Public health nursing in the United States U. The new public health nursing role struggled, and continues to struggle, with appropriate interventions that would achieve quick results, but also leave lasting improvements in the population. With the advent of preventive health care, a moral tension arose between giving resources to the needy, and teaching them how to meet their own needs. Nursing of the acutely ill fits more easily into a model of one-way flow of resources from nurse to patient Buhler-Wilkerson, The Christian principle of helping those who help themselves guided this tension, but could not easily resolve it Brainard, , Giving free services or free supplies to the poor was seen as creating dependency and upsetting the natural social fabric of communities.
Public health nurses have addressed this moral tension over many years with innovative solutions that seek positive health outcomes, as well as advocate for vulnerable populations. By the early s, public health nursing roles extended beyond the care of the sick to encompass advocacy, community organizing, health education, and political reform American Nurses Association [ANA], Several examples of exceptional PHN initiatives show how these roles improved the health of communities and populations.
Public health nurses and other community professionals have continued to recognize the advantages of community participatory methods, including the potential for more effective intervention outcomes and capacity-building for long term benefit to the community Savage et al. The community participation and ethnographic model see Figure 1 is an innovative framework that demonstrates evolving public health nursing practice. The community participation and ethnographic model builds on assumptions underlying community-based participatory research CBPR and encourages engagement of community members and trusted community leaders in processes from problem identification to project evaluation and dissemination.
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The community participation and ethnographic model is especially appropriate for public health nurses working with communities and populations because it provides a framework that builds upon local community knowledge. This enables public health nurses and their community partners to be sensitive to the ecological context and culture. The model is a useful guide for developing programs to promote healthy communities and health equality Isreal et al.
It is an approach that allows socio-cultural contexts, systems, and meaning to emerge through a collaborative process between public health nurses and community members. Early ethnographic work in substance use prevention Agar, ; Agar, ; Trotter, provided a foundation for the community participation and ethnographic model. Karim pointed out that the work of Agar ; and Trotter described the importance of acquiring local community knowledge of substance nonuse and use to provide a richer understanding of the health-related assets and needs of the community; circumstances and environment surrounding substance-related health and illness; community and population conditions; and attitudes, beliefs, and traditions directed toward substance nonuse- or use-related health risk behaviors.
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Unique strategies utilized in the community participation and ethnographic model include mapping, e. GIS is a tool that facilitates assessment and analysis of the ecological context of a population, as well as phenomena such as youth substance nonuse and use within the community Aronson et al. With community input, maps can be generated depicting areas where community members, i. Photovoice, or picture-taking to create a photo narrative, incorporates CBPR assumptions and enables economically and politically disenfranchised populations to express themselves with greater voice.
Photovoice uses pictures taken by community members to promote effective sharing of beliefs, knowledge, and thoughts about a given topic. Practitioners or researchers have used Photovoice to facilitate group conversations and develop action steps Tobacco, alcohol, and other drug use remain pervasive problems worldwide and are responsible for a large proportion of morbidity and mortality in the US CDC, Healthy People HP U. Department of Health and Human Services [DHHS], pointed to the long-term health threat of adolescent substance use and the need to increase the proportion of adolescents who remain substance free.
Many rural counties, however, have little knowledge of effective intervention strategies to prevent adolescent substance use. Healthy People DHHS, recommended increasing population-oriented, primary prevention programs provided by community-based organizations to prevent youth tobacco, alcohol, and drug use. A project involving the community participation and ethnographic model provides an exemplar of evolving PHN roles in community participatory health promotion.
An inter-professional team, led by an advanced practice public health nurse and a human development specialist, is currently using these innovative, community participatory strategies, including GIS mapping and Photovoice, to design a substance use prevention program in a rural tobacco-growing county in the south.
Public health nurses and interdisciplinary researchers created a team with youths, parents, and community leaders, to complete a comprehensive community and environmental assessment of the county, its rural ecological context and culture; and, to review evidence-based prevention programs, as the foundation for a youth substance use prevention program that will be acceptable, effective, relevant, and sustainable by the rural county. The inter-professional research team previously worked with youths, parents, and community leaders in a rural tobacco-growing county of Virginia on two collaborative research projects focused on youth tobacco prevention Kulbok et al.
With first-hand knowledge of the challenges faced by this rural county when attempting to prevent youth substance use, the team proposed and received funding for a project Kulbok, Meszaros, Bond et al. The project aims were to:. This youth substance use prevention project is currently in year three, the final stages of designing and testing a preventive intervention with the CPRT. The project, which is being implemented in stages that correspond to the aims, was reviewed and approved by the Institutional Review Boards of the University of Virginia and Virginia Tech.
The inter-professional project team currently includes an advanced practice public health nurse and specialists from anthropology, architecture and urban planning, epidemiology, human development, and psychology. The team also includes public health nursing and psychology doctoral students. The community members of the CPRT, during the course of the three year project, included four community leaders, twelve youths, and eight parents. In order to gather qualitative data about substance use in this county, the team completed 14 individual interviews of community leaders and five youth group interviews, with a total of 34 youths, 14 to 18 years of age.
The team also completed one group interview with seven parents. Analysis of the data from these multiple sources was integrated into a comprehensive community assessment by the CPRT. Guided by the community participatory and ethnographic model, and using innovative strategies i. The data used to create these maps was collected during monthly CPRT meetings held in the county and semi-structured interviews conducted by teams of CPRT members with community leaders, youths, and parents.
Interview questions were developed by the CPRT to obtain community assessment data, and identify assets and needs.
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Public health nurses can use GIS mapping to visualize and analyze assessment data more effectively. Figure 2. Photovoice is another method public health nurses can use in the community assessment process. The CPRT utilized the Photovoice method as part of their community assessment and in response to semi-structured interview questions about their rural county. Five youths received instructions to take pictures as a visual means of answering the community assessment questions.
During the timeframe that the community assessment was conducted, the CPRT used nominal group process to analyze and select six relevant effectiveness criteria for a youth substance use prevention program in their rural county. The CPRT then examined three existing substance use prevention programs with effectiveness data to assess whether they met these criteria. Selection of a prevention program that meets the chosen effectiveness criteria and fits with the ecological context and culture of their rural community is a challenging process.
It is ongoing at this time and involves consideration of multi-level factors identified in the community assessment process including culture, economics, politics, and psychosocial concerns related to youth substance nonuse and use. Although the CBPR process is challenging, the resulting local knowledge and understanding of the unique characteristics of this rural county are providing direction in the selection of a program.
This exemplar demonstrates the need for specialized knowledge, competencies, and skills utilized by public health nurses to successfully carry out complex assessments and interventions in communities. Emphasis on essential knowledge and skills in core PHN competencies and education helps to ensure that public health nurses are prepared to move their nursing practice into the future as leaders in community participatory health promotion and prevention.
Public health nurses can acquire important knowledge, competencies, and skills to promote and protect the health of communities and populations by understanding and applying CBPR approaches. These competencies and skills are requisite for public health nurses to serve in contemporary, evolving roles with communities and populations that face complex, multifaceted challenges Levin et al. The nature of many threats is not unlike threats that faced PHN leaders in the early 20 th century. They involve an appreciation of culture, economics, politics, and psychosocial problems as determinants of health and illness.
By using CBPR methods, public health nurses can apply and enhance these competencies.
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Analytic assessment skills represent an important domain of PHN competencies utilized when applying community participatory health promotion strategies Quad Council, Public health nurses should develop analytic assessment skills to pursue health promotion and prevention in partnership with communities facing complex challenges. For example, when Andrews et al. Therefore, they were able to reveal multi-level factors related to smoking patterns of that community by partnering with community insiders, which provided a foundation for developing effective smoking cessation interventions.
Public health nurses can improve their cultural competence through the use of participatory practices with diverse communities. Public health nurses can improve their cultural competence through the use of participatory practices with diverse communities Marcus et al. Listed here are several examples of research supporting acquisition of cultural competence skills using a community participatory approach:. Program planning skills are used in community participation approaches to optimize community health promotion and disease prevention by public health nurses Quad Council, In program planning for community health promotion and prevention, PHNs can plan evidence-based programs by using in-depth analytic assessment skills, and can implement programs more effectively by utilizing collaborations and partnerships gained from the CBPR method Andrews et al.
Public health nurses can develop sustainable programs and build community capacity for health promotion by taking into account the ecological context of the community from an ethnographic assessment. Public health nurses can develop sustainable programs and build community capacity for health promotion by taking into account the ecological context of the community from an ethnographic assessment Andrews et al. Perry and Hoffman demonstrated how PHNs can incorporate findings from their assessment into program development by having lively discussions and distributing information to develop the tailored program in the community.
PHNs strategically utilized these partnerships to design and implement the program.
These CBPR strategies were also utilized successfully to develop effective prevention and intervention programs including both primary and secondary prevention programs for cardiovascular disease prevention Fletcher et al. Community dimensions of practice skills focus on communication, collaboration, and linkages between public health nurses and the many stakeholders in a community Quad Council, PHNs can develop these skills by building community capacity and engaging community members and partners to design more effective, sustainable health-promoting programs.
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Public health nurses are able to gain these skills by creating collaborative partnerships with community leaders and stakeholders and identifying resources and solutions to problems through the CBPR method Fletcher et al. Ultimately, PHNs can develop these skills by building community capacity and engaging community members and partners to design more effective, sustainable health-promoting programs. Again, there are examples of research that used a community participatory approach to foster these community practice skills. Andrews et al. In another study, PHNs built partnerships with community stakeholders Hassouneh et al.
As shown in these examples, public health nurses can use CBPR to enhance partnerships and empower community members as participants by including them in the decision-making processes of assessment and program planning Andrews et al. The important skills of analytic assessment, cultural competence, program planning, and community dimensions of practice are critical for pursuing community health promotion goals as public health nurses become more widely involved in community participatory approaches.
Other important competencies for the health promotion role are required for public health nurses, including communication; financial planning and management; leadership and systems thinking; policy development ; and public health science Quad Council, Public health nurses can further develop these skills by continuing to engage in community participatory practices.
For example, PHN practice utilizes public health science knowledge, competencies, and skills by partnering with public health educators and researchers to develop evidence-based prevention interventions programs and thus contribute to nursing science. Community initiatives by PHNs can contribute to the development of policies based on in-depth evidence, assist community health advocates, and lead to improved long term outcomes Fletcher et al.
Public health nursing practice at the generalist and advanced or specialist level is competency based. PHN core competencies include knowledge and skills derived from the core public health workforce competencies, which were developed by the Council on Linkages COL Council on Linkages, These core competencies are necessary to implement community participatory health promoting roles.
These national initiatives provide new opportunities for emerging roles in PHN focused on community health promotion and prevention practices. The community participation and ethnographic model includes important long-standing PHN processes, as well as innovative strategies that public health nurses can utilize in community assessment and prevention program development. Using PHN core competencies Quad Council, and guided by the community participation and ethnographic model, public health nurses can empower communities and populations to become more involved in community health promotion and prevention.
This empowerment can reduce health threats and increase health equity. As the roles of public health nurses as advocates, collaborators, educators, partners, policy-makers, and researchers evolve in the area of community health promotion and prevention, greater emphasis on community participatory and ethnographic approaches in PHN education will provide benefits to students at the generalist and advanced practice levels Zandee et al.
Moreover, basic and advanced public health nursing practice roles, which emphasize inter-professional collaboration, community participatory strategies, and the importance of local knowledge to address community health problems, will continue to contribute to improved community and population health outcomes. It helps illustrate the ownership of knowledge Rawson and Grigg , issues of power and control in the client— practitioner relationship Naidoo and Wills and delineates individual and collective modes of intervention.
It makes these points of convergence and divergence and the tensions and conflicts between them explicit and helps clarify the options that are enabled by the competing models.
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