mini-
mize the effect of the health problem and to encourage pos-
itive intervention results. PHNs continually reassess for risk
and protective factors, because these factors can be tempo-
ral; one day a risk might exist (e.g., lack of health insurance
coverage), but the following week the family might have new
health insurance coverage. PHNs commit to efforts that
routinely assess, intervene, evaluate, and reassess.

A PHN also stays informed about emerging diseases and
pandemic threats. For example, during 2015 pertussis cases
decreased by 37% compared with 2014. See Table 4.2 for
states that had the highest reported rates of pertussis in 2015.
The majority of deaths continue to occur among infants
younger than 3 months of age, and the incidence rate of per-
tussis among infants exceeds that of all other age groups.
The Centers for Disease Control again observed increased

TABLE 4.2 States With Incidence of Pertussis the Same or Higher Than the National Incidence
During 2015, Which Is 6.5/100,000 Persons

Nebraska 27.2 Oregon 14.6 Minnesota 10.9

Montana 22.3 Kansas 14.5 California 9.2

Maine 21.1 Alaska 14.2 Arizona 8.5

Washington 19.3 Wisconsin 13.1 Vermont 7.8

Colorado 16.7 Idaho 11.7 Pennsylvania 6.9

Utah 16.6 New Mexico 11.6

Source: 2015 Final Pertussis Surveillance Report, Centers for Disease Control and Prevention [CDC], 2015

rates in adolescents ages 13–15 as well as in 16-year-olds.
In the case of pertussis, the PHN would recognize pertus-
sis vaccination as a protective factor. Lack of vaccination,
waning immunity from vaccination, and posing immune-
compromising conditions would be risk factors.

Elizabeth prepares to call Billy’s parents. She places the pro-
tocol nearby and has her report form ready. Billy’s mother
answers the phone, and Elizabeth introduces herself as a
PHN who works with infectious diseases. She explains how
she has obtained a pertussis report on Billy and inquires
whether his mother has about 15 minutes to speak with her.
Billy’s mother states that she operates an in-home daycare,
but most of the children have not yet arrived.

Elizabeth mentally notes this information about the
daycare and then explains that the purpose of the call is
to identify what can be done to prevent the spread of the
disease. Elizabeth starts with what she thinks is the most
logical question—when did this cough start? Billy’s mother
recalls that he started coughing on September 17 and had
a paroxysmal cough without a whooping sound. He occa-
sionally coughed so hard that he vomited. About 1 week
before his cough started, he had a low-grade fever and a
runny nose.

Because his cough was not getting any better, his mother
brought Billy to the clinic on September 26. Billy did not
have pneumonia or any other complications of pertussis. He
was given azithromycin antibiotic and is now on his third
day of a 5-day course of treatment. Elizabeth jots down a
note that states the period of infectivity started about Sep-
tember 10, or about a week before the cough started.

Next Elizabeth asks how many other family members
are in the home. Billy lives with his parents and has no
siblings. Neither parent has been coughing. Elizabeth dis-
cusses with his mother the public health recommendation
that other household members take a preventive course of
antibiotics. She agrees to call the clinic for prescriptions.

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82 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’

a PHN might be interested in exploring trends related to
tuberculosis cases in the community over the past 5 years—
that is, the nurse is doing surveillance of TB in the juris-
diction (see Figure 4.3). The data in a graph form provide
a snapshot of how the number of cases is increasing, main-
taining, or decreasing. In the tuberculosis example, it is
apparent that active TB cases are progressively increasing,
whereas latent TB cases can dramatically decrease, increase,
and then stabilize. This information might lead the PHN to
ask questions about pulmonary versus nonpulmonary TB
or population changes in the community and explore spe-
cific intervention strategies to reduce the number of active
TB cases over the next few years.

healthypeople.gov

Healthy 
People

  The Healthy People 2020 website offers  
  opportunities to explore the uses of data in  
  public health. On the website, click “Data 
Search.” From here, you can do a data search on a public health 
topic of interest to you. Select the health topic and then limit 
your search by a variety of factors, such as sex, age, race/ 
ethnicity, and geographic location. The results are presented 
using the Healthy People 2020 indicators (goals/markers) and 
show trends over the past few years. What do you observe in 
the data you explore? How might these data be useful to a PHN 
engaged in health promotion?

Data Trend per 100,000 in a Graph
Similarly, a PHN might examine the trend of chlamydia
cases over a period of five years. Rather than looking at
the raw number of cases (as in the tuberculosis example),
the PHN might prefer to examine the rate of cases, which
is always based on a ratio or number of cases per 100,000
persons. The raw case number in the tuberculosis exam-
ple does not give a picture of how serious the problem is,

To further assess for close contacts, Elizabeth asks
questions about Billy’s school. Billy told his mother “a lot
of kids” were coughing in his classroom. Elizabeth states
that she will talk to the school nurse about sending a noti-
fication letter to the parents of the students in Billy’s class-
room; Elizabeth is careful to inform the mother that Billy
will not be identified in the letter. Elizabeth explains that
she will also be working with the school to identify children
who sit adjacent to Billy, as they might also need preventive
antibiotics.

Obtains and Interprets Information
Regarding Risks and Benefits to
the Community
PHNs need to know how to find and use data. Data drive
so much of what PHNs do. In fact, PHNs determine health
priorities by using data to identify key problem areas or con-
cerns. PHNs also use data to evaluate whether interventions
or programs are successful in reducing the risks or health
problems in a local community. Unfortunately, data are not
always easy to interpret or understand; data are often pre-
sented in such formats as tables, figures or graphs, or raw
numbers. They might be posed as percentages or risk ratios.
Although in-depth knowledge of data, formulas, and calcu-
lations is not necessary for entry-level PHNs, some aware-
ness of how to read data and data types is useful.

Data Trend in a Graph
Often, data are presented over time by using graphs to show
what is happening in a community with respect to a par-
ticular health problem or population trend. For example,

FIGURE 4.3 Sample Trend of Active and Latent Tuberculosis Cases in a Community

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83CHAPTER 4  n  Competency #2

because the graph does not indicate how many people are
in the community. For example, if the community popu-
lation count were 100 and there were 50 cases of latent TB,
the PHN would be much more concerned than if there were
50 cases in a community population of 100,000. In the chla-
mydia example, the rate of cases appears to be increasing,
from around 340 per 100,000 in year 1 to nearly 428 per
100,000 in year 5 (see Figure 4.4). This increase is concerning
by itself, but the PHN might want to compare the rate in one
community with the rate in another community. Compar-
ing rates in different communities or populations provides
the PHN with perspective about the relative severity of the
disease incidence or prevalence and helps determine how to
prioritize efforts to prevent the spread of chlamydia.

Evidence Example 4.2 discusses using data regard-
ing incidence rates to identify a problem and evaluate the
impact of a system-wide intervention—in this case the rate
of tuberculosis among correctional system inmates.

Data Comparison Between State  
and National Sources
Comparing health and disease trends across communities
can be challenging and create turmoil if it is not done care-
fully. No community wants to appear worse than another
when it comes to a health problem or condition. On the other
hand, if resources are scarce, a community might want to
justify acquiring greater access to available resources. Care-
ful comparison of data within and across communities is
vital to ensure that public health priorities are appropriate
and that the chosen resource allocation is warranted. Com-
parison is useful because it can bring understanding of the
severity or scope of a problem, especially if policymakers
are unaware of the problem or not convinced that it requires
attention.

EVIDENCE EXAMPLE 4.2
Use of Epidemiological Tuberculosis Data to Inform 
a New York State Corrections Intervention

In a study addressing tuberculosis, data were used to inform
strategies to prevent increases of tuberculosis among
inmates in the New York State Corrections system (Klopf,
1998). Data indicated that the incidence of tuberculosis
had increased over a 6-year period from 43 per 100,000
to 225 per 100,000, a serious problem that warranted
intervention. Collaboratively, people from corrections, the
local department of health, and the parole division devel-
oped a comprehensive TB control program that focused on
the prevention and containment of disease. Importantly,
they implemented a nurse-led case management program,
using infection control nurses to carefully monitor and
intervene on active and suspected TB cases. The program
was truly comprehensive, including policies, development
of a TB registry, surveillance, detection, and case man-
agement involving preventive and directly observed ther-
apy among the inmates. The staff and inmates received
education regarding testing, diagnoses, disease process,
and treatment. It is believed that this comprehensive pro-
gram contributed to the reduced incidence of TB. Six years
later, the rate decreased from 225 per 100,000 to 61 per
100,000—a 73% reduction! The data informed the need
for an intervention that relied heavily on nurses. The data
also demonstrated, in part, the impact of the intervention
program, showing a significant reduction in the new cases
of TB among New York’s inmates.

FIGURE 4.4 Chlamydia Example of Case Rate per 100,000 Over 5 Years

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84 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

different timeframes, and it’s good to note when discrepan-
cies exist. In Figures 4.5 and 4.6, both MDH and CDC data
are reported for 2015, which offers a useful comparison. An
effective PHN tries to find the most comparable data possi-
ble but does point out discrepancies when comparisons are
made between incomparable data. Using data that are not
a perfect match is not wrong, but these differences must be
identified so that people can make informed decisions based
on the existing data. It might not be true that people can
make data say exactly what they want them to say, but it
certainly is possible to inadvertently or purposefully present
data in ways that might not be entirely accurate. Therefore,
PHNs need to spend time practicing how to present data in
meaningful, representative ways, and, equally vital, they
need to have the ability to interpret and critique any data
that are presented to them.

Data Comparison Between National  
and Global Sources
To understand the context from which a client originates, a
PHN may be interested in disease incidence in other parts
of the world. The earlier PHN who graphed active TB cases
against latent TB cases may have found increasing numbers
of families from several parts of the world now living in her
community. Reviewing information from the World Health
Organization (WHO) will inform her of the distribution
of TB elsewhere. This information can then be applied to
determine communicable disease risk related to immigra-
tion patterns in her community.

Data as Population Trends
Equally valuable are data that demonstrate population
trends. These are most commonly presented in the form of
a population pyramid, which at a glance provides a picture
of population growth (see Figure 4.7). In this figure, the age
distribution of people in the U.S. is portrayed. Compared
with other years, one can visually see changing trends in
population age distribution. This could be valuable to
determining priorities for PHN interventions, particularly

A good example of this scenario is Lyme disease, which
is contracted through exposure to ticks. Lyme disease cases
between 1996 and 2016 have varied from 252 to 1,431 cases
in Minnesota and have steadily increased since 2002 (see
Figure 4.5). However, without being able to compare these
numbers to those of another state, it is difficult to determine
whether the problem is serious or relatively consistent with
national trends. The PHN investigating this issue might
look beyond state-level data to what is occurring nationally.
Review of national data provided by the CDC demonstrates
that Minnesota has one of the highest density areas of Lyme
disease, second only to states along the East Coast (see
Figure 4.6). The data in Figure 4.6 are from a Geographic
Information System (GIS) wherein a dot is placed within the
county of residence for each confirmed case of Lyme disease.
GIS is an example of a mapping tool that PHNs may use for
surveillance. (See “Innovative Data Collection: Maps and
Apps,” for more GIS information.) These data would sup-
port efforts by PHNs to bring attention to the problem and
to invest in preventive messages for Minnesotans regarding
the spread of Lyme disease.

Often data are not easily and perfectly comparable
between sources due to different years of reported data or

EVIDENCE EXAMPLE 4.3
Comparing Virtual and Outpatient Tuberculosis 
Clinic Models of Care

In a recent study, the use of a virtual public health clinic was
compared with a traditional outpatient clinic for managing
tuberculosis in a Canadian province (Long, Heffernan, Gao,
Egedahl, & Talbot, 2015). The TB prevention and care model
was delivered through one virtual and two outpatient clin-
ics, which were subsequently assessed on 28 performance
indicators. Overall, one clinic type did not demonstrate
superiority to the other, which is promising for virtual or
tele-health models of healthcare delivery and management
for challenging public health concerns such as TB.

Addressing Asthma to Improve Health in Cities

GOAL 11 Nurses are on the front line globally for addressing asthma, which is the most common
chronic condition among children that can have long-term consequences when left undiagnosed and
undertreated. Nurses in Iceland and the United States developed an International School Nurse Care
Coordination Model that informs strategies addressing asthma at both the student and the school
levels, including symptom management, care coordination within and outside the school setting, and
broader educational strategies (Garwick et al., 2015). Collaborative efforts such as this offer promise of
achieving this SDG by recognizing where global challenges might be met with similar strategic models.

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85CHAPTER 4  n  Competency #2

FIGURE 4.6 Reported Cases of Lyme Disease—United States, 2016 
Source: Centers for Disease Control and Prevention [CDC], 2016

FIGURE 4.5 Reported Cases of Lyme Disease in Minnesota, 1996–2016 (n = 17,744)
Source: Minnesota Department of Health [MDH], 2016

Reported Cases of Lyme Disease
in Minnesota by Year, 1996–2016 (n = 17,744)

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86 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

be interested in more in-depth statistical comparisons and
analysis, such as chi-square analysis. PHNs might not rou-
tinely calculate these numbers, but they often read and ana-
lyze research that includes reported rates, risk ratios, odds
ratios, chi-squares, and levels of significance (i.e., p < .001
or p < .05). It is beyond the scope of this book to completely
explain how to calculate each of these, but it is useful for
PHNs to have an awareness of what the numbers mean and
how to appropriately interpret them.

Table 4.3 shows an example of data used to calculate odds
and an OR. This ratio is useful in identifying the odds of con-
tracting the disease, given the presence or absence of a risk
factor. The formula for calculating the OR is (a/c) / (b/d) =
ad/bc. Specifically, the odds of contracting the disease in the
presence of the risk factor is calculated by dividing the num-
ber of people with the disease and the risk by the number of
people without the disease but with the risk (i.e., 75/25, or 3).
Similarly, the odds of contracting the disease but not having
the risk factor can be calculated 2/98, or 0.0204. The OR is
calculated by dividing the odds with the risk factor by the
odds without the risk factor (3/0.0204), or 147. In this exam-
ple, someone with the risk factor is 147 times more likely to
contract the disease than someone without the risk factor. A
PHN with this information needs to make decisions on how
to act based on many factors. For example, even though the
OR is so high, the disease might not be life threatening, or

when resources are limited. Population data are important
because they offer a glimpse into the big picture of how peo-
ple are distributed, but the data by themselves might not be
sufficient to guide intervention decisions or justify program
budget priorities.

Data as Risk Ratios and Odds Ratios
Another very common tool used to examine the data regard-
ing risks and health outcomes is a 2×2 table (see Table 4.3).
This table aids in understanding how a disease is distributed
in a population based on the presence or absence of a risk fac-
tor. From this table, a PHN can calculate the rate of disease
in each group; the risk ratio (RR: the rate of disease for those
with the risk behavior divided by the rate of disease for those
without the risk behavior); and the odds ratio (OR), which
is regularly used to describe the likelihood of contracting a
disease for someone with the risk factor compared to some-
one without. In the example shown in Table 4.3, the rate of
disease for the “Yes” risk behavior group is 0.75 (75/100),
and the rate of disease for the “No” risk behavior group is
0.02 (2/100). Already a relationship between the risk behav-
ior and the disease seems obvious given the raw rates (0.75
versus 0.02). Taking this a step further, you can calculate
the RR (0.75/0.02 = 37.5). PHNs do not often use the RR by
itself, but it is an important calculation for those who might

FIGURE 4.7 Population Pyramid of United States—2016
Source: Central Intelligence Agency: The World Factbook, 2016

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87CHAPTER 4  n  Competency #2

Innovative Data Collection:  
Examples of Maps and Apps
Data are typically collected through surveillance systems
at the local, state, or national levels. Sometimes healthcare
professionals provide the data, and other times individuals,
families, or communities are surveyed. PHNs need to be
aware of the variety of tools used to collect epidemiologi-
cal data, because they might participate in data collection,
interpretation, or dissemination. A Geographic Informa-
tion System (GIS) is an example of a tool growing in pop-
ularity in the field of public health. Technological advances
make it possible for local PHNs (and the general public) to
access GIS data and contribute to mapping efforts readily
via smartphones, tablets, and laptops.

GIS tools can yield data useful to a neighborhood, com-
munity, state, or country in advancing public health pri-
orities. The County Health Rankings & Roadmaps provide
an annual check-up of the health of each county in the U.S.
(County Health Rankings & Roadmaps, 2012). This publica-
tion shows that some places are doing very well, while oth-
ers have room for improvement. Figure 4.8 shows maps that
provide insights about health outcomes and health factors
in Minnesota, with healthier counties depicted in lighter
colors. See Figure 4.8, County Health Rankings & Road-
maps; and Figure 4.9, a sample interactive GIS map from
the California Department of Public Health that addresses
nutrition, from www.cnngis.org.

TABLE 4.3 Association Between
Risk Factor and Disease

Disease

Risk Factor Yes No Total

Yes a c a + c

No b d b + d

Total a + b c + d a + b + c + d

Disease

Risk Factor Yes No Total

Yes 75 25 100

No 2 98 100

Total 77 123 200

the risk factor might not be common. The risk factor might
easily be eliminated with an intervention, or the risk factor
might not be easily identified, making it difficult to inter-
vene. PHNs need to consider numerous factors when data
are interpreted and then acted upon. PHNs have an import-
ant role in helping interpret data so that they are not used
inappropriately to justify action or inaction.

FIGURE 4.8 County Health Rankings & Roadmaps: Minnesota 
Source: County Health Rankings & Roadmaps, 2018

2018 Health Factors: Minnesota2018 Health Outcomes: Minnesota

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88 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

n Federal Emergency Management Agency (FEMA)
Geoplatform (at http://fema.maps.arcgis.com/
home/index.html) provides geospatial data and
analytics for emergency management (see also
www.geoplatform.gov)

n FEMA Geospatial Coordination Mapping
and Data (see https://data.femadata.com/
NationalDisasters/HurricaneHarvey/Documents/
Geospatial%20Coordination%20Call%20Notes/
for Hurricane Harvey examples)

n American Red Cross Online Mapping provides infor-
mation about open shelters and ongoing storm data (see
http://arc-nhq-gis.maps.arcgis.com/home/index.html)

n National Oceanic and Atmospheric Administration
NowCOAST provides real-time coastal observations,
warnings, and forecasts (see https://nowcoast.noaa.gov/)

n Ushahidi crowdsource mapping was used to aid
in response and recovery efforts (see https://
irmamiami.ushahidi.io/views/map) including oil
spill tracking after Hurricane Harvey (see https://
skytruth.ushahidi.io/views/map)

GIS data are also being used to carefully examine
community-level assets and risks related to public health
problems such as obesity prevention. For example, GIS data
can aid in understanding how communities compare in
terms of access to full-scale grocery stores, corner supermar-
kets, gas stations, and liquor stores. Additionally, GIS data
can indicate the location of parks and transpose (e.g., over-
lay) violent crime data, which might provide insights into
why youth in certain neighborhoods are reporting higher
levels of physical activity than youth in other neighborhoods.

In emergency situations, GIS programs are playing a cru-
cial role. In Haiti in 2010, a GIS program was used within
the first few hours after the earthquake to update a base-
line map of Haiti. People on the ground used OpenStreet-
Map, a GIS crowdsourced mapping program, to modify the
existing map in real time, thereby facilitating rescue efforts.
The pre-earthquake terrain maps that existed were not very
helpful, but the real-time maps provided valuable support to
search-and-rescue teams. Since then, the use of GIS to map
disaster events and response has dramatically increased.
Consider just a few of the following GIS resources that were
available and used in 2017 to aid in addressing hurricanes
(Harvey, Irma, Matthew, and others):

FIGURE 4.9 Sample GIS Map Viewer: Network for a Healthy California

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89CHAPTER 4  n  Competency #2

Mapping is also being used to monitor and visualize
outbreaks across the globe (see http://www.healthmap.org/
en/) and can be valuable historically to review an outbreak,
such as the 2014 Ebola outbreak (see https://www.cdc.gov/
vhf/ebola/outbreaks/2014-west-africa/distribution-map.
html). The data behind the mapping are useful not only in
the real-time incidents that require response and interven-
tion, but also in the future, as scientists use data to develop
algorithms that could help to predict future outbreaks. With
public health professionals questioning when, not if, the
next worldwide outbreak or pandemic threat might occur,
the ability to see and process a large amount of real-time
data, and historic data, is very important.

Consider learning about the Global Health Security
Agenda (see https://www.ghsagenda.org/) to “advance a
world safe and secure from infectious disease threats, to
bring together nations from all over the world to make new,
concrete commitments, and to elevate global health security
as a national leaders-level priority” (Global Health Secu-
rity Agenda [GHSA], 2017, para. 1). This initiative is exten-
sive, promoting efforts that engage global partners, local
government, universities, those already in the workforce,
and those who are about to graduate and enter the public
health workforce as public health nurses, veterinarians, and
environmental health professionals. Examples of these ini-
tiatives are found online: One Health Workforce at https://
medium.com/one-health-workforce and PREDICT at http://
www.vetmed.ucdavis.edu/ohi/predict/.

In addition to broad use of mapping data in public health,
there are real-time data collection strategies being used
to more quickly and more thoroughly understand public
health problems and to more efficiently deliver public health
interventions. Consider the extensive and overwhelming
availability of smartphone apps designed to help individu-
als manage their health, quit an unhealthy behavior, begin a

healthy one, and track every step along the way. Visit an app
store and do a search for a common public health challenge
you might address as a PHN working with individuals or
families. You will find dozens, if not hundreds, of possible
tools. Of value are articles that summarize the benefits and
challenges of these apps, as well as websites that offer rank-
ings and scores to help potential users consider the right app
for them. An example is provided for mental health apps
at https://adaa.org/finding-help/mobile-apps. Not every sit-
uation warrants use of an app (or a map), and it is really
important for PHNs to understand this. Just because a tech-
nological tool exists does not inherently mean it should be
used. PHNs need to consider the challenge being addressed,
the stakeholders, the benefits or challenges associated with
the technological solution, and then make an informed
decision about using it.

Applies an Epidemiological Framework
When Assessing and Intervening With
Communities, Systems, Individuals,
and Families
How a PHN comes to understand a problem and its possible
causes and solutions is somewhat dependent on the frame-
work that the PHN uses. The epidemiological triangle has
traditionally been used to understand disease transmission.
This triangle consists of identifying a host system affected
by the condition, an agent that causes the condition, and the

EVIDENCE EXAMPLE 4.4
Using Big Data to Inform PHN  
Home Visiting Interventions

There is so much data generated in every home visit, and
over time and across visits, the data repository grows and
becomes a valuable source of broad information. PHNs
have traditionally provided the data, offering rich chart-
ing and thorough details for each home visit, but now
PHNs are using these data to understand patterns and
inform interventions to a much greater extent. Monsen
et al. (2017) analyzed data from 4,263 women who had
received home visits, examining social and behavioral
determinants of health as well as outcomes following the
home visits. Analyses demonstrated that minority women
showed greater improvements following the interventions
and revealed the value of using big data to begin to unravel
intervention elements and intervention outcomes.

EVIDENCE EXAMPLE 4.5
Screening for Neurodevelopmental Delays in  
Four Communities in Mexico and Cuba 

Cuban and Mexican PHNs used a newly developed com-
puterized evaluation instrument to assess and compare
the prevalence of neurodevelopmental problems in three
areas: language/communication, psychomotor, and hear-
ing/vision (Guadarrama-Celaya et al., 2012). Four hun-
dred children ages 1 to 5 years were screened using the
Neuropediatric Development (NPED) screening tool in
urban and suburban cities in Cuba and Mexico. Results
demonstrated failures in all communities (e.g., 2.3% vision,
16.5% language) and differences by country (e.g., higher
failures rate for hearing in Cuban communities). Results
also demonstrated successful use of this computerized
Spanish-language tool for broad community assessment
of key neurodevelopmental problems among children at
important stages of development. This tool can facilitate
earlier identification and intervention so that long-term
neurodevelopmental problems can be avoided as children
develop.

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90 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

the web design to identify all the factors influencing the cen-
ter of the web (i.e., the disease, such as cardiovascular disease
or asthma, or the social health problem, such as teen preg-
nancy). After you have drawn the web, you are faced with a
dilemma—specifically, which related thread to address first.
How do you decide whether to prioritize a biological-related
factor or a social-based factor? The web might help identify
numerous potential causes, contributors, and influences,
yet the model by itself does not yield readily apparent strat-
egies or solutions. More than 10 years ago, Nancy Krieger
(1997) identified these criticisms of the web framework and
proposed an ecosocial framework for developing epidemio-
logical theories about public health problems and possible
solutions. The central question answered using an ecosocial
framework is, “Who and what is responsible for population
patterns of health, disease, and well-being, as manifested in
present, past, and changing social inequalities in health?”
(Krieger, 2001a, p. 694).

A shift in thinking about traditional epidemiology mod-
els has occurred, with growing recognition of the impor-
tance of social epidemiology, the field that acknowledges
and seeks to address the complex combination of biological
and social factors influencing health and well-being. Social
epidemiology was initially defined in the 1950s but has in
more recent decades grown in popularity and use among
public health professionals (Krieger, 2001b, 2012). PHNs
need to be aware of the trends in public health as well as
the theories that guide understanding of the “risk-asset-
problem-intervention” relationships in public health.

environment that contributes to the condition. Host consid-
erations include genetics; inherent characteristics, such as
age and gender; acquired characteristics, such as immune
status; and lifestyle factors. Agents are typically categorized
as infectious, chemical, or physical agents. Environmental
factors might include a variety of physical, social, and eco-
nomic factors. Interactions between these three elements
of the triangle are examined to determine how diseases are
transmitted and how intervention strategies can be targeted
to stop or prevent transmission of the health conditions.
Using influenza as an example of the three triangle compo-
nents, the host would be the individual susceptible to the flu,
the agent is the influenza virus, and the environment might
be the physical apartment that is overcrowded and under-
heated (Clark, 2008).

This model has been adapted to consider more complex
scenarios that might be contributing to disease or illness
(see Figure 4.10). It is an important adaptation, because for
most health problems that PHNs address, the contributing
factors are complex and multifaceted. Illnesses result not
merely from a simple transmission in the right time and
place but also because of factors not easily controlled or
resolved (e.g., poverty, inadequate housing, food shortages).

For many in public health, complex contributing factors
to poor health or well-being have been informed by such
models as the web of causation. The name itself implies
greater complexity than the epidemiological triangle, yet
this model is also not perfect. For example, imagine a spider
web (where the name is drawn from) and how you might use

FIGURE 4.10 Epidemiological Triangle in the 21st Century
Source: Merrill, 2017, p. 11

Environment
Behavior and culture,
physiological factors,

ecological factors

Causative Factors
Biological (infectious agents),
chemical (drugs, acids, alkali,
heavy metals, poisons, some

enzymes), physical (excessive
heat, cold, noise, radiation,

collisions, injuries, etc.)

Group or Population
Age, gender, ethnicity, religion, customs,

occupation, heredity, marital status,
family background, previous diseases

Time

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91CHAPTER 4  n  Competency #2

’’

‘‘

Permanente (see https://www.cdc.gov/violenceprevention/
acestudy/index.html) have been done, showing the strong—
and in some cases, predictive—relationship between expo-
sure to these risks in childhood and poor outcomes in
young adulthood and adulthood (Holman et al., 2016; Wolff,
Baglivio, & Piquero, 2015).

The life course perspective views health not in stages
separate from each other (infancy, early childhood, adoles-
cence, adulthood) but as a continuum. As Krieger (2001a,
p.  695) describes, “Life course perspective refers to how
health status at any given age, for a given birth cohort,
reflects not only contemporary conditions but embod-
iment of prior living circumstances.” A classic life course
study was the research on the effects of the 1944–1945 Dutch
famine that linked malnutrition with subsequent effects on
human development and mental performance (Stein, Susser,
Saenger, & Marolla, 1975). Throughout the life course con-
tinuum, biological, behavioral, environmental, psycholog-
ical, and social factors dynamically interact, contributing
to one’s health. As Matthias Richter (2010, p. 458) summa-
rizes, “This perspective was truly helpful to contribute to a
better understanding of biological, behavioural and social
influences—from gestation to death—for health as well as
health inequalities.”

The next area for Elizabeth to assess for close contacts is
the in-home daycare. Billy’s mother states that they have a
split-entry home and that the lower level is for the licensed
daycare. On a normal day, she has five children who stay
until 5:30 p.m. In addition, a set of 1-year-old twin girls
stay until approximately 11:00 p.m. Billy’s mother indicates
that since Billy has been ill, he has stayed only on the upper
level, away from most of the lower-level childcare children.
However, the situation with the twins is different: Billy eats
supper with them and plays with them until bedtime. The
twins have been exposed to pertussis and, according to
the definition in the protocol, are considered face-to-face
contacts.

Elizabeth asks whether the twins’ parents have been told
about Billy’s pertussis. The mother states that she has not
told them because she is concerned about losing her clients
and income. Elizabeth explains that the public health rec-
ommendation is that the twins receive preventive antibiot-
ics because of their close contact with Billy. Billy’s mother
agrees to notify the twins’ parents by passing out to all par-
ents a standardized notification letter from the PHN.

Public health nursing is grounded in the science of
epidemiology. On numerous levels, epidemiological data
help describe the scope of a problem, prioritize interven-
tion strategies, and evaluate outcomes or trends over time.
Data are presented and collected using many different for-
mats; nurses need the skills to interpret and critique these
data, regardless of how they are presented. PHNs also use

Nursing practice should always be informed by theory.
It is relatively easy in nursing practice to get caught up in
the tasks one has to do and to forget, at times, to take a step
back, reflect, and consider why something is being done a
certain way or why certain events are occurring. Theories
are always advancing, and an effective PHN strives not only
to use theory but also to keep up with theoretical ideas that
guide and inform practice and the care of individuals, fam-
ilies, communities, and populations. Epidemiology is an
ideal example of the value and importance of theory as a
guide for understanding and intervening in extremely com-
plex societal health problems and conditions.

Another important theoretical framework in public
health that PHNs should be aware of is referred to as life
course epidemiology. Historically, as the focus of epidemiol-
ogy shifted from infectious disease to chronic illness in the
mid–20th century, new and expanded paradigms emerged
to better recognize and understand the antecedents and
causes of chronic diseases. Consider adverse childhood
experiences (ACEs); these are now commonly understood
as important life events that can have physical and men-
tal health effects that persist into adulthood (Felitti et al.,
1998). ACEs include a range of experiences, but most com-
mon are those that children experience directly (e.g., sex-
ual abuse, emotional abuse, physical abuse), and through
exposure in the home (e.g., parental substance use or incar-
ceration, parental mental health problems, parental abuse,
parental divorce or separation). Numerous studies since
the original ACEs Study conducted by the CDC and Kaiser

THEORY APPLICATION
Ecosocial Theory

Krieger’s ecosocial theory offers an integrated framework
that considers pathways of public health problems in the
context of life course (e.g., from infancy to older adulthood),
and ecological layers (e.g., individual, family, community,
system, etc.). Critical to the theory is the explanatory man-
ner in which complex, intersectional risks and protections
can be considered when examining a public health or social
problem (see Krieger, 2012, p. 938, for a modeling of the
framework applied to racism, for example). Krieger states
that the ecosocial theory is a tool that:

fosters analysis of current and changing population
patterns of health, disease, and well-being in rela-
tion to each level of biological, ecological and social
organization (e.g., cell, organ, organism/individual,
family, community, population, society, ecosystem)
as manifested at each and every scale, whether rel-
atively small and fast (e.g., enzyme catalysis) or rel-
atively large and slow (e.g., infection and renewal
of the pool of susceptible for a specified infectious
disease) (Krieger, 2001b, p. 671).

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