PublicHealthEmerging Issues

5/19/2015
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EvolvingPublicHealthNursingRoles
FocusonCommunityParticipatoryHealthPromotionandPrevention
PamelaA.Kulbok,DNSc,RN,PHCNSBC,FAAN,EstherThatcher,MSN,RN,EunheePark,BSN,RN,PeggyS.Meszaros,
PhD.
OnlineJIssuesNurs.201217(2)
AbstractandIntroduction
Abstract
Publichealthnursing(PHN)practiceispopulationfocusedandrequiresuniqueknowledge,competencies,andskills.
Earlypublichealthnursingrolesextendedbeyondsickcaretoencompassadvocacy,communityorganizing,health
education,andpoliticalandsocialreform.Likewise,contemporarypublichealthnursespracticeincollaborationwith
agenciesandcommunitymembers.ThepurposeofthisarticleistoexamineevolvingPHNrolesthataddresscomplex,
multicausal,communityproblems.Abriefbackgroundandhistoryofthisroleintroducesanexplanationofthe
communityparticipationhealthpromotionmodel.Acommunitybasedparticipatoryresearchproject,YouthSubstance
UsePreventioninaRuralCountyprovidesanexemplarfordescriptionofevolvingPHNrolesfocusedoncommunity
healthpromotionandprevention.AlsoincludedisdiscussionaboutspecificcompetenciesforPHNsincommunity
participatoryhealthpromotingrolesandthecontemporaryPHNrole.
Introduction
Publichealthnursing(PHN)involvesworkingwithcommunitiesandpopulationsasequalpartners,andfocusingon
primarypreventionandhealthpromotion(ANA,2007).TheseandotherdistinguishingcharacteristicsofPHNevolvedin
thecontextofhistoricalandphilosophicalperspectivesonhealth,preventivehealthcare,andtheprofessionalizationof
nursing.Specifically,thesearerolesthatinvolvecollaborationandpartnershipswithcommunitiesandpopulationsto
addresshealthandsocialconditionsandproblems.
Publichealthnursingdevelopedasadistinctnursingspecialtyduringatimewhenexpandingscientificknowledgeand
publicobjectiontosqualidurbanlivingconditionsgaverisetopopulationoriented,preventivehealthcare.Publichealth
nurseswereseenashavingavitalroletoachieveimprovementsinthehealthandsocialconditionsofthemost
vulnerablepopulations.EarlyleadersofPHNalsosawthemselvesasadvocatesforthesegroups.
Inthe21stcentury,publichealthnursespracticeindiversesettingsincluding,butnotlimitedto,communitynursing
centershomehealthagencieshousingdevelopmentslocalandstatehealthdepartmentsneighborhoodcenters
parishesschoolhealthprogramsandworksitesandoccupationalhealthprograms.Highrisk,vulnerablepopulationsare
oftenthefocusofcareandmayincludethefrailelderly,homelessindividuals,sedentaryindividuals,smokers,teen
mothers,andthoseatriskforaspecificdisease.
ContemporaryPHNpractice,likethepracticeofearlyPHNleaders,isoftenprovidedincollaborationwithseveral
agenciesandfocusedonpopulationcharacteristicsthatcrossinstitutionalboundaries(AssociationofCommunityHealth
NursingEducation[ACHNE],2003).PHNpracticeandrolesaredefinedfrom,
theperspective,knowledgebase,andthefocusofcare,ratherthanbythesiteinwhichthesenursespractice.Even
thoughtheyarefrequentlyemployedbyagenciesinwhichdirectcareisprovidedtoindividualsandfamilies,these
nursesviewindividualandfamilycarefromtheperspectiveofthecommunityand/orthepopulationasawhole(ACHNE,
2003,p.10).
Atanadvancedlevel,PHNknowledgeandcompetenciespreparenursestotakealeadershiproletoassessassetsand
needsofcommunitiesandpopulationsandtoproposesolutionsinpartnership.Communityorpopulationfocused
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solutionscanhavewidespreadinfluenceonhealthandillnesspatternsofmultiplelevelsofclientsincludingindividuals,
families,groups,neighborhoods,communities,andthebroaderpopulation(ACHNE,2003).
Thepurposeofthisarticleistodescribeevolvingrolesinthespecialtyofpublichealthnursing.AbriefhistoryofPHN
providesahistoricalandphilosophicalbackgroundforcurrentpractice.Amodelforcommunityparticipationwith
ethnographicorientation,andanexemplarofitsuseinaruralyouthsubstanceusepreventionproject,illustratescurrent
advancedPHNpractice.ThearticleconcludeswithadiscussionofessentialPHNcompetencies,evidencethatsupports
evolvingPHNroles,andimplicationsforcontemporarypublichealthnursingroles.
BriefBackgroundandHistoryofPHNRole
Preventionandcurativecarehavebeendistinctconceptssinceancienttimes.InGreekmythology,Hygeiawasthe
goddessofpreventivehealth,andhersisterPanaceawasthegoddessofhealing(Lundy&Bender,2001).Thenotionof
healthcareashealing,ortreatingthosealreadysick,maintaineddominanceoverpreventivecareformanycenturies.
Duringthemid19thcenturyhowever,newscientificunderstandingoftransmissionofdiseaseenabledsuccessful
sanitationinterventionsthatpreventeddiseaseonalargescale.
Tocarrypreventivecareforward,districtnursingevolvedasthefirstroleforpublichealthnurses,andFlorence
Nightingaleconcurrentlyprofessionalizednursingasanoccupation(Brainard,1922,1985).EvolvingPHNpractice
requiredanunderstandingofhowculture,economics,politics,psychosocialproblems,andsanitationinfluencedhealth
andillnessandthelivesofpatientsandfamilies(Fitzpatrick,1975).PublichealthnursingintheUnitedStates(U.S.),
England,andothercountriesquicklygrewtoincludeworkingwithvulnerablepopulationsindiversesettingsincluding
communities,homes,schools,neighborhoods,andworksites.
Withtheadventofpreventivehealthcare,amoraltensionarosebetweengivingresourcestotheneedy,andteaching
themhowtomeettheirownneeds.Nursingoftheacutelyillfitsmoreeasilyintoamodelofonewayflowofresources
fromnursetopatient(BuhlerWilkerson,1989).Thenewpublichealthnursingrolestruggled,andcontinuestostruggle,
withappropriateinterventionsthatwouldachievequickresults,butalsoleavelastingimprovementsinthepopulation.
TheChristianprincipleofhelpingthosewhohelpthemselvesguidedthistension,butcouldnoteasilyresolveit
(Brainard,1922,1985).Publichealthnurseswereurgedtobalance"wisdomandkindness"(BuhlerWilkerson,1989,
p.32).Givingfreeservicesorfreesuppliestothepoorwasseenascreatingdependencyandupsettingthenaturalsocial
fabricofcommunities.Publichealthnurseshaveaddressedthismoraltensionovermanyyearswithinnovativesolutions
thatseekpositivehealthoutcomes,aswellasadvocateforvulnerablepopulations.
Bytheearly1900s,publichealthnursingrolesextendedbeyondthecareofthesicktoencompassadvocacy,community
organizing,healtheducation,andpoliticalreform(AmericanNursesAssociation[ANA],2007).Severalexamplesof
exceptionalPHNinitiativesshowhowtheserolesimprovedthehealthofcommunitiesandpopulations.Thevisionary
workofLillianWald'sHenryStreetSettlement,startedinNewYorkCityin1906,evolvedfromfindingandcaringforthe
sickpoor,toadvocatingandeducatingaboutthepoortootherorganizations.Waldexpandedthismissiontoadvocating
fornewfederalagenciesandahostoflocalimprovements(Stanhope&Lancaster,2011).
Inthe1920sinMississippi,MaryOsborneformedacollaborativebetweenpublichealthnursesandAfricanAmerican
(AA)laymidwivestoimproveperinatalmortalityofAAwomenandbabies(Lundy&Bender,2001).Inthe1960sin
Detroit,NancyMiliointegratedcommunityorganizing,communitydecisionmaking,andPHNtodevelopamaternalchild
healthcenterthatwashighlyacceptedandevenprotectedbytheAAneighborhoodduringthe"Detroitriots"(Milio,
1970).Publichealthnursesandothercommunityprofessionalshavecontinuedtorecognizetheadvantagesof
communityparticipatorymethods,includingthepotentialformoreeffectiveinterventionoutcomesandcapacitybuilding
forlongtermbenefittothecommunity(Savageetal.,2006).
CommunityParticipatoryHealthPromotionModel
Thecommunityparticipationandethnographicmodel(seeFigure1)isaninnovativeframeworkthatdemonstrates
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evolvingpublichealthnursingpractice.Itwasdeveloped,basedontheworkofAronson,Wallis,O'Campo,Whitehead,
andSchafer(2007a),byaninterprofessionalresearchteamfromtheUniversityofVirginia(UVA),VirginiaPolytechnic
InstituteandStateUniversity(VirginiaTech[VT]),andCarilionClinic(CC)(Kulbok,Meszaros,Bond,Botchwey,&
Hinton,2009)toaddressyouthsubstanceusepreventioninaruraltobaccogrowingcountyofVirginia.Thecommunity
participationandethnographicmodelbuildsonassumptionsunderlyingcommunitybasedparticipatoryresearch(CBPR)
andencouragesengagementofcommunitymembersandtrustedcommunityleadersinprocessesfromproblem
identificationtoprojectevaluationanddissemination.TheCBPRapproachisphilosophicallybasedincriticalandsocial
actiontheoryitbuildspartnershipswithcommunitymembersacrosssocialeconomicstatusandfocusesoncommunity
assetsandresourcesratherthanondeficits(Israel,Eng,Schulz,&Parker,2005Kretzmann&McKnight,1997).CBPR
seeksbalancebetweencommunitymembersandpractitionersorresearchersthroughsharedleadership,coteaching,
andcolearningopportunitiesitbenefitsfromtheexpertiseofbothcommunitymembersandpractitionersorresearchers
(Anderson,Calvillo,&Fongwa,2007Isrealetal.,2005).
Figure1.
ACommunityParticipationandEthnographicModel
Thecommunityparticipationandethnographicmodelisespeciallyappropriateforpublichealthnursesworkingwith
communitiesandpopulationsbecauseitprovidesaframeworkthatbuildsuponlocalcommunityknowledge.This
enablespublichealthnursesandtheircommunitypartnerstobesensitivetotheecologicalcontextandculture.The
modelisausefulguidefordevelopingprogramstopromotehealthycommunitiesandhealthequality(Isrealetal.,
2005).Anethnographicallyinformedapproachtocommunityandpopulationassessmentandevaluationinvolvesdata
collectionandanalysisthatgoesbeyondadoptingqualitativemethods(Aronson,Wallis,O'Campo,&Schafer,2007b).It
isanapproachthatallowssocioculturalcontexts,systems,andmeaningtoemergethroughacollaborativeprocess
betweenpublichealthnursesandcommunitymembers.
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Earlyethnographicworkinsubstanceuseprevention(Agar,1973Agar,1986Trotter,1993)providedafoundationfor
thecommunityparticipationandethnographicmodel.Karim(1997)pointedoutthattheworkofAgar(19731986)and
Trotter(1993)describedtheimportanceofacquiringlocalcommunityknowledgeofsubstancenonuseandusetoprovide
aricherunderstandingofthehealthrelatedassetsandneedsofthecommunitycircumstancesandenvironment
surroundingsubstancerelatedhealthandillnesscommunityandpopulationconditionsandattitudes,beliefs,and
traditionsdirectedtowardsubstancenonuseoruserelatedhealthriskbehaviors.
Uniquestrategiesutilizedinthecommunityparticipationandethnographicmodelincludemapping,e.g.,Geographic
InformationSystems(GIS),andPhotovoice,e.g.,picturetakingbycommunitymembersandpractitionersor
researchers.GISisatoolthatfacilitatesassessmentandanalysisoftheecologicalcontextofapopulation,aswellas
phenomenasuchasyouthsubstancenonuseandusewithinthecommunity(Aronsonetal.,2007b).Mappingenables
communitypartnersandpractitionersorresearcherstoassessneighborhoods,cities,and/orcountiestotarget
interventionsandtoidentifygeographictrendsovertime(Shannonetal.,2008).
GIShasbeenusedtoidentifyunmarriedteenmothers(Blake&Bentov,2001)interventionlocationsforsyringe
distribution(Shannonetal.,2008)andminoritydiabetesmanagement(Gesleretal.,2004).Usingmappingmethods
allowscommunitypartnersandpractitionersorresearcherstoidentifyspecificareasforbothassessmentsand
interventions(Cravey,Washburn,Gesler,Arcury,&Skelly,2001).Withcommunityinput,mapscanbegenerated
depictingareaswherecommunitymembers,i.e.,youths,parents,andcommunityleaders,reportprotectiveorrisk
relatedfactorsincreasedordecreasedsubstanceuseandpotentialinterventionsites.
Photovoice,orpicturetakingtocreateaphotonarrative,incorporatesCBPRassumptionsandenableseconomicallyand
politicallydisenfranchisedpopulationstoexpressthemselveswithgreatervoice.Thisresultsinmorebalancedpower,a
senseofownership,developmentoftrust,potentialtobuildcapacity,andanewsensitivitytoculturalpreferences
(Castleden,Garvin,&Nation,2008).Photovoiceusespicturestakenbycommunitymemberstopromoteeffective
sharingofbeliefs,knowledge,andthoughtsaboutagiventopic.
PractitionersorresearchershaveusedPhotovoicetofacilitategroupconversationsanddevelopactionsteps(Wang&
Burris,1994)inmanyways.ExamplesincludeexaminingqualityoflifewithAAbreastcancersurvivorsinruralNorth
Carolina(Lopez,Eng,RandallDavid,&Robinson,2005)engagingyouthsinhealthpromotion(Strack,Magill,&
McDonagh,2003),andbuildingcommunitywithyouths,adults,andpolicymakers(Wang,MorrelSamuels,Hutchison,
Bell,&Pestronk,2004).ThegoalsofPhotovoiceinthecontextofthecommunityparticipationandethnographicmodel
areto(1)enablepeopletorecordtheircommunity'sassetsandstrengths,aswellasconcernsandareasfor
improvement(2)promotecriticaldialogueandknowledgeaboutimportantissuesthroughgroupdiscussionof
photographsand(3)reachpolicymakers.
YouthSubstanceUsePreventioninaRuralCounty:AnExemplar
TheProblem
Adultsandyouthsinruralsouthernstateshavesomeofthehighestratesofcigaretteandsmokelesstobacco(ST)usein
theUS(CentersforDiseaseControlandPrevention[CDC],2010).Adolescenttobaccouseishighlycorrelatedwithuse
ofalcoholandotherdrugs(Hair,Park,Ling,&Moore,2009Kulbok&Cox,2002).Tobacco,alcohol,andotherdruguse
remainpervasiveproblemsworldwideandareresponsibleforalargeproportionofmorbidityandmortalityintheUS
(CDC,2010).HealthyPeople(HP)2020(U.S.DepartmentofHealthandHumanServices[DHHS],2010)pointedtothe
longtermhealththreatofadolescentsubstanceuseandtheneedtoincreasetheproportionofadolescentswhoremain
substancefree.Manyruralcounties,however,havelittleknowledgeofeffectiveinterventionstrategiestoprevent
adolescentsubstanceuse.HealthyPeople2020(DHHS,2010)recommendedincreasingpopulationoriented,primary
preventionprogramsprovidedbycommunitybasedorganizationstopreventyouthtobacco,alcohol,anddruguse.
TheProject
AprojectinvolvingthecommunityparticipationandethnographicmodelprovidesanexemplarofevolvingPHNrolesin
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communityparticipatoryhealthpromotion.Aninterprofessionalteam,ledbyanadvancedpracticepublichealthnurse
andahumandevelopmentspecialist,iscurrentlyusingtheseinnovative,communityparticipatorystrategies,including
GISmappingandPhotovoice,todesignasubstanceusepreventionprograminaruraltobaccogrowingcountyinthe
south.Publichealthnursesandinterdisciplinaryresearcherscreatedateamwithyouths,parents,andcommunity
leaders,tocompleteacomprehensivecommunityandenvironmentalassessmentofthecounty,itsruralecological
contextandcultureand,toreviewevidencebasedpreventionprograms,asthefoundationforayouthsubstanceuse
preventionprogramthatwillbeacceptable,effective,relevant,andsustainablebytheruralcounty.
Theinterprofessionalresearchteampreviouslyworkedwithyouths,parents,andcommunityleadersinaruraltobacco
growingcountyofVirginiaontwocollaborativeresearchprojectsfocusedonyouthtobaccoprevention(Kulboketal.,
2010Kulbok,Meszaros,Hinton,Botchwey,&Noonan,2009).Withfirsthandknowledgeofthechallengesfacedbythis
ruralcountywhenattemptingtopreventyouthsubstanceuse,theteamproposedandreceivedfundingforaproject
(Kulbok,Meszaros,Bondetal.,2009)basedonHealthyPeople2020(DHHS,2010)recommendationsforcommunity
based,populationorientedprimaryprevention.Theprojectaimswereto:
1. Establishacommunityparticipatoryresearchteam(CPRT)inaruralcountycomposedofyouth,parents,and
trustedcommunityleaders
2. ConductacommunityandenvironmentalassessmentwiththeCPRTtoidentifyecological,cultural,and
contextualfactorsinfluencingsubstancefreeandsubstanceusingadolescentlifestyles
3. EvaluatetheeffectivenessofpreventionprogramswiththeCPRTinlightofthecommunity'secological,cultural,
andcontextualdimensions,healthattitudesandbehaviors,andonthatbasisdevelopatobacco,alcohol,and
drugusepreventiveinterventionforthisruraltobaccoproducingcommunityand,
4. Pilottesttheinterventiontodeterminefeasibility,acceptability,obtainpreliminaryeffectivenessdata,andrefine
theinterventionforformaltestinginotherruralcommunities.
Thisyouthsubstanceusepreventionprojectiscurrentlyinyearthree,thefinalstagesofdesigningandtestinga
preventiveinterventionwiththeCPRT.Theproject,whichisbeingimplementedinstagesthatcorrespondtotheaims,
wasreviewedandapprovedbytheInstitutionalReviewBoardsoftheUniversityofVirginiaandVirginiaTech.Theinter
professionalprojectteamcurrentlyincludesanadvancedpracticepublichealthnurseandspecialistsfromanthropology,
architectureandurbanplanning,epidemiology,humandevelopment,andpsychology.Theteamalsoincludespublic
healthnursingandpsychologydoctoralstudents.ThecommunitymembersoftheCPRT,duringthecourseofthethree
yearproject,includedfourcommunityleaders,twelveyouths,andeightparents.AlloftheadultCPRTmembers
successfullycompletedresearchethicseducationrequiredbytheInstuitionalReviewBoards.
TheCPRTcompletedacomprehensivecommunityandenvironmentalassessmentoftheruralcountytoidentifyassets
andneedsrelatedtofiveassessmentdomains:thecommunity'speopleandhistory,anditsphysicalenvironment,idea
systems,socialsystems,andbeliefsystems.Inordertogatherqualitativedataaboutsubstanceuseinthiscounty,the
teamcompleted14individualinterviewsofcommunityleadersandfiveyouthgroupinterviews,withatotalof34youths,
14to18yearsofage.Theteamalsocompletedonegroupinterviewwithsevenparents.Analysisofthedatafromthese
multiplesourceswasintegratedintoacomprehensivecommunityassessmentbytheCPRT.Guidedbythecommunity
participatoryandethnographicmodel,andusinginnovativestrategies(i.e.,GISandPhotovoice)describedinthe
previoussection,theteamusedtheGISmethodtovisualizeandanalyzetheassesseddatarelatedtosubstanceuse.
InnovativeStrategiesforCommunityAssessment
Aseriesofcommunityassessmentmapsdisplayedsociodemographicinformationaboutteensinthecommunity,as
wellasimportant"teenplaces"thatwereassociatedwithsubstancenonuseanduse(refertoFigure2forone
hypotheticalmapof"teenplaces"withcommentsfromCPRTmembers).Thedatausedtocreatethesemapswas
collectedduringmonthlyCPRTmeetingsheldinthecountyandsemistructuredinterviewsconductedbyteamsofCPRT
memberswithcommunityleaders,youths,andparents.InterviewquestionsweredevelopedbytheCPRTtoobtain
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communityassessmentdata,andidentifyassetsandneeds.PublichealthnursescanuseGISmappingtovisualizeand
analyzeassessmentdatamoreeffectively.
Figure2.
Mapof"TeenPlaces"andFactorsRelatedtoYouthSubstanceNonuseandUse
Photovoiceisanothermethodpublichealthnursescanuseinthecommunityassessmentprocess.TheCPRTutilized
thePhotovoicemethodaspartoftheircommunityassessmentandinresponsetosemistructuredinterviewquestions
abouttheirruralcounty.Fiveyouthsreceivedinstructionstotakepicturesasavisualmeansofansweringthecommunity
assessmentquestions.Subsequently,theirpicturesweredisplayedon"pictureboards"accordingtothefivecommunity
assessmentdomains,i.e.,peopleandhistory,physicalenvironment,ideasystems,socialsystems,andbeliefsystems,
andusedtofacilitatediscussionduringgroupinterviewswithyouthsandparents.These"pictureboards"weredisplayed
attheendoftheyouthandparentgroupinterviewstoenhanceeachgroup'sdescriptionofyouthsubstancenonuseand
userelatedfactorsintheircommunity.
AnalysistoDate
Duringthetimeframethatthecommunityassessmentwasconducted,theCPRTusednominalgroupprocesstoanalyze
andselectsixrelevanteffectivenesscriteriaforayouthsubstanceusepreventionprogramintheirruralcounty.These
criteriawereselectedfromtenestablishedcriteriaonsubstanceuseprevention(Winters,Fawkes,Fahnhorse,Botzet,&
August,2007).TheCPRTthenexaminedthreeexistingsubstanceusepreventionprogramswitheffectivenessdatato
assesswhethertheymetthesecriteria.Selectionofapreventionprogramthatmeetsthechoseneffectivenesscriteria
andfitswiththeecologicalcontextandcultureoftheirruralcommunityisachallengingprocess.Itisongoingatthistime
andinvolvesconsiderationofmultilevelfactorsidentifiedinthecommunityassessmentprocessincludingculture,
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economics,politics,andpsychosocialconcernsrelatedtoyouthsubstancenonuseanduse.
AlthoughtheCBPRprocessischallenging,theresultinglocalknowledgeandunderstandingoftheuniquecharacteristics
ofthisruralcountyareprovidingdirectionintheselectionofaprogram.Forexample,preliminarydecisionsmadebythe
CPRTinclude:(1)thetargetpopulationforthepreventionprogramwillbemiddleschoolagedadolescents(2)themost
feasibleanddesirablesettingforapreventionprogramisthesummer4Hyouthcampheldinthecountyand,(3)high
schoolstudents,4Hcampcounselors,maybethebest"instructors"forthepreventionprogram.
Thisexemplardemonstratestheneedforspecializedknowledge,competencies,andskillsutilizedbypublichealth
nursestosuccessfullycarryoutcomplexassessmentsandinterventionsincommunities.Emphasisonessential
knowledgeandskillsincorePHNcompetenciesandeducationhelpstoensurethatpublichealthnursesarepreparedto
movetheirnursingpracticeintothefutureasleadersincommunityparticipatoryhealthpromotionandprevention.
CompetenciesforPHNSinCommunityParticipatoryHealthPromotingRoles
Publichealthnursescanacquireimportantknowledge,competencies,andskillstopromoteandprotectthehealthof
communitiesandpopulationsbyunderstandingandapplyingCBPRapproaches.Thesecompetenciesandskillsare
requisiteforpublichealthnursestoserveincontemporary,evolvingroleswithcommunitiesandpopulationsthatface
complex,multifacetedchallenges(Levinetal.,2008)suchaspublichealththreatsthataffectatriskpopulations(e.g.,
lackofaccesstohealthcare,emerginginfectiousdiseases,poorenvironmentalandlivingconditions,theepidemicof
overweightandobesity,andthecultureofsubstanceuseandabuse).
ThenatureofmanythreatsisnotunlikethreatsthatfacedPHNleadersintheearly20thcentury.Theyinvolvean
appreciationofculture,economics,politics,andpsychosocialproblemsasdeterminantsofhealthandillness.Thecore
competenciesinPHN(QuadCouncilPublicHealthNursingOrganization[QuadCouncil],2011)discussedbelowprovide
aguidelineforPHNpractice.ByusingCBPRmethods,publichealthnursescanapplyandenhancethesecompetencies.
AnalyticAssessment
AnalyticassessmentskillsrepresentanimportantdomainofPHNcompetenciesutilizedwhenapplyingcommunity
participatoryhealthpromotionstrategies(QuadCouncil,2011).Publichealthnursesshoulddevelopanalyticassessment
skillstopursuehealthpromotionandpreventioninpartnershipwithcommunitiesfacingcomplexchallenges.Analytic
assessmentskillsareusedincommunityparticipatoryapproachessuchasCBPRandprovideopportunitiestohear
multiplevoicesfromcommunityinsiderswhenconductingassessments(Andrews,Bentley,Crawford,Pretlow,&Tingen,
2007).
Publichealthnursescanenhancetheseskillsbyinteractingwithcommunitymembersandusingactivecommunication
togainindepthinsightsaboutthecommunity'sassetsandneeds.Forexample,whenAndrewsetal.(2007)used
participatorymethodstoassessanAApopulationlivinginanimpoverishedneighborhood,theywereassistedby
communitypartners,advisoryboardmembers,andcommunityhealthworkersininterpretingthedatathroughaseriesof
thecommunityforums.Therefore,theywereabletorevealmultilevelfactorsrelatedtosmokingpatternsofthat
communitybypartneringwithcommunityinsiders,whichprovidedafoundationfordevelopingeffectivesmoking
cessationinterventions.Inaddition,asshownintheexampleoftheCPRTworkrelatedtoyouthsubstanceuse
prevention,publichealthnursescanapplyanalyticassessmentskillsbyutilizingdifferent,usefulmethodssuchasGIS,
Photovoice,andindividualand/orgroupinterviewswithactiveparticipationofcommunitymembers.
CulturalCompetence
AnotherimportantdomainofPHNisculturalcompetenceskills(QuadCouncil,2011).Thiscoreabilityenhancesother
competenciesusedbypublichealthnurseswhenengaginginpartnershipswithcommunitiesandpopulations(Anderson
&McFarlane,2011).Culturalcompetencehelpspublichealthnursesunderstandinvisiblefactorsinthecommunitythat
promotehealthandpreventdisease,suchasassets,values,strengths,andspecialcharacteristicsofthecommunities
(Anderson&McFarlane,2011).
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Publichealthnursescanimprovetheirculturalcompetencethroughtheuseofparticipatorypracticeswithdiverse
communities(Marcusetal.,2004McQuiston,Parrado,Martinez,&Uribe,2005Perry&Hoffman,2010Zandee,
Bossenbroaek,Friesen,Blech,&Engbers,2010).Asmentionedpreviously,thecommunityparticipationand
ethnographicmodelisrootedinlocalknowledge,whichcanbederivedfromcommunitymembersofdifferingraceand
ethnicity,withdivergentattitudes,beliefs,andvalues(McGrath&Ka'ili,2009).Listedhereareseveralexamplesof
researchsupportingacquisitionofculturalcompetenceskillsusingacommunityparticipatoryapproach:
1. PerryandHoffman's(2010)studydemonstratedthatadoptingacommunityparticipatoryapproachenabledthem
todevelopastrategybasedonAmericanIndianyouthculturetoassesstheirlevelofphysicalactivityby
integratingcommunityinsidersintheprocessofassessmentandprogramplanning.
2. InaCBPRprojecttoreducesubstanceabuseinatribalcommunity,Thomas,Donovan,Sigo,Austin,and
Marlatte(2009)providedanexampleofhowpublichealthnursescouldattainculturallysensitiveknowledgeofthe
tradition,history,andstrengthsofthecommunitybyencouragingfullparticipationofadvisorycouncilsas"cultural
facilitators"intheirmeetings(p.4).
3. McQuisitonandcolleagues(2005)appliedanethnographiccommunityparticipatoryapproachtorevealimportant
culturalaspects,throughtheuseofnominalgroupprocessinmeetings,whenassessinghealthdisparitiesina
Latinopopulation.
4. Zandeeetal.(2010)describedhowapplyingCBPRenabledPHNstudentstobetterunderstandthecultural
backgroundofthecommunitiesinwhichtheyworkedandthusimprovetheirculturalcompetencebypartnering
withcommunityhealthworkers.
ProgramPlanning
Programplanningskillsareusedincommunityparticipationapproachestooptimizecommunityhealthpromotionand
diseasepreventionbypublichealthnurses(QuadCouncil,2011).Inprogramplanningforcommunityhealthpromotion
andprevention,PHNscanplanevidencebasedprogramsbyusingindepthanalyticassessmentskills,andcan
implementprogramsmoreeffectivelybyutilizingcollaborationsandpartnershipsgainedfromtheCBPRmethod
(Andrewsetal.,2007Hassouneh,AlcalaMoss,&McNeff,2011Marcusetal.,2004Perry&Hoffaman,2010).
Publichealthnursescandevelopsustainableprogramsandbuildcommunitycapacityforhealthpromotionbytakinginto
accounttheecologicalcontextofthecommunityfromanethnographicassessment(Andrewsetal.,2007Perry&
Hoffaman,2010).PerryandHoffman(2010)demonstratedhowPHNscanincorporatefindingsfromtheirassessment
intoprogramdevelopmentbyhavinglivelydiscussionsanddistributinginformationtodevelopthetailoredprograminthe
community.Marcusandcolleagues(2004)showedhowCBPRwasusedtodevelopaprogramtodecreaseHIV/AIDSin
AAadolescentsbycreatingacoalitionbetweenuniversitybasedinvestigatorsandchurchbasedstakeholders.PHNs
strategicallyutilizedthesepartnershipstodesignandimplementtheprogram.TheseCBPRstrategieswerealsoutilized
successfullytodevelopeffectivepreventionandinterventionprograms(includingbothprimaryandsecondaryprevention
programs)forcardiovasculardiseaseprevention(Fletcheretal.,2011).
CommunityDimensionsofPractice
Communitydimensionsofpracticeskillsfocusoncommunication,collaboration,andlinkagesbetweenpublichealth
nursesandthemanystakeholdersinacommunity(QuadCouncil,2011).TheseskillsarecentraltoPHNs'participation
inCBPRandenableafocusontheecologicalcontextindevelopinghealthpromotionprograms.
Publichealthnursesareabletogaintheseskillsbycreatingcollaborativepartnershipswithcommunityleadersand
stakeholdersandidentifyingresourcesandsolutionstoproblemsthroughtheCBPRmethod(Fletcheretal.,2011
Hassounehetal.,2011Marcusetal.,2004).Theseskillsareenhancedbyempoweringcommunitymemberstoaddress
theircommunity'shealthissuesandincreasingindividualandcommunityselfefficacyforhealthpromotionthroughout
theCBPRprocess(Andrewsetal.,2007Marcusetal.,2004).Ultimately,PHNscandeveloptheseskillsbybuilding
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communitycapacityandengagingcommunitymembersandpartnerstodesignmoreeffective,sustainablehealth
promotingprograms.
Again,thereareexamplesofresearchthatusedacommunityparticipatoryapproachtofosterthesecommunitypractice
skills.Andrewsetal.(2007)illustratedcommunitydimensionsofpracticeskillswhenpartneringwithcommunity
stakeholderstodevelopmultiplelevelsofinterventionsusinganecologicalframeworkthatenhancedsustainability.In
anotherstudy,PHNsbuiltpartnershipswithcommunitystakeholders(Hassounehetal.,2011)toincreasetrustandto
betterutilizecommunityresourcesinapplyinginterventionssuchastraining.Asshownintheseexamples,publichealth
nursescanuseCBPRtoenhancepartnershipsandempowercommunitymembersasparticipantsbyincludingthemin
thedecisionmakingprocessesofassessmentandprogramplanning(Andrewsetal.,2007Hassounehetal.,2011
Perry&Hoffaman,2010).
OtherSkills
Theimportantskillsofanalyticassessment,culturalcompetence,programplanning,andcommunitydimensionsof
practicearecriticalforpursuingcommunityhealthpromotiongoalsaspublichealthnursesbecomemorewidelyinvolved
incommunityparticipatoryapproaches.Otherimportantcompetenciesforthehealthpromotionrolearerequiredfor
publichealthnurses,includingcommunicationfinancialplanningandmanagementleadershipandsystemsthinking
policydevelopmentandpublichealthscience(QuadCouncil,2011).Publichealthnursescanfurtherdeveloptheseskills
bycontinuingtoengageincommunityparticipatorypractices.Forexample,PHNpracticeutilizespublichealthscience
knowledge,competencies,andskillsbypartneringwithpublichealtheducatorsandresearcherstodevelopevidence
basedpreventioninterventionsprogramsandthuscontributetonursingscience.CommunityinitiativesbyPHNscan
contributetothedevelopmentofpoliciesbasedonindepthevidence,assistcommunityhealthadvocates,andleadto
improvedlongtermoutcomes(Fletcheretal.,2011).
TheContemporaryPublicHealthNursingRole
Publichealthnursingpracticeatthegeneralistandadvancedorspecialistleveliscompetencybased.PHNcore
competenciesincludeknowledgeandskillsderivedfromthecorepublichealthworkforcecompetencies,whichwere
developedbytheCouncilonLinkages(COL)(CouncilonLinkages,2010).ThesePHNcorecompetenciesincludethe
threetiersofpracticeusedintheCOLcompetencies,i.e.,Tier1thePHNgeneralistTier2thePHNspecialistor
managerand,Tier3thePHNorganizationleaderorexecutiveleveladministrator(QuadCouncril,2011).Thesecore
competenciesarenecessarytoimplementcommunityparticipatoryhealthpromotingroles.Inaddition,itisessentialto
emphasizecollaborationandpartnershipswithcommunitiesandpopulationsascontemporaryPHNrolesevolveinthe
contextofHealthyPeople2020(DHHS,2010),thePatientProtectionAffordableCareAct(ACA)(U.S.Houseof
Representatives,2010),andtheNationalPrevention,HealthPromotion,andPublicHealthCouncil(ExecutiveOrder
13544,2010).ThesenationalinitiativesprovidenewopportunitiesforemergingrolesinPHNfocusedoncommunity
healthpromotionandpreventionpractices.
ThecommunityparticipationandethnographicmodelincludesimportantlongstandingPHNprocesses,aswellas
innovativestrategiesthatpublichealthnursescanutilizeincommunityassessmentandpreventionprogram
development.UsingPHNcorecompetencies(QuadCouncil,2011)andguidedbythecommunityparticipationand
ethnographicmodel,publichealthnursescanempowercommunitiesandpopulationstobecomemoreinvolvedin
communityhealthpromotionandprevention.Thisempowermentcanreducehealththreatsandincreasehealthequity.
Astherolesofpublichealthnursesasadvocates,collaborators,educators,partners,policymakers,andresearchers
evolveintheareaofcommunityhealthpromotionandprevention,greateremphasisoncommunityparticipatoryand
ethnographicapproachesinPHNeducationwillprovidebenefitstostudentsatthegeneralistandadvancedpractice
levels(Zandeeetal.,2010).Moreover,basicandadvancedpublichealthnursingpracticeroles,whichemphasizeinter
professionalcollaboration,communityparticipatorystrategies,andtheimportanceoflocalknowledgetoaddress
communityhealthproblems,willcontinuetocontributetoimprovedcommunityandpopulationhealthoutcomes.
References
9/13
5/19/2015
Agar,M.H.(1973).Ethnographyandtheaddict.InNadar,L.,andMaretzki,T.W.,(eds.)CulturalIllnessand
Health.Washington,DC:AmericanAnthropologicalAssociation.
Agar,M.H.(1986).Speakingofethnography.BeverlyHills,CA:SagePublications
AmericanNursesAssociation(ANA)(2007).Publichealthnursing:Scopeandstandardsofpractice.Washington,
DC:AmericanNursesPublishing.
Anderson,E.T.,&McFarlane,J.(2011).Communityaspartner:Theoryandpracticeinnursing(6thed.).
Philadelphia,PA:WoltersKluwerHealth/LippincottWilliams&Wilkins.
Anderson,N.L.R.,Calvillo,E.R.,&Fongwa,M.N.(2007).Communitybasedapproachestostrengthencultural
competencyinnursingeducationandpractice.JournalofTransculturalNursing,18(1S),49s59s.
Andrews,J.O.,Bentley,G.,Crawford,S.,Pretlow,L.&Tingen,M.S.(2007).Usingcommunitybased
participatoryresearchtodevelopaculturallysensitivesmokingcessationinterventionwithpublichousing
neighborhoods.EthnicityandDisease,17(2),331337.
Aronson,R.E.,Wallis,A.B.,O'Campo,P.J.,Whitehead,T.L.,&Schafer,P.(2007a).Ethnographicallyinformed
communityevaluation:Aframeworkandapproachforevaluatingcommunitybasedinitiatives.MaternalChild
HealthJournal,11(2),97109.
Aronson,R.E.,Wallis,A.B.,O'Campo,P.J.&Schafer,P.(2007b).Neighborhoodmappingandevaluation:A
methodologyforparticipatorycommunityhealthinitiatives.MaternalChildHealthJournal,11(4),373383.
AssociationofCommunityHealthNursingEducators(2003).Essentialsofmaster'slevelnursingeducationfor
advancedcommunity/publichealthnursingpractice.Latham,NY:Author.
Blake,B.J.&Bentov,L.(2001).Geographicalmappingofunmarriedteenbirthsandselectedsociodemographic
variables.PublicHealthNursing,18(1),3339.
Brainard,A.M.(1922,1985).TheEvolutionofpublichealthnursing.NewYork:Garland.
BuhlerWilkerson,K.(1989).Falsedawn:Theriseanddeclineofpublichealthnursing,19001950.NewYork:
Garland.
Castleden,H.,Garvin,T.,&Nation,H.A.A.F.(2008).Modifyingphotovoiceforcommunitybasedparticipatory
Indigenousresearch.SocialScienceandMedicine,66(6),13931405.
CentersforDiseaseControlandPrevention.(2010).Tobaccocontrolstatehighlights,2010.Atlanta:U.S.
DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,NationalCenterfor
ChronicDiseasePreventionandHealthPromotion,OfficeonSmokingandHealth.
CouncilonLinkagesbetweenAcademiaandPublicHealthPractice(CouncilonLinkages,COL).(2010).Core
competenciesforpublichealthprofessionals.Retrievedfrom
www.phf.org/resourcestools/Documents/Core_Public_Health_Competencies_III.pdf
Cravey,A.J.,Washburn,S.A.,Gesler,W.M.,Arcury,T.A.,&Skelly,A.H.(2001).Developingsociospatial
knowledgenetworks:aqualitativemethodologyforchronicdiseaseprevention.SocialScienceMedicine,52(12),
17631775
ExecutiveOrder13544Establishingthenationalprevention,healthpromotion,andpublichealthcouncil.(2010).
Retrievedwww.whitehouse.gov/thepressoffice/executiveorderestablishingnationalpreventionhealthpromotion
10/13
5/19/2015
andpublichealth
Fitzpatrick,M.L.(1975).Thenationalorganizationforpublichealthnursing,19121950:developmentofa
practicefield.NewYork:NationalLeagueforNursing.
Fletcher,B.J.,Himmelfarb,C.D.,Lira,M.T.,Meininger,J.C.,Pradhan,S.R.,&Sikkema,J.S.(2011).Global
cardiovasculardiseaseprevention:Acalltoactionfornursingcommunitybasedandpublichealthprevention
initiatives.EuropeanJournalofCardiovascularNursing,10(2),S32S41.
Gesler,W.M.,Hayes,M.,Arcury,T.A.,Skelly,A.H.,Nash,S.,&Soward,A.C.M.(2004).Useofmapping
technologyinhealthinterventionresearch.NursingOutlook,52(3),142146.
Hair,E.C.,Park,M.J.,Ling,T.J.,&Moore,K.A.(2009).Riskybehaviorsinlateadolescence:Cooccurrence,
predictors,andconsequences.JournalofAdolescentHealth,45(3),25361.
Hassouneh,D.,AlcalaMoss,A.&McNeff,E.(2011).Practicalstrategiesforpromotingfullinclusionof
individualswithdisabilitiesincommunitybasedparticipatoryinterventionresearch.ResearchinNursingand
Health,34,253265.
Israel,B.A.Eng,E.,Schulz,A.J.&Parker,E.A.(Eds.).(2005)Methodsincommunitybasedparticipatory
researchforhealth,SanFrancisco:JosseyBass.
Karim,G.(1997).Inlivingcontext:Aninterdisciplinaryapproachtorethinkingruralprevention.InE.B.Robertson,
Z.Sloboda,G.M.Boyd.L.Beatty&N.J.Kozel,eds.Ruralsubstanceabuse:Stateofknowledgeandissues
(NationalInstituteofDrugAbuse,Monograph168).RockvilleMD:USDepartmentofHealthandHuman
Services.
Kretzmann,J.P.,&J.L.McKnight.(1997).Buildingcommunitiesfromtheinsideout:Apathtowardfindingand
mobilizingacommunity'sassets.Chicago,IL:ACTAPublications.
Kulbok,P.A.&Cox,C.L.(2002).Dimensionsofadolescenthealthbehavior.JournalofAdolescentHealth,31(5),
394400.
Kulbok,P.A.,Meszaros,P.,Bond,D.C.,Botchwey,N.D.,&Hinton,I.(2009).Partneringwithruralyouthand
parentstodesignandtestatobacco,alcohol,anddrugusepreventionprogrammodel(Abstract).Virginia
FoundationforHealthyYouth(formerlytheVirginiaTobaccoSettlementFoundation).Retrievedfrom
http://healthyyouthva.org/vtsf/research/projects.asp
Kulbok,P.,Meszaros,P.,Botchwey,N,Hinton,I.,Bovbjerg,V.,Rhee,H.,Noonan,D.(2010).Mother
daughtercommunication:AprotectivefactorfornotSmoking.TheJournalofAddictionsNursing,21,(23),69
78.
Kulbok,P.A.,Meszaros,P.S.,Hinton,I.,Botchwey,N.,&Noonan,D.(2009).Protectivefactorsandtobaccofree
maleadolescentsinruralVirginia.Paperpresentedatthe137thAPHAAnnualMeeting,Philadelphia,PA.
Levin,P.,Cary,A,Kulbok,P.,Leffers,J.,Molle,M.,&Polivka,B.(2008).Graduateeducationinpublichealth
nursing:Atthecrossroads.PublicHealthNursing,25(2):17693.
Lopez,E.D.S.,Eng,E.,RandallDavid,E.,&Robinson,N.(2005).QualityoflifeconcernsofAfricanAmerican
breastcancersurvivorswithinruralNorthCarolina:Blendingthetechniquesofphotovoiceandgroundedtheory.
QualitativeHealthResearch,15(1),99115.
Lundy,K.S.,&Bender,K.W.(2001).Historyofcommunityhealthandpublichealthnursing,inCommunity
HealthNursing:CaringforthePublic'sHealth.Sudbury,MA:JonesandBartlett.
11/13
5/19/2015
Marcus,T.M.,Walker,T.,Swint,J.M.,Smith,B.P.,Brown,C.,Busen,N.,vonSternberg,K.(2004).
CommunitybasedparticipatoryresearchtopreventsubstanceabuseandHIV/AIDSinAfricanAmerican
adolescents.JournalofInterprofessionalCare,18(4),347359.
McQuiston,C.,Parrado,E.A.,Martinez,A.P.,&Uribe,L.(2005).Communitybasedparticipatoryresearchwith
Latinocommunitymembers:HorizonteLatino.JournalofProfessionalNursing,21(4),210215.
McGrath,B.B.,&O.Kali,T.(2009).CreatingprojectTalanoa:Aculturallybasedcommunityhealthprogramfor
U.S.PacificIslanderadolescents.PublicHealthNursing,27(1),1724.
Milio,N.(1970).9226Kercheval:Thestorefrontthatdidnotburn.AnnArbor,MI:UniversityofMichiganPress.
Perry,C.&Hoffaman,B.(2010).Assessingtribalyouthphysicalactivityandprogrammingusingacommunity
basedparticipatoryresearchapproach.PublicHealthNursing,27(2).104114.
QuadCouncilofPublicHealthNursingOrganizations.(2011).Corecompetenciesforpublichealthnurses.
Washington,DC:QuadCouncilofPublicHealthNursingOrganizations.
Savage,C.L.,Xu,Y.,Lee,R.,Rose,B.L.,Kappesser,&Anthony,J.S.(2006).Acasestudyintheuseof
communitybasedparticipatoryresearchinpublichealthnursing.PublicHealthNursing,23(5),472478.
Shannon,K.,Rusch,M.,Shoveller,J.,Alexso,D.,Gibson,K.,&Tyndall.M.W.(2008).Mappingviolenceand
policingasanenvironmentalstructuralbarriertohealthserviceandsyringeavailabilityamongsubstanceusing
womeninstreetlevelsexwork.InternationalJournalofDrugPolicy,19(2),140147.
Strack,R.W.,Magill,C.,&McDonagh,K.(2003).Engagingyouththroughphotovoice."HealthPromotion
Practice,5(1),4958.
Stanhope,M.,&Lancaster,J.(2011).Publichealthnursing:Populationcenteredcareinthecommunity(8thed.).
St.Louis,MO:Mosby.
Thomas,L.R.,Donovan,D.M.,Sigo,R.LW.,Austin,L.,&Marlatt,G.A.(2009).Thecommunitypulling
together:Atribalcommunityuniversitypartnershipprojecttoreducesubstanceabuseandpromotegoodhealthin
areservationtribalcommunity.JournalofEthenSubstanceAbuse,8(3),113.
Trotter,R.(1993).Ethnographicmethodsandinhalantuseamongthreeethnicpopulations.Paperpresentedat
theInhalantConference,FortCollins,CO,August1993.
U.S.DepartmentofHealthandHumanServices(2010).Healthypeople2020.Washington,DC:U.S.
GovernmentPrintingOffice.
U.S.HouseofRepresentatives.(2010).Patientprotectionandaffordablecareact.Retrievedfrom
http://docs.house.gov/energycommerce/ppacacon.pdf
Wang,C.C.&Burris,M.A.(1994).Empowermentthroughphotovoice:Portraitsofparticipation.HealthEducation
Quarterly,21(2),171186.
Wang,C.C.,MorrelSamuels,S.,Hutchison,P.,Bell,L.,&Pestronk,R.M.(2004).Flintphotovoice:Community
buildingamongyouth,adults,andpolicymakers.AmericanJournalofPublicHealth,94(6),911913.
Winters,K.C.,Fawkes,B.A.,Fahnhorse,T.,Botzet,&August,G.(2007).Asynthesisreviewofexemplarydrug
abusepreventionprogramsintheUnitedStates.JournalofSubstanceAbuseTreatment,32(4),371380.
Zandee,G.,Bossenbroek,D.,Friesen,M.,Blech,K.,&Engber,R.(2010).Effectivenessofcommunityhealth
12/13
5/19/2015
worker/nursingstudentteamsasastrategyforpublichealthnursingeducation.PublicHealthNursing,27(3),277
284.
Acknowledgement
ThisprojectwassupportedbyagrantfromtheVirginiaFoundationforHealthyYouth(formerlytheVirginiaYouth
TobaccoSettlementFoundation)20092012.
OnlineJIssuesNurs.201217(2)2012AmericanNursesAssociation
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