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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.
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Acknowledgement
ThisprojectwassupportedbyagrantfromtheVirginiaFoundationforHealthyYouth(formerlytheVirginiaYouth
TobaccoSettlementFoundation)20092012.
OnlineJIssuesNurs.201217(2)2012AmericanNursesAssociation

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