SPECIAL FEATURES: HEALTH POLICY

Organizational Attributes That

Assure Optimal Utilization of Public
Health Nurses
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ABSTRACT Optimal utilization of public health nurses (PHNs) is important for strengthening public
health capacity and sustaining interest in public health nursing in the face of a global nursing shortage. To
gain an insight into the organizational attributes that support PHNs to work effectively, 23 focus groups
were held with PHNs, managers, and policymakers in diverse regions and urban and rural/remote settings
across Canada. Participants identied attributes at all levels of the public health system: government and
system-level action, local organizational culture of their employers, and supportive management practices.
Effective leadership emerged as a strong message throughout all levels. Other organizational attributes
included valuing and promoting public health nursing; having a shared vision, goals, and planning; build-
ing partnerships and collaboration; demonstrating exibility and creativity; and supporting ongoing learn-
ing and knowledge sharing. The results of this study highlight opportunities for fostering organizational
development and leadership in public health, inuencing policies and programs to optimize public health
nursing services and resources, and supporting PHNs to realize the full scope of their competencies.
Key words: nursing administration, organizations, public health nursing practice, public health
systems.
A sustainable public health nursing workforce is vital
for building public health capacity. The need to
strengthen public health infrastructure and capacity
is widely recognized, including provision for surge
capacity, emergency planning, and activities to ad-
dress social health determinants within communities
(Baumann et al., 2006; Baumann, Blythe, & Under-
wood, 2006; Butler-Jones, 2008; Campbell, 2004;
Federal/Provincial/Territorial Advisory Committee
on Population Health and Health Security, 2005;
Moloughney, 2006). Since public health nurses
(PHNs) are the largest group within the public health
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433
Public Health Nursing Vol. 27 No. 5, pp. 433441
0737-1209/r2010 Wiley Periodicals, Inc.
doi: 10.1111/j.1525-1446.2010.00876.x
workforce, support for them to work effectively will
improve public health service delivery and outcomes
(Naylor, 2003).
Public health nursing is challenged by an aging
workforce and fewer young nurses entering the eld
(Underwood et al., 2009). While there is no evidence
of a nursing shortage currently in public health in
Canada, there is a global nursing shortage that makes
it essential to maintain nurses interest in the public
health subsector (Oulton, 2006). PHNs have reached
consensus about what their roles should be (Canadian
Public Health Association, 1990; Chambers et al.,
1994; MacDonald & Schoenfeld, 2003; Manitoba
Health, 1998). In 2003, the Community Health
Nurses Association of Canada (CHNAC) released the
Canadian Community Health Nursing Standards of
Practice (2003). Publication of the Core Competen-
cies for Public Health in Canada further claried the
knowledge, skills, and attitudes necessary for practice
in public health (Public Health Agency of Canada,
2007). Public health systems need to ensure organi-
zational conditions that attract PHNs and sustain
their competencies.
Information about how PHNs practice could
be optimized, however, is lacking. The focus of this
study was to examine the organizational attributes
that support PHNs to practice effectively. The study is
part of a broader pan-Canadian research program
examining community health nursing workforce
capacity and enablers for optimal community health
nursing practice (Underwood et al., 2009). The study
results can aid public health decision makers (includ-
ing employers and administrators) in developing pol-
icies and programs to optimize public health nursing
services.
Methods
Design and sample
Focus groups were conducted using an appreciative in-
quiry approach. Appreciative inquiry emphasizes what
works best in organizations rather than focusing on
needs and gaps (Cooperrider & Whitney, n.d.; Ham-
mond, 1998; Reed, 2007). Data were collected from 23
focus groups (156 participants) in six geographically di-
verse Canadian regions, fromSeptember 2007 to Febru-
ary 2008. The focus groups comprised 12 groups of
frontline PHNs (from urban or rural/remote settings)
and 11 groups of policymakers/managers associated with
public health nursing practice (urban or rural/remote)
(see Table 1). Nurses were invited to participate if they
had a role title Public Health Nurse or, in regions
where the title does not exist, if they were primarily as-
signed to prevention and health promotion activities in
organizations that focus on public health issues. The
study was approved by university and health authority
research and ethics boards. Participants provided writ-
ten informed consent before taking part in focus groups.
The average length of time for focus groups was 3hr.
Participants were invited by the facilitator to identify an
experience when a public health nursing intervention
worked very well and the organizational attributes that
contributed to that success. After initial group discus-
sions, participants posted written notes around the room
highlighting their discussion points. These notes sum-
marized the organizational attributes that contributed to
their successful experiences.
Analytic strategy
Qualitative data analysis was conducted in three
stages. Preliminary analysis took place during the
TABLE 1. Focus Group Participation
Canadian
geographic
region
Frontline rural/remote
(n57 focus groups)
Frontline
urban (n55
focus groups)
Policymaker/manager
rural/remote (n56
focus groups)
Policymaker/manager
urban (n55
focus groups)
Total
(n523
focus groups)
Atlantic 7 8 7 9 31
Quebec 4 4 2 3 13
Ontario 8 8 8 8 32
Prairies 9 11 9 5 34
British Columbia 6 7 7 4 24
Northern Canada 914 (2 sessions) NA 9 NA 22
Total participants 47 38 42 29 156
Note. NA5not applicable.
434 Public Health Nursing Volume 27 Number 5 September/October 2010
focus groups. Using a nominal group process adapted
from the Institute for Cultural Affairs methodology
(1998), groups discussed the posted statements they
had generated, claried meanings and interpreta-
tions, and produced a thematic analysis. This process
lent credibility to the ndings and assured partici-
pants that they had been accurately heard.
In the second stage, the researchers collated,
organized, analyzed, and compared results within the
four focus groups categoriesfrontline PHNs (rural
and urban) and policymakers/managers (rural and
urban)using established procedures for thematic
analysis (Miles & Huberman, 1994). Finally, the
research team rened the preliminary thematic anal-
ysis, recommendations, and conclusions.
Results
Organizational attributes identied as best supporting
PHNs to practice their full scope of competencies
relate to three themes: (a) government and other sys-
tem attributes (macro level); (b) local organizational
culture, including values and leadership characteris-
tics (meso level); and (c) frontline management prac-
tices (micro level). The organizational attributes are
illustrated with subthemes and direct quotes from
focus group data. Quotations, while elicited from spe-
cic groups, are representative of discussions across
focus groups and reect the rst level of analysis as
written by participants.
Government/system attributes (macro)
Focus group participants identied a strong role for
government- and system-level action to optimize pub-
lic health nursing practice, particularly in areas of
funding and public health leadership. Three attributes
were identied at the government/system level (see
Table 2 for illustrative quotes).
Flexible and adequate funding structures.
Having sufcient and exible public health funding
was important for stable, long-term program support.
In particular, rural groups emphasized that funding
exibility helped them respond to emerging needs.
Champions for public health. Participants
saw a strong leadership role for government as a po-
litical advocate for public health in publicly funded
health care delivery. This attribute was further em-
phasized at meso and micro levels.
Public health planning and coordination.
Participants identied the importance of public health
planning coordination across regions and nationally.
This coordination included shared public health
infrastructure and resources, such as national
databases, research and evaluation, and standardized
educational resources.
Local organizational culture: values and
leadership characteristics (meso)
Participants recognized three organizational charac-
teristics that supported optimal nursing practice and
outcomes (see Table 3 for illustrative quotes).
A shared vision. Participants stressed that or-
ganizations were effective when they maintained a
TABLE2. Government/System Attributes (Macro Level)
Attributes Illustrative group quotes
Flexible and adequate
funding structures
Flexibility allows organizations to
redirect resources and to take
advantage of opportunities/
respond to threats
Standardized funding versus
requests for proposals
Champions for public
health
Minister of Health supports
public health
A system champion (provincial
and regional level)
Public health planning
and coordination
System planning [involving] all
health partners, provincial/
regional health authorities
Provincial coordination and
sharing of resources that may be
adapted at the local level;
decrease duplication of efforts
TABLE3. Local Organizational Culture: Values and Leader-
ship Characteristics (Meso Level)
Attributes Illustrative group quotes
A shared public health
vision
Provides direction and guidance
toward health promotion and
prevention
Evidence base updated regularly,
current and . . . supports the
mission
Culture of creativity
and responsiveness
Organization provides exibility
[re: styles of practice
assignments]
Effective leadership Transformational leadership
Clear, consistent, visionary
leadership
Meagher-Stewart et al.: Identifying Organizational Attributes 435
clear vision, mission, and goals for public health, and
these were understood throughout the organization.
Policy, as well as practice guidelines, should respond to
research evidence, professional expertise, and commu-
nity issues to support public health nursing practice.
Culture of creativity and responsiveness.
All focus groups indicated that effective public health
organizations fostered a culture of innovation, at both
management and frontline levels. Policymaker/man-
ager groups recognized that this required leadership
willingness to take risks to address community needs.
Effective leadership. Participants described
effective leadership that valued diverse public health
roles, demonstrating respect, trust, and support for
PHNs working to their optimal level of competencies.
These attributes should be promoted and modeled at
senior levels and throughout the organization.
Management practices (micro)
Participants strongly associated management prac-
tices with optimal public health nursing practice.
Eight management practices that included day-to-
day organizational functioning and working condi-
tions were specied (see Table 4 for illustrative
quotes).
Program planning. Effective planning was in-
formed by evidence and was outcome driven, incor-
porating the results of ongoing evaluation. All groups
believed that public health programs worked well
when diverse community and client needs were taken
into account. PHNs worked effectively when they
were involved in and took responsibility to inform
the program planning, using expertise they gained
from daily practice, as well as their community devel-
opment and needs assessment activities.
All groups recommended that the roles and
responsibilities in public health be dened in relation
to the overall goals and accountabilities, rather than
particular tasks. Roles dened in terms of what was
to be accomplished were a foundation for autonomous
professional practitioners to determine how to best
achieve outcomes.
Promoting and valuing public health nurs-
ing practice. All groups thought that managers
played an important leadership role in building stake-
holder understanding and promoting the public
health nursing role to various levels of government,
other providers, community partners, and the public.
Two groups identied the strategic importance of
physician support for public health nursing programs
because physicians serve as an important gateway to
the public.
All groups recognized the importance of manage-
ment acknowledging public health nursing contribu-
tions. Effective leaders had knowledge and experience
in public health and public health nursing practice.
Some groups described the difculty in reporting to a
manager without public health or nursing experience
who could not provide the needed support and guidance.
Supporting autonomous practice. Partici-
pants stated that PHNs should be recognized as the
public health leaders best suited to determine effec-
tive strategies in their assigned context. Policymaker/
manager groups recommended organizational leader-
ship that trusted, supported, and recognized autono-
mous public health nursing practice. There were some
differences among groups. Rural policymaker/man-
ager and frontline groups spoke of autonomy as being
creative and responsive to a communitys needs.
Urban groups described autonomy as freedom of
action/voice, physical separation frommanagers, doc-
tors, etc., and support to be proactive in everyday
practice. Some frontline groups also noted that auton-
omous practice involved broad job descriptions, sup-
port, and exibility to utilize the full range of their
public health nursing skills.
Commitment to learning and professional
development. Participants valued strong learning
environments with organizational investment in
ongoing professional development, training, and
education. Rural groups emphasized that explicit
organizational and personal investments in learning
opportunities supported PHNs in maintaining their
competencies and, subsequently, use their full scope
of competencies in practice. PHNs also needed to be
responsible for professional development for them-
selves and their peers. For some groups, establishing
nursing practice councils enhanced professional
exchange and their ability to address nursing issues.
Policymaker/manager groups supported invest-
ment in strong orientation programs for new staff and
informal knowledge sharing and mentoring for all
staff. This point was especially emphasized by rural/
remote groups, who experienced difculties in freeing
up staff time for travel to conferences.
Frontline groups reinforced the importance of
knowledge exchange, including the provision of
436 Public Health Nursing Volume 27 Number 5 September/October 2010
educational tools and policy manuals and access to
specialist expertise (e.g., epidemiology, nurse educa-
tors, social marketing). Information technology infra-
structure and relevant training and support were
essential to working effectively, particularly in rural
settings.
Effective human resources planning. All
participants identied the need for effective recruit-
ment and retention strategies and sufcient numbers
of frontline staff to implement programs that meet di-
verse community needs. To ensure a consistent supply
of skilled staff, it was imperative to hire PHNs with
adequate entry-level skills, knowledge, and attitudes
to do the job effectively.
Enough time to complete work assignments was
seen as a necessity for effective public health nursing
practice. Frontline groups particularly emphasized
having staff and relief coverage, including provision
for vacation and professional development days.
PHNs needed time and exibility in schedules and
work assignments.
Supporting public health partnerships
and community development. Participants noted
the importance of partnerships involving community
groups, agencies, providers, and fellow team mem-
bers. They emphasized the interdisciplinary and
intersectoral nature of public health and manage-
ments role in supporting linkages and collaboration.
Communities were identied as important contribu-
tors to the success of public health organizations,
and community capacity building as an important
role within public health nursing. PHNs could build
TABLE4. Management Practices (Micro Level)
Attributes Illustrative group quotes
Program planning Provide time and framework for assessment of needs of community to foster sustainability
Ongoing evaluation for all programs . . . using criteria that values outcomes rather than
number of referrals
Clear guidelines and roles (for all staff not just PHN)
Promoting and valuing public
health nursing practice
Upper management and Medical Health Ofcers communicate clearly in the community
about public health programs/services
Demonstrating respect for the role of PHN as prevention and promotion agent
Supporting autonomous
practice
Senior management support independent practice/leadership in PHN practiceexibility
Opportunity for varied nursing practice (expand/develop other PHN skills)
Not being pigeon-holed into one small area
Commitment to learning and
professional development
Organization supports and values education/professional development across all sectors of
nursing and all levels of the organization. . . as demonstrated by nancial resources
Training and orientation to population health/determinants of health
Need more debrieng opportunities depending on location (e.g., single nursing clinics)
Access to experts (especially in rural) for development of practice guidelines and for research
Effective human resources
planning
and adequate stafng
Human resourcesadvanced planning (e.g., mentoring/training [new staff])
Recruit the right people that support values of [the organizations] culture (e.g., respect,
working with [others])
Adequate PHN and support staff for relationship building and sustaining these relationships
for the long term in some cases in the community
Supportive public health
partnerships
and community
development
Support to integrate initiatives/services across disciplines and agencies
Support for community and capacity building
Fostering effective
communication
Organization values open communication, not restricted to hierarchy
Team case reviewsapproach to deconstruct and reconstruct situationissues, players,
priorities
Structured debrieng (regularlysupervisor meetings and feedback), [and] informal
(unexpected debrieng)
Healthy workplace policies Family-friendly policies; exible hours
Safe and health-promoting workplace environment
Note. PHN5public health nurse.
Meagher-Stewart et al.: Identifying Organizational Attributes 437
trusting, respectful partnerships with clients, com-
munity groups, and representatives by involving these
stakeholders in program development. Organizations
needed to allot PHNs time to build these partnerships.
Fostering effective communication. Regular
communication and information sharing between
PHNs and management, between peers, and within
interdisciplinary teams was important. Policymaker/
manager groups valued open and clear communica-
tion strategies throughout the organization, as well as
participatory decision making among management
and PHNs. Rural frontline groups, and remote North-
ern groups in particular, appreciated opportunities for
debrieng sessions through staff meetings and team
case reviews.
Healthy workplace policies. All focus groups
discussed healthy workplace policies. Rural groups
highlighted family-friendly policies citing job sharing,
breastfeeding policies, and exible work hours as
examples. Urban groups also valued exible work
accommodation but emphasized the need for safe
and health-promoting work environments.
Discussion
Public health nursing practice
. . .combines knowledge from public health science,
primary health care (including determinants of
health), nursing science and social sciences; focuses
on promoting, protecting and preserving health of
populations; links health and illness experiences of
individual, families and communities to population
health practice; and practices in increasingly diverse
settings. (CHNAC, 2008, p. 8)
Adding to their practice complexity, PHNs work in
organizational systems that vary widely between
and within provinces (Crea & Underwood, 2008).
When participants were asked about organizational
attributes that supported successful practice, they
identied the importance of government policy, orga-
nizational culture, and management and leadership
practices. They also recognized their own role in pro-
moting optimal practice. The identied attributes
included work processes and relationships (e.g.,
shared vision and goals, partnerships and collabora-
tion, creativity and exibility, learning and informa-
tion sharing) rather than particular structures or
things. These ndings are consistent with research
in acute care related to magnet hospitals (Upenieks,
2003), while providing an insight into essential orga-
nizational attributes for effective public health prac-
tice. Furthermore, these ndings support a growing
recognition that health care systems and organiza-
tions are best understood as complex, adaptive
systems rather than machines (Glouberman &
Zimmerman, 2002; Pisek & Wilson, 2001). In com-
plex systems, relationships between parts are more
important than the parts themselves, and problems
(or solutions) are not reducible to parts alone. Change
requires integrated action, with each system area in-
crementally reinforcing and developing other areas.
Participants recognized the need for strong lead-
ership throughout the public health system to create
an integrated system and support effective and em-
powered public health nursing practice (as reected
in government, local organization, and management
levels). A recent provincial public health capacity re-
view similarly identied leadership as a current and
future challenge (Ontario Ministry of Health and
Long-Term Care Capacity Review Committee, 2006).
Consistent with other research ndings in health care
and other industries (Greco & Laschinger, 2006; Kan-
ter, 2008; Leatt & Porter, 2003), frontline and policy-
maker/manager focus groups identied a strong link
between middle management practices and effective
nursing practice. Thus, how public health managers
do their job is a key driver for optimizing public health
nursing effectiveness.
Successful public health nursing practice requires
a shared public health vision that is linked to clear
goals and roles and is informed by evidence and com-
munity needs. However, the complex nature of public
health makes dening specic tasks inadequate since
workers must be adaptive and creative. The focus
groups recommendation for sound human resource
planning that provides sufcient time, exibility, and
support to allow PHNs to effectively perform their
complex roles was consistent with other research nd-
ings that identied role clarity, a exible environment,
and PHNs participation in decision making as being
associated with higher satisfaction (Campbell, Fowles,
& Weber, 2004). In the present study, participants re-
peatedly stressed the benets of having the time to
build partnerships, assess community needs, nurture
client participation, respond to new program oppor-
tunities, and pursue ongoing professional develop-
ment. The conicting economic demands and
uncertainties inherent in public health practice may
pose particular challenges to developing, recruiting,
438 Public Health Nursing Volume 27 Number 5 September/October 2010
and retaining PHNs. Ensuring that PHNs are appro-
priately assigned and effectively supported to meet
their complex role demands will enhance retention
and provide an attractive work environment for
potential recruits.
Participants emphasized the need for exibility
and autonomy at all levels. At a system level, funding
bodies should ensure adequate and exible funding
for public health organizations to address public
health goals in a way that meets local needs. At a local
organizational level, leaders should foster a culture of
innovation, risk taking, and responsiveness to emerg-
ing needs. Management should support PHNs to prac-
tice independently and autonomously. Public health
nursing practice should be exible, creative, and open
to change depending on the community needs and
opportunities. Both PHNs and their managers needed
to demonstrate this exibility to work effectively.
Promoting public health and public health nurs-
ing practice was a strong message from all groups,
with a particular emphasis on managements role.
Leaders had an important function in promoting the
role of PHNs within the organization and publicly
acknowledging their contributions. PHNs needed
knowledgeable organizational advocates, such as their
supervisors and directors, to support effective prac-
tice. They also stressed the need to promote public
health practice in the wider community of providers,
community partners, and the public. Public health
managers with knowledge and experience in public
health and the public health nursing role were most
successful in achieving this goal. In a health care cul-
ture dominated by illness care, fully successful public
health renewal will mean a strong public health deliv-
ery system recognized by and taking its place with all
health system players.
Focus groups reiterated that public health plan-
ning and delivery is dependent on collaboration among
multiple players. Developing and drawing on partner-
ships is a core public health approach at all levels, but
requires structural supports that respect the time and
resources necessary for effective collaboration.
Focus group participants valued ongoing learning
for effective public health nursing practice. Invest-
ments are required for orientation and professional
development, for leaders to nurture informal knowl-
edge sharing and mentoring between providers. When
staff members are physically separated in day-to-day
roles, efforts are needed to foster group interaction.
Frontline groups especially desired attention to infor-
mation and knowledge exchange, including techno-
logical infrastructure and training, educational tools,
and policy manuals.
Implications for research
This study supports appreciative inquiry as a method-
ology for use by public health researchers (Lind &
Smith, 2008). The involvement of participants
through participatory action research and nominal
group process in the focus groups exposed the poten-
tial of public health nursing practice and supported
the identication of solution-focused policy change
recommendations.
Further investigation of leadership capacity
needs within public health organizations could inform
how to best support and further develop leadership
capacity, as well as shape the development of educa-
tional and professional development resources to
close existing gaps. Research focused on strengthen-
ing interdisciplinary partnerships in public health
would also be benecial. In addition, research to un-
derstand the needs of novice PHNs for both workforce
retention and professional development, including
leadership skills, is critical and could ultimately
strengthen public health systems.
Implications for practice
While the results of this study specically inform pub-
lic health practice in Canada, ndings on the impact of
organizations and leadership on optimizing nursing
outcomes may be relevant to other health care sectors
and systems. The geographical diversity, urban and
rural/remote practice settings, and participation of
frontline PHNs, public health managers, and policy-
makers may strengthen the applicability to other pub-
lic health settings. Differences between frontline and
policymaker/manager groups were mostly nuances
within themes rather than conicting themes. A
strong agreement emerged on supportive organiza-
tional attributes, including government/system attri-
butes, local organizational culture, and management
practices. The consistency of ndings, across contexts
and positions, highlights a common understanding
and shared perspectives in public health across Can-
ada. This congruence is particularly important in
complex systems where collaborative approaches con-
tribute more to optimal outcomes than discrete indi-
vidual actions. The results highlight areas for
organizational and leadership development in public
health and require detailed consideration and action
Meagher-Stewart et al.: Identifying Organizational Attributes 439
at all levels (see the recommendations in Table 5). By
involving researchers and decision makers from
across Canada, it is likely that the recommendations
will be acceptable at local levels.
Effective, visionary leadership at all levels, in-
cluding public health planning, human resources pol-
icies, and active promotion of public health nursing, is
essential for optimizing public health nursing out-
comes. In turn, PHNs need to be creative and exible
in their practice, take responsibility for professional
development, contribute to public health planning,
and lead in addressing community needs.
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TABLE 5. Recommended Actions
Theme Recommendation
Government/system
level
The Public Health Agency of Canada, provincial ministries of health, local health authorities, and
universities provide targeted funding for leadership and management development at all levels of the
public health system
All levels of public health governance coordinate public health planning to foster clear public health
vision, goals, and responsibilities, which in turn will effectively manage surge capacity, sharing of
resources, and reduced duplication
All levels of government collaboratively develop comprehensive public health communication strategies
to ensure widespread understanding of the role of public health within the health care system
The new schools of public health, along with local health authorities, continue to develop and share
comprehensive public health education resources, giving particular consideration to the learning and
knowledge exchange needs of rural and remote public health delivery environments
Local organizational
culture
Public health decision makers, managers, and practitioners share responsibility for evidence-informed
healthy, effective workplace practices
Local public health managers and policy makers implement stafng models to allow for changing local
needs, including challenges of emergency and pandemic outbreaks management and growing
prevalence of chronic disease
Academic researchers and local public health decision makers collect and share information related to
public health nursing roles and stafng strategies and collaborate to improve public health stafng models
Public health decision makers and managers continue to assure that programs have funding exibility and
PHNs have practice autonomy to support effective community development and partnerships that
ultimately optimize health outcomes
Local public health decision makers and managers invest in professional development budgets, setting
clear benchmarks, to provide PHNs with ongoing access to learning opportunities and that PHNs take
advantage of these opportunities
Management
practices
Local public health management further develops outcome-driven evidence-informed service delivery
models that facilitate PHN creativity and responsiveness to community needs
Public health managers have an in-depth understanding of the PHN role and support PHNs to maximize
public health competencies
Note. PHN5public health nurse.
440 Public Health Nursing Volume 27 Number 5 September/October 2010
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Meagher-Stewart et al.: Identifying Organizational Attributes 441
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