DOI: 10.1111/phn.

12369

S P E C I A L F E AT U R E S : T H E O RY

Critical caring theory and public health nursing advocacy for

comprehensive sexual health education

Elizabeth Dickson MSN, RN  | Marie L. Lobo PhD, RN, FAAN

College of Nursing, University of New Mexico,

Albuquerque, NM, USA
Correspondence
Elizabeth Dickson, Rio Rancho, NM, USA.
Email: edickson@salud.unm.edu
Funding information
Robert Wood Johnson Foundation Nursing
and Health Policy Collaborative, Grant/Award
Number: 73654
Abstract
Public health nurses (PHNs) often work with adolescent populations at risk for un-
planned pregnancies who do not have access to comprehensive sexual health educa-
tion (CSHE). Evidence-­
based CSHE can have a significant protective effect on
adolescent sexual behaviors. This article applies critical caring theory to public health
nursing advocacy for CSHE. Critical caring theory defines the social justice work of
PHNs as an expression of their caring as nurses. The lack of CSHE in schools for ado-
lescents is a social justice issue, and PHNs can be important advocates. The purpose
of this article is to explore how critical caring theory can inform public health nursing
practice regarding the importance of CSHE advocacy with the goal of creating equita-
ble access to CSHE for all adolescents.

KEYWORDS
adolescent unplanned pregnancy, critical caring theory, public health nursing advocacy, sexual
health education, social justice

1 |  BACKGROUND
Although there have been significant decreases in the rates of adoles-
cent pregnancy over the past two decades, the United States still has
one of the highest adolescent pregnancy rates of all developed coun-
tries (Sedgh, Finer, Bankole, Eilers, & Singh, 2015). Most adolescent
pregnancies are unplanned and unintended, and most adolescents
want to prevent pregnancy (Finer & Zolna, 2014; Martinez, Copen,
& Abma, 2011). Yet 41% of U.S. adolescents report having had sexual
intercourse in high school, and 14% of sexually active adolescents re-
port not using any method to prevent pregnancy (Centers for Disease
Control and Prevention [CDC], 2015). Demographic data show that
adolescents from minority racial and ethnic groups, and those who live
in rural geographic areas of the United States are at particularly high
risk of unplanned pregnancy (Atkins, Sulik, Hart, Ayres, & Read, 2012;
Ng & Kaye, 2015).
Even more, inequitable socioeconomic conditions such as lack of
access to confidential reproductive health services, disparate rates of
poverty, unemployment, and high school incompletion can place ad-
olescents at risk for unsafe sexual behavior and unplanned pregnancy
(Kost & Henshaw, 2014; Ng & Kaye, 2015). The purpose of this paper
will be to explore how critical caring theory can elucidate the role of
PHNs as they advocate for comprehensive sexual health education
(CSHE) in schools to support those adolescents at risk for unplanned
pregnancies.
1.1 | Need for comprehensive sexual health education
Two significant factors involved in unplanned pregnancies are level
of sexual activity, and whether contraceptives were used correctly
(Sedgh et al., 2015). CSHE is effective at addressing these factors by
reducing the level of sexual activity and risky behaviors (e.g. reduc-
ing the number of partners and unprotected sexual activity) and by
increasing protective behaviors (e.g. abstinence from and delaying
initiation of sexual activity, condom use, contraception use) (Chin
et al., 2012; Lindberg & Maddow-Zimet, 2012; Oringanje et al.,
2016; Stanger-Hall & Hall, 2011). For this paper, CSHE is defined
as a comprehensive approach to sexual health education that em-
phasizes evidence-­based, medically and scientifically accurate, age-­
appropriate content that includes human development, puberty
and reproduction, relationships, decision-­
making, sexual violence
prevention, body image, gender identity and sexual orientation,

Public Health Nurs. 2017;1–7. © 2017 Wiley Periodicals, Inc. |  1

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abstinence or delaying sexual activity, contraception, condom use,
and disease prevention (Advocates for Youth, 2009; Sexuality
Information and Education Council of the United States, n.d.).
Multiple professional groups concerned with adolescent health edu-
cation support CSHE including the National Education Association
(2017), National School Nurses Association (2017), American
Academy of Pediatrics (Breuner & Mattson, 2016), American Public
Health Association (2014), American Medical Association (2009),
and the Society of Adolescent Health and Medicine (Santelli, Ott,
Lyon, Rogers, & Summers, 2006).
School settings are key locations for CSHE. However, significant
barriers exist to effective delivery in secondary schools (Comberllick
& Brindis, 2011; Fields, 2008; Kirby & Laris, 2009). Publicly available
resources are available to help guide the development and delivery
of CSHE in schools (CDC, 2016; Future of Sex Education Initiative,
2011; U.S. Department of Health and Human Services, 2016); Office
of Disease Prevention and Health Promotion, 2015). However, 57% of
sexually active adolescent females and 43% of sexually active adoles-
cent males report they did not receive any formal education on con-
traceptives prior to engaging in sexual activity (Guttmacher Institute,
2016). Lindberg and Maddow-Zimet (2012) also found that adoles-
cents with higher rates of sexually transmitted infections and adoles-
cent pregnancy are less likely to have received CSHE than groups that
experience lower rates.
For adolescent populations who lack access to the protective
information offered in CSHE, this is a social justice issue. From a
health equity standpoint, the advantages of offering CSHE are cru-
cial. Sexually active adolescents benefit from the presence of CSHE,
as well as those who are not (Chin et al., 2012). This is particularly
important in communities where adolescents are at high risk, where
the presence and quality of CSHE can significantly affect adolescent
outcomes, and where the absence of CSHE is arguably unjust and un-
fair. PHNs who serve these communities work with these adolescents,
and often teaching health education in schools (Borawski et al., 2015;
Brewin, Koren, Morgan, Shipley, & Hardy, 2014). For this reason, PHNs
can view advocating for CSHE as addressing a social justice issue crit-
ical to the adolescent population for whom they care.
1.2 | Social justice advocacy in public health nursing
The nursing literature defines social justice as the “full participation
in society and the balancing of benefits and burdens by all citizens,
resulting in equitable living and a just ordering of society” (Buettner-­
Schmidt & Lobo, 2012, p. 955). PHNs can find strong, official man-
dates for social justice advocacy within the public health discipline,
and across the larger nursing profession. The American Nurses
Association (2014) called on all nurses to “integrate principles of social
justice into nursing and health policy” (p. 1). PHNs combine nursing,
F I G U R E   1   Critical caring theory model.
Source: Chinn (2013)
DICKSON and LOBO
public health knowledge, and health advocacy into their work with
communities every day, emphasizing prevention, policy development
and planning, with a commitment to social justice advocacy (American
Public Health Association, 2013). The Quad Council Coalition for
Public Health Nursing Practice described PHN practice involving lev-
els of population-­focused advocacy and leadership, supporting health
improvement among the populations they serve (Association of
Community Health Nurse Educators, 2011). PHN advocacy also sup-
ports self-­determination and authentic empowerment for the com-
munities they serve (Falk-Rafael, 1995, 2001).
These directives for social justice advocacy help define PHN ac-
tions within school environments to promote equitable access to
CSHE. This includes PHNs who work directly with school environ-
ments where adolescents spend their time and PHNs who work with
families and communities that include adolescents for whom the PHN
is caring. PHNs working with school nurses, counselors, teachers, par-
ents, families, and communities can collaborate in their support for
CSHE in schools and community programs. To better frame the social
justice perspective that PHNs use in their work with adolescent popu-
lations, we apply critical caring theory to CSHE advocacy PHNs do for
students at risk for unplanned pregnancy.
1.3 | Critical caring theory
Critical caring theory is a descriptive, middle-­range nursing theory
developed by Adeline Falk-Rafael, PhD, RN (2005a) that defines the
science behind public health nursing practice (Figure 1).
When applying existing nursing frameworks to public health nurs-
ing practice, Falk-Rafael (2000) identified several challenges: they
focus primarily on individuals, not on populations, their development
was within the context of illness and disease, not of health promotion
and prevention; and PHNs do not always consider them applicable to
their work with groups, communities, and populations. Many disci-
plines influence public health nursing practice, such as public health,
sociology, and epidemiology and PHNs inform their work from the
rich intersection of different theoretical influences. However, this can
create two issues: (a) other theoretical influences might diminish the
unique connection PHNs have with individuals, families, and commu-
nities as nurses, and (b) the impact of nursing science that sets public
health nursing apart from other public health disciplines can be re-
duced (Falk-Rafael, 2005a).
The roots of critical caring theory derive from three important
influences: Watson’s theory of human caring, the historical writings
of Florence Nightingale, and feminist critical theory (Falk-Rafael &
Betker, 2012a) (the tree roots in Figure 1). Falk-Rafael (2000) found
a philosophical similarity between Watson’s theory of human caring
and the PHN’s work in the community. Both promote a concept of
nursing practice that focuses on not only the individual patient, but
also on families, communities, and populations, as aspects of the entire
“whole” individual. Falk-­Rafael also included aspects of Nightingale’s
nursing identity: advocacy that focused on factors outside of a tra-
ditional medical environment, critique of the traditional biomedical
science model’s power over the delivery of health care, and promotion
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of primary prevention and health promotion frameworks (Falk-Rafael,
2000; Watson, 2008). Finally, Falk-Rafael (2001) framed core beliefs
and expressions of nursing caring within the concepts of social justice,
power, and advocacy. In particular, she created the concept of “critical
caring” by including both critical feminist theory and nursing feminist
theory to public health nursing practice (Falk-Rafael, Chinn, Anderson,
Laschinger, & Rubotzky, 2004). This “critical caring” includes critique
of health inequities, and support for the community as a change agent
to correct the imbalance of social power that contributes to health
inequities.
Critical caring theory consists of seven “carative” health-­promoting
processes (CHPP) that apply the concepts of human caring (health, ho-
lism, caring, and interconnectedness with self, others, and the environ-
ment) to public health nursing practice (Falk-Rafael, 2005a, p. 41). Two
processes define critical caring as a way of being (ontology), knowing
(epistemology), and choosing (ethics) (the tree trunk in Figure 1). The
other five processes define critical caring as praxis, an action/reflec-
tion practice (the tree branches in Figure 1). Falk-­Rafael created all
seven processes to provide a lens with which to view the core of pub-
lic health nursing practice: caring for individuals, families, communities
and populations, the environments in which they live, and the policies
that affect them.
Formal evaluation criteria for theory shows us that critical caring
theory is important and relevant to the field of public health nursing,
and it is ethical and accessible to PHNs (Chinn & Kramer, 2011; Falk-
Rafael & Betker, 2012a; Jaccard & Jacoby, 2010). We believe critical
caring theory can be a lens for PHNs to view health inequities faced by
the communities they serve, an important vehicle for understanding
the social, political, economic, and historical contexts in which inequi-
ties exist, and the policy advocacy needed to address them. PHNs can
develop what Valderama-Wallace (2017) described as a new “blue-
print” to expand the views of nursing practice to include a broader
understanding of social justice (p. 6).
2 | APPLICATION OF THEORY TO
COMPREHENSIVE SEXUAL HEALTH
EDUCATION ADVOCACY
PHNs can apply all seven of the critical caring theory processes to
CSHE advocacy (Table 1).
The first process (CHPP I) “preparing self,” describes how nurses
can prepare to engage with critical caring using reflective practice.
PHNs assess their knowledge, intention, and attitude, striving to be
authentically present, aware of their own belief systems (Falk-Rafael,
2005a, p. 43). This process involves a PHN identifying the different
types of knowledge at their disposal (personal, empirical, aesthetic, and
ethical). For CSHE advocacy, PHNs combine clinical experience work-
ing with adolescents and the empirical knowledge of evidence-­based
interventions to reduce risk behavior. Sociopolitical knowing is crucial
to critical caring (Falk-Rafael, 2005b) and is important for discussions
regarding CSHE within the community. PHNs, who have reflected on
their own values and beliefs, are better able to communicate respect
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4       DICKSON and LOBO

T A B L E   1   Application of carative health-­promoting processes (CHPP) to advocacy for comprehensive sexual health education (CSHE)

CHPP I–III: Critical caring as a way of being,

knowing, choosing Examples of PHN advocacy for CSHE using CHPPs

I. Preparing self
II. Developing and maintaining a helping–trust-
ing relationship
CHPP 3-7: Critical caring as praxis
III. Using a systematic, reflexive approach
IV. Engaging in transpersonal
teaching-­learning
V. Providing, creating, and/or maintaining
supportive and sustainable environments
VI. Meeting needs and building capacity
VII. Being open and attending to spiritual-­
mysterious and existential dimensions
I. Engage reflective practice to identify own belief system; integrate open, nonjudgmental
approach; combine public health and sociopolitical knowing regarding CSHE advocacy.
II. Engage individuals (school staff, students, and families/community) to explore barriers to
offering CSHE; cultivate respectful, authentic relationships; develop trust through consistent
community presence.
III. Employ empirical training and caring science; collect/analyze epidemiological data and combine
with student/client stories regarding impact of CSHE on school and students.
IV. PHN as teacher/learner for CSHE; open to listening and learning from the experiences of
students, clients, and community partnerships.
V. Policy advocacy for CSHE on all levels: state agencies, school boards and administrators,
funding agencies; collaborate with school nurses; address community/family concerns regarding
CSHE content.
VI. Support grassroots capacity building to address community concerns; present at school board
meetings; support school health advisory committees/councils; review CSHE curriculum for
evidence-­based content.
VII. Engage faith communities; respect community spiritual/faith traditions; help frame conversa-
tions (with school, student, family, community) about CSHE within shared concerns regarding
adolescent health.

and empathy to clients, and can more effectively engage discussions
about contentious CSHE content areas, such as adolescent sexuality,
adolescent autonomy, gender identity and expression, sexual orien-
tation, contraceptive choices, and reproductive health services. This
process PHNs develop open, nonjudgmental approaches for effective
CSHE advocacy.
The second process (CHPP II), “developing and maintaining help-
ing–trusting relationships,” describes a public health nursing practice
that cultivates relationships with respect, authenticity, active listening,
integrity, and an open attitude (Falk-Rafael, 2005a, p. 43). When ap-
plying this process, PHNs listen to students and school staff to assess
what type of sexual health education is being taught and by whom,
and help explore any barriers to teaching CSHE in the school envi-
ronment. These trusted relationships provide support for conversa-
tions with decision-­making groups (e.g., school administration, school
boards, community groups, advocacy groups, school health advisory
committees, etc.) about CSHE. Often the PHN becomes a trusted re-
source about CSHE, recommending guest speakers, or reviewing cur-
riculum. PHNs can maintain a consistent presence in the community,
attending school and community events to develop and strengthen
relationships with those involved in school and adolescent programs.
PHNs incorporate the third carative process (CHPP III), “using a
systematic, reflexive approach,” when advocating for community
health issues (Falk-Rafael, 2005a, p. 44). PHNs regularly collect, an-
alyze, and present epidemiological data on important health issues
in their community. This carative process can describes how PHNs
work with community members to combine quantitative assessment
data with qualitative stories of individual experiences. As an CSHE
advocate, the PHN can work with community partners to combine
epidemiological data on unplanned adolescent pregnancy, curriculum
used by schools, and evidence supporting CSHE, along with personal
narratives from school staff, students, and family experiences. PHNs
can help emphasize the assets and strengths of approaches used by
schools to offer CSHE, and emphasize the need for CSHE as identified
by the data and personal stories. This process exemplifies how PHNs
use their empirical, scientific training, and reflexive critical caring to
contribute to building community capacity around CSHE.
The fourth carative process (CHPP IV), “engaging in transpersonal
teaching/learning” (Falk-Rafael, 2005a, p. 44), is particularly important
for nurses as educators, teaching sexual health education to students,
and providing current research evidence in support of CSHE to school
and community leaders. This process embodies more than a traditional
patient-­education dynamic and didactic delivery of information from
teacher to student. Rather, this process incorporates a bidirectional
experience: PHNs as teachers presenting CSHE information, and as
learners respectfully listening to students and community members
as they share their experience, stories, and concerns related to CSHE
and unplanned adolescent pregnancy. The transpersonal aspect of this
process defines a transformational experience, enriching a collabora-
tive relationship between nurse and client when PHNs are teacher-­
learners. This carative process also articulates the importance of how
PHNs support and learn from other groups who are advocating for
CSHE to strengthen their advocacy partnerships.
At the core of PHN advocacy for social justice is the fifth carative
process (CHPP V), “creation of supportive and sustainable physical, so-
cial, political, and economic environments” (Falk-Rafael, 2005a, p. 45).
Much of the larger, upstream work for PHNs involves policy advocacy,
that intersection of public policy and personal lives for many PHNs
and their clients (Falk-Rafael, 2005b). This important process defines
PHNs engagement of policy advocacy supportive to CSHE at multiple
levels. This can include meeting with administrators and school boards
to advocate for supportive policy and administrative regulation codes,
DICKSON and LOBO
and advocating for state and federal grant funding supportive of ado-
lescent health education and reduction of risk behaviors. This process
also highlights the PHN’s political advocacy that stem from both their
education and their expertise, and the importance of working with
school staff, to respond to community and family concerns and ques-
tions about CSHE content taught in class.
The sixth carative process (CHPP VI), “meeting needs and building
capacity,” describes how PHNs can assess the community’s concerns,
and support grassroots capacity building focused on community con-
cerns and strategies for community-­identified social change and ac-
tion (Falk-Rafael, 2005a, p. 46). This process defines the PHNs work
around CSHE advocacy with communities to address the root causes
of adolescent health disparities, often involving assessment of social,
cultural, and economic developments. PHNs can collaborate with
school nurses to identify opportunities for community capacity build-
ing (Association of Public Health Nursing, 2016), and can help support
individual and group attendance at school board meetings address-
ing CSHE. PHNs can also attend school health advisory committee
meetings, and advise student and parent members seeking to research
different CSHE curriculum approaches.
The seventh and final process (CHPP VII), “being open and at-
tending to spiritual-­
mysterious and existential dimensions,” chal-
lenges and invites PHNs to consider how they engage community
belief systems and their own. This aspect of their work might not
be measurable ­
(Falk-Rafael, 2005a, p. 46). PHNs have described
this process as connectedness, intimacy, finding inner strength and
meaning, and being open (Falk-Rafael & Betker, 2012a). For the
PHN with experience working in faith communities, expressions of
this carative process include recognizing, honoring, and respecting
the strong spiritual and faith connections that hold communities to-
gether. While discussing CSHE, there can be both strong support and
opposition to CSHE within different faith communities. Community
discussions can become complicated when groups introduce ideo-
logical and religious beliefs regarding ­adolescent sexuality to the
conversation. PHNs can reflect how to frame difficult conversations
and traverse deep ­divisions of personal faith to include larger shared
concerns about ­adolescents that individuals and community groups
share.
2.1 | Implications
Critical caring theory has great potential for use in nursing education,
research, and practice. Undergraduate and graduate public and com-
munity health nursing faculty can use the important tools outlined in
the different carative processes to structure conversations about chal-
lenges nurses face in different care settings. As an example, Swartz
(2014) creatively presented critical caring as a useful framework for
both faculty and students in academic settings, to frame the social,
political, and economic influences affecting healthcare settings. Nurse
researchers can further refine critical caring theoretical concepts, such
as the work of Falk-Rafael and Betker (2012a, 2012b) that confirmed
the importance and relevance of critical caring theory to the practice
of PHNs. Shearer (2016) incorporated the processes of critical caring
|
      5
theory to the development of a theoretical framework for migrant
farmworkers, “critical caring protection concepts” (p. 8).
The application of critical caring theory is especially powerful to
harness what Falk-Rafael (2005b) called Nightingale’s “legacy of social
action” (p. 213). It provides social justice foundations to help PHNs
learn about the larger policy impacts of their advocacy actions. For
CSHE advocacy, this includes supporting inclusion of adolescent
voices into decision-­making around CSHE. PHNs and school nurses
teach CSHE in schools (Borawski et al., 2015), and critical caring the-
ory can help structure how to most effectively bring student voices
into the discussion of CSHE advocacy. Both PHNs and school nurses
speak as members of the most trusted profession in the United States
(Gallup, 2016). Their united nursing voice can speak with experience,
knowledge, and trusted credibility to the needs of adolescents, fami-
lies, schools, and larger communities.
2.2 | Limitations
Not all PHNs will be familiar with the critical social and feminist theo-
retical foundations of critical caring theory, and they might not see so-
cial justice work as core to their caring and advocacy with individuals,
families, and communities. In addition, the tenets of Watson’s theory
of caring that form the carative processes might not resonate with all
PHNs, including those who are not working directly in the community
or have more administrative responsibilities. However, the application
of critical caring theory presented in this article present the opportu-
nities to discuss PHN advocacy work around CSHE and the impor-
tance of using a social justice framework to frame the PHN’s work in
communities.
3 | CONCLUSION
For adolescents growing up in communities already facing inequita-
ble social and economic conditions, an unplanned pregnancy can add
tremendous complexity and difficulty. Ensuring that schools offer
CSHE can help reduce risky sexual behavior and increase protective
behavior associated with unplanned health outcomes, such as an un-
planned pregnancy. Critical caring theory is a powerful social justice
lens for PHNs advocating for the implementation of CSHE in schools
and the positive impact it can have on adolescents. This theory frames
the caring work expressed by PHNs as social justice work that strives
to improve the lives of communities and populations marginalized
from the effects of unjust policies and conditions, such as schools that
lack CSHE in communities at highest risk for unplanned adolescent
pregnancy.
Critical caring theory helps explain and guide the work that
PHNs perform in their advocacy for CSHE and the adolescent popu-
lations they care for in their practice. The deep, trusting relationships
PHNs form within the communities they serve give them a unique
understanding of the harm that can result from shortsighted policies
(Falk-Rafael, 2005b). For PHNs working with adolescents, critical
caring theory provides clarity regarding why they are motivated to
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6       DICKSON and LOBO
advocate for CSHE and, more importantly, how to best advocate for
reducing the health inequities faced by the adolescents for whom
they care.
ACKNOWLE DG E MEN TS
Support provided for this manuscript from the Robert Wood Johnson
Foundation Nursing and Health Policy Collaborative at the University
of New Mexico, College of Nursing.
O RCI D
Elizabeth Dickson  http://orcid.org/0000-0003-1248-368X
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How to cite this article: Dickson E, Lobo ML. Critical caring
theory and public health nursing advocacy for comprehensive
sexual health education. Public Health Nurs. 2017;00:1–7.
https://doi.org/10.1111/phn.12369