Getting Your Feet Wet Becoming a PublicHealth Nurse, Part 1.docx

Getting Your Feet Wet: Becoming a Public
Health Nurse, Part 1
Lee SmithBattle, R.N., D.N.Sc.,
Margaret Diekemper, R.N., M.S.N., C.S.,
and Sheila Leander, R.N., M.S.N.
Abstract While the competencies and theory relevant to public
health nursing (PHN) practice continue to be described, much
less attention has been given to the knowledge derived from
practice (clinical know-how) and the development of PHN
expertise. A study was designed to address this gap by
recruiting
nurses with varied levels of experience and from various
practice
sites. A convenience sample of 28 public health nurses and
seven
administrators/supervisors were interviewed. A subsample,
com-
prised of less-experienced public health nurses, were followed
longitudinally over an 18-month period. Data included more

than 130 clinical episodes and approximately 900 pages of tran-
scripts and field notes. A series of interpretive sessions focused
on identifying salient aspects of the text and comparing and
contrasting what showed up as compelling, puzzling, and mean-
ingful in public health nurses’ descriptions. This interpretive
analysis revealed changes in understanding of practice and cap-
tured the development of clinical know-how. In Part 1, we
describe the sample, study design, and two aspects of clinical
knowledge development—grappling with the unfamiliar and
learning relational skills—that surfaced in nurses’ descriptions
of
early clinical practice. In Part 2, which is to be published in the
next issue of Public Health Nursing (SmithBattle, Diekemper, &
Leander, 2004), we explore gradual shifts in public health
nurses’
understanding of practice that led to their engagement in
upstream, population-focused activities. Implications of these
findings for supporting the clinical learning of public health
nurses and the development of expertise are described.

Key words: clinical knowledge, community health nursing,
home visiting, public health nursing.
While the competencies and theory relevant to public
health nursing (PHN) practice continue to be described
(Kenyon et al., 1990; Bramadat, Chalmers, & Andrusyszyn,
1996; Block et al., 2001), much less attention has been
given to the knowledge derived from practice (clinical
know-how) and the development of PHN expertise. This
study was designed to address this gap and to draw
on scholarship regarding the role of experience, percep-
tion, embodiment, and engaged reasoning in the develop-
ment of expertise (Schon, 1983/1994; Dunne, 1993;
Benner, Tanner, & Chesla, 1996; Dreyfus & Dreyfus,
1996; Benner, 1999, 2000a; Benner, Hooper-Kyriakidis,
& Stannard, 1999). In describing the experiential gains,
ethical discernment, and perceptual acuity central to clin-
ical expertise in acute care settings, Benner and her col-
leagues (1984, 1996, 1999, 2000b) have articulated crucial
distinctions between theoretical, applied knowledge
(knowing-that) and the practical, engaged reasoning
(knowing-how) that responds to the salient particulars
of a clinical situation. This research program has led
Benner to conclude that ‘‘practice is a way of knowing
in its own right that must be in dialogue with science and
technology’’ (2000b, p. 32).
Several researchers have adopted Benner’s approach in
examining PHN expertise (McMurray, 1992; Zerwych,
We use the terms public health nursing and community health
nursing
interchangeably.

An earlier draft of this paper was presented at the annual
meeting of the
American Public Health Association Meeting on October 22,
2001 in
Atlanta, Georgia.
Lee SmithBattle is Professor, Saint Louis University, St. Louis,
Missouri. Margaret Diekemper is Associate Professor, Maryville
University, St. Louis, Missouri. Sheila Leander is Adjunct
Clinical
Instructor, Saint Louis University, St. Louis, Missouri.
Address correspondence to Lee SmithBattle, Saint Louis
University,
3525 Caroline Street, St. Louis, MO 63104. E-mail:
[email protected]
Public Health Nursing Vol. 21 No. 1, pp. 3–11
0737-1209/04
# Blackwell Publishing, Inc.
3
1992a,b; SmithBattle, Drake, & Diekemper, 1997; Diekemper
et al., 1999a,b; SmithBattle, Diekemper, & Drake,
1999; SmithBattle & Diekemper, 2001). Although we
described several aspects of PHN expertise in our
previous study (SmithBattle et al., 1997; Diekemper

et al., 1999a,b; SmithBattle & Diekemper, 2001), the
small cohort of less-experienced nurses in that study pro-
vided limited data from which to generate a fine-grained
analysis of skill development. Two years later, upon
learning that new public health nurses had been hired in
various positions across the metropolitan area, we
returned to the field to conduct a second study that
would capture patterns and transitions in the skill acqui-
sition of public health nurses. In this article, we describe
the sample, study design, and two aspects of beginning
practice—grappling with the unfamiliar and learning rela-
tional skills—that surfaced in the public health nurses’
early clinical practice. In Part 2, we address additional
aspects of clinical learning that led public health nurses to
think and act ‘‘upstream.’’
STUDY DESIGN
This study was designed within the interpretive phenom-
enological tradition (Leonard, 1989; Benner, 1994; Benner
et al., 1996; Angen, 2000). Because this approach
places priority on understanding human action in its
own terms, the perspectives of participants are privileged
over prevailing theories or methodological procedures.
Understanding of varied meanings and patterns is sought,
rather than the discovery of unvarying ‘‘essences’’ or an
underlying structure of the phenomenon. Participants’
accounts and actions are carefully examined to uncover
the taken-for-granted aspects and meanings of a phenom-
enon that ‘‘reside’’ in human activities.
In embarking on this study, we used our professional
networks to identify public health nurses employed by
schools, parishes, public health departments, neighbor-
hood health centers, and social service agencies in the
metropolitan area. Letters were sent to all public health

nurses who had completed at least a baccalaureate nur-
sing degree and who had not participated in our earlier
study. Thirty-five nurses agreed to participate. Those who
had been in PHN practice for less than 3 years were
identified as less-experienced public health nurses for
study purposes. Among this cohort of public health
nurses, four began the study with less than 1 year of
PHN experience, six had less than 2 years of experience,
and three had been in PHN practice between 2 and 3
years. The 15 public health nurses who had been in
practice for more than 3 years were referred to as experi-
enced public health nurses. We also interviewed seven
public health nurse supervisors or nursing administrators
from the same agencies as the staff participants.
The 13 less-experienced public health nurses were
followed longitudinally over an 18-month period. They
participated in a group interview at the beginning of the
study and were re-interviewed individually at 6-month
intervals. They were also observed in clinical activities
for a maximum of 6 hours and debriefed. Field notes
were recorded as soon as possible after leaving the field.
The 15 experienced public health nurses were interviewed
once individually to refine our understanding of clinical
expertise. During group and individual interviews, public
health nurses were asked to describe clinical situations in
which they had ‘‘made a difference’’ or which were espe-
cially difficult in promoting the health and well-being of
an individual, family, or community. Interviews were tape
recorded and transcribed verbatim. Data included more
than 130 clinical episodes and approximately 900 pages of
transcripts and field notes. The individual, tape-recorded
interviews with the seven supervisors/administrations
provided background for understanding how agencies
organized, supervised, and funded PHN services.

Members of the research team read selected cases in
preparation for each of several interpretive meetings. Dis-
cussion at these meetings focused on identifying salient
aspects of the text and comparing and contrasting what
showed up as compelling, puzzling, and meaningful in
public health nurses’ descriptions. In moving back and
forth between clinical vignettes and field notes, we paid
attention to what public health nurses of varying experi-
ence noticed as well as what was missing in their
accounts. (For example, who the public health nurse
identified as the client upon receiving a referral was
revealing, because this so powerfully shaped understand-
ing and action.) Careful notes were taken during group
meetings for the purpose of creating detailed interpretive
summaries of each case. This summary included the
public health nurse’s educational background, her
current practice and setting, references to specific clinical
episodes, and the researchers’ discussion regarding the
participant’s language, engagement, skill, and taken-
for-granted understandings of practice. Previous research
on clinical learning and know-how (Benner, 1984; Benner
et al., 1996, 1999; SmithBattle & Diekemper, 2001) and
the transcripts from administrators/supervisors served as
important background, as we noted similarities and dis-
similarities in the way that the clinical world revealed
itself to public health nurses with various levels of experi-
ence. During interpretive sessions, we systematically com-
pared and contrasted clinical episodes of the experienced
and less-experienced public health nurses and noted shifts
in the less-experienced public health nurses’ perceptual
4 Public Health Nursing Volume 21 Number 1 January/February
2004

abilities, skills of responsiveness, and clinical reasoning.
When different interpretations surfaced among the team
members, we returned to the text to review, clarify, and
argue for our different understandings until consensus
was reached.
Codes were then identified for entering data into
Ethnograph (Seidel, 1998). While this qualitative software
package allowed for easy retrieval of clinical vignettes,
our interpretive summaries proved indispensable in
recovering the details, nuances, variations, and similarities
that we had noted in the text. After the study was com-
pleted, all participants were invited to a public health
nurse or a supervisor/administrator session to discuss
the findings. Two dimensions of early practice—grap-
pling with the unfamiliar and learning relational skills—
are now described with clinical vignettes and interpretive
commentary.
GRAPPLING WITH THE UNFAMILIAR
Narratives from inexperienced public health nurses cap-
tured their effort, anxiety, and excitement as well as their
limited perceptual abilities and practical know-how. For
example, the first interview conducted with the least experi-
enced nurse in our sample, who had been hired 3 months
earlier after a year of hospital experience, revealed an over-
riding self-consciousness in making telephone calls and
scheduling visits, entering the home and interacting with
clients, understanding and describing her role to others, and
acting in clinical situations. In her next interview 6 months
later, the clinical world was no longer so utterly foreign:
[Int: Now that you’ve been here almost a year, does it

still feel new to you?] No, it’s feeling more familiar.
I’ve kind of developed standard approaches [from my
colleague] for different situations…I have my standard
lines for when I call patients to set up appointments.
The standard things that I go through when I go for a
prenatal appointment, or lead, or hypertension, or
problems with medications. So while each one is dif-
ferent, I’ve kind of developed my standard approaches,
which I then modify for each patient. [Int: So that feels
a lot more comfortable to you now?] Much. Much.
[Int: And what about visits? Which ones are you feeling
more comfortable with?] I’m feeling a lot more
comfortable with the postpartum and prenatals.
I know more of what I need to ask, what I need to
assess, what’s important to address, and ways to lead
the conversation into it, so it doesn’t feel and seem so
awkward for me and the patient. [Int: Does it still feel
pretty effortful to you at this point?] Kind of half and

half. It depends on the situation. Some are very effort-
ful…At first, doing newborn and postpartums were
kind of effortful. I didn’t have a whole lot of experi-
ence with them…It’s getting better. My knowledge
base is improving and I’ve been developing my whole
spiel and system for those home visits. But, when I get
into more complicated [ones], that’s when it gets more
effortful…Generally, any of my first visits of a certain
type have been really effortful, but the more my
knowledge base tends to grow and the resources I’m
aware of, it’s gotten better.
As this nurse suggests, repetition with similar clinical
situations is required for beginners to grasp what is rele-
vant and to gain skill in knowing how to assess, address,
and ‘‘lead the conversation.’’ A sense of competence
emerges as she gains familiarity with typical parameters
and responses and is thus able to modify ‘‘standard’’
approaches. While she becomes less self-conscious in
dealing with ‘‘typical’’ situations, she is confronted by
her inexperience and limited understanding when entering
novel clinical situations.
In her second year of practice, the novelty of the clin-
ical world remained prominent in a school nurse’s inter-
view. As a solo health provider in an educational setting,

she necessarily relied on textbooks for making many
nursing and medical judgments:
I’m learning every day from these children. Every time
you think you’ve heard it all, you hear something
else…There’s always something new coming in that I
don’t know all the answers to. I have all my anatomy
books, dictionaries, physiology, and skin condition
books at my school, because I want to know what’s
wrong…I feel that if I can steer the parent in the right
direction, or not send a kid home because the kid has
allergies…And I’m doing really good at identifying
ringworm from eczema. And child abuse has reared
it’s ugly head which I’m real uncomfortable with.
Similar to the beginning nurses in acute care settings
described by Chesla (1996), novice public health nurses
relied on external guidelines for structuring their actions.
In addition to the borrowed standards and textbook
knowledge described by the above nurses, the referral,
agency protocols and forms, standardized care plans,
and documentation systems played this crucial role. For
example, in making three home visits with a less-
experienced public health nurse, the first author observed
the nurse as she closely followed agency forms to complete
an initial family assessment and to teach a parent about

infant care and development. The next excerpt highlights
how referrals also provided this necessary structure for
less-experienced public health nurses:
It was about four o’clock in the evening. And a hospi-
tal nurse called and said that there was a baby whose
SmithBattle et al.: Becoming a Public Health Nurse. Part 1 5
mother had no prenatal care and the baby was dis-
charged a day before the test results were back and she
was positive for Hepatitis B. And they didn’t give the
baby the H Big, but they did give the baby her first
Hepatitis B. So I was like, oh, God. This had never
happened [to me] before. We’re trying to figure out how
we can get this baby H Big…So, I called my regional
manager who’s over the vaccine program, and she says,
‘‘I’ll call the hospital and see if they can supply us with
one vial of HBig for the baby, and then you can do the
home visit on Friday.’ So we were playing with time
because the baby was born on a Monday, and after

seven days, H Big is no good. So I was thinking, I have
to get this baby injected by Friday or I’ll be crazy all
weekend. So we got it all together. Got the H Big from
the hospital. When I was on my way to work, I was
thinking, I should draw the father’s blood while I’m
there. So I did the H Big on the baby and I drew
his blood. And it was like an adrenaline type rush, like,
I got two things done at the same time.
Like other beginners in our study, this nurse decided
what to do on a home visit, largely based on the referral
alone. To her credit, she went beyond the single task
identified by the referral—to vaccinate the infant—and
relied on her knowledge of communicable disease trans-
mission to realize that the boyfriend might be infected.
While the story captured a beginner’s excitement in trans-
lating theory into practical situations—‘‘an adrenaline
rush type of thing’’—her learning does not progress to
include follow-up and interventions beyond the one visit.
She lacked the skill, support, and clinical reasoning to
assess the situation beyond the immediate health threat
and to provide follow-up to the family.
Although referrals provided needed direction to launch
the inexperienced public health nurse on a home visit,
they did not help a nurse to discern what was salient in
the situation. Upon receiving referrals for the chronically
ill, less-experienced public health nurses often presumed,
based on the referral, that the goal was to promote

patient ‘‘compliance’’ with medical management. In
maternal–child cases, health-promotion guidelines were
closely followed. In all cases, health teaching was highly
nurse directed. Inexperienced public health nurses had
not yet learned the lesson related by an experienced
nurse: ‘‘Basically you may go in for one thing when you
get the referral, but it turns out that it may be other
things; it’s never the way it appears.’’
Inexperienced public health nurses’ lack of perceptual
skills and practical experience made it difficult for them
to translate theoretical knowledge or clinical guidelines
into skillful clinical judgments. In the next excerpt, a
nurse described learning to make clinical judgments
about the progress of labor:
[My patient] was thirteen at the time and pregnant,
and the night before, I went by just to see how she was
doing, and she wasn’t feeling so well. So we talked
about contractions and labor. This is what you need
to look for, and you’ll time them, and stuff like that.
So the next day, I was telling [my mentor] about the
visit, and I said, ‘‘Something is just not right.’’ She
said, ‘‘Well, we can just drive by and see how she’s
doing.’’ Jane would always tell me, ‘‘Follow your gut
instinct.’’ So we went by the house, she was laying in

bed, she’s not feeling well, and I asked her what was
wrong. She said that she’d been in pain all night long.
‘‘Do you think you’re in labor?’’ ‘‘I don’t know, but
I’m really in pain.’’ So I was kind of evaluating her and
it sounded like she was in labor. And I said, ‘‘I’ve got
another nurse in the car. I’d like for her to just give me
a second opinion if you don’t mind.’’ And Jane came
in and assessed her. ‘‘Yes, she’s in labor.’’ So, we called
911 and she delivered the next day. So Jane was right
there for me, because that was the first time that ever
happened to me. And I was really kind of nervous
about it because my patient was young and had had
some complications. But Jane, with her ‘‘You’ve
always got to follow your gut feeling. And that was
just such a good call.’’ And just on and on with the
encouragement.
This excerpt illustrates how a novice nurse clearly bene-
fits from an experienced colleague who translates formal
theory (e.g., the progress of labor) into practical situ-
ations and who reinforces the beginner’s practical learning.

Less-experienced public health nurses also relied on
patient educational pamphlets to make up for their lack
of experience. For example, in describing a visit to a child
with asthma, a nurse said:
[The visit] gave me an opportunity to continue learning
more asthma management. I’ve got a little bit of
knowledge about a lot of things, but I don’t have
in-depth knowledge about enough. [Int: So what did
you do about that?] I did some reading, research on
things. As I gathered educational materials and tools for
the family, I also read them myself, so that I would know
what I was giving them and I could learn from them
as well.
Families themselves provide an important resource for
teaching the inexperienced public health nurse. Consider
the following example of how a nurse learns to refine her
assessment of neonatal jaundice:
In the beginning, jaundice was really hard for
me…because of all the different skin tones in African
Americans. You will get some that are more yellow by
nature and to me it was, ‘‘Oh my God, that’s jaun-

dice?’’ So I’ve really relaxed a lot. You’ll see it. If it gets
this bad, it’s gonna show up in other places. And, I’ll
6 Public Health Nursing Volume 21 Number 1 January/February
2004
ask questions, ‘‘What’s the father of the baby’s skin
tone like? Is it darker or is it the same as yours? Is it
lighter?’’ And a lot of my patients will just say, ‘‘I have
a lot of yellow in my skin tone and so the baby is very
similar to me.’’ [Int: Did anybody coach you in that?
Did you sort of learn that on your own?] I think a lot of
times, the moms really were the ones that taught me.
Cause I would say, ‘‘Your baby looks a little yellow. I
wonder if this could be some jaundice.’’ And they
would say, ‘‘No, no. I’m yellowy skin color too and
so’s my boyfriend. I think it’s just that he looks like
us.’’ And then we’d take him over to the window and
look at his eyes and everything. A lot of times, it would
turn out they were right.

Coping with unfamiliar aspects of clinical practice was
also noted in the many ways the inexperienced public
health nurses were caught off-guard and embarrassed by
social worlds that differed quite radically from their middle-
class backgrounds. The difficulty in soliciting psycho-
social information from families was quite pronounced
among several public health nurses who felt they were
prying into sensitive or private issues. As one nurse
explained, ‘‘I really don’t feel I have a right to know all
of that stuff.’’ During an observation of a home visit,
another nurse introduced an agency form to the patient
by saying, ‘‘This is the nosy form, mostly about family
composition and financial status. If you don’t want to
answer any questions, just tell me.’’ A third nurse
reported that she eventually broached financial issues
but only after a full year as a public health nurse:
When I first started having to fill out the socioeco-
nomic sheet, I just dreaded it. And half the time
I wouldn’t even ask. I would just kind of look. I hear
water running. Roof’s not leaking. There’s a smoke
detector. And I didn’t even ask. It took me a while to
get up to the point that, okay, I can ask these [ques-
tions] and it even got to, there probably are really good
reasons why we’re asking these questions. Because
nobody really gave me good reasons why we’re asking

all this stuff.
Inexperienced public health nurses were not only reluc-
tant to ask families about their income, but they were
often embarrassed and loathe to address roach problems
or to assess family violence. As an experienced nurse
made clear, an experiential cushion is required to go
beyond one’s comfort level: ‘‘In the beginning, I wasn’t
comfortable raising some issues. Like violence…I’ve got-
ten more confidence in how to broach the subject better,
what’s the right way to ask and when to ask, and that
type of thing. Whereas when you’re new, you have your
agenda, I have to do this and this and you don’t really
listen to the client.’’
Public health nurses early in their careers enter situ-
ations with an agenda and focus on accomplishing those
tasks (‘‘I have to do this and this’’) that are largely dic-
tated by external guidelines and prior education. As the
above nurse explained, going beyond a predetermined
agenda requires listening, being in partnership with cli-
ents, and creating ‘‘common ground’’ (Kristjanson &
Chalmers, 1990). Creating this shared understanding pre-
sumes a set of highly developed relational skills atypical
of less-experienced public health nurses.
LEARNING RELATIONAL SKILLS
Many stories from less-experienced public health nurses
detailed the challenges of developing relational skills [see
Benner et al. (1996) for similarities in acute-care settings].
Our study confirmed Zerwych’s (1992a) conclusion that
newer public health nurses ‘‘tend to overshoot one way or
the other’’ (p. 102) by doing too much or too little for
families. The inclination to rescue families and ‘‘fix’’ prob-
lems is a hallmark of beginning public health nurses:

[Int: When you think back on this last year, has your
practice changed in any way?] Yeah, I think that I’ve
been able to be less enabling (laughter). All of us have
talked about this being a trademark of brand new
CHNs. I will save you all. I will do everything for
you. I will make your appointments. I will drive you
there if I need to. (laughter) Not quite that bad, but it
gets pretty bad. You just want to help them so much.
And over time, you get frustrated at the times you
make these appointments and they blow them off.
You just get a little bit wiser and more street savvy.
It’s like, hey, wait a minute, why am I making this
appointment for you? If this really mattered to you,
you’d make your own appointment. You stop hand
holding so much. And I can see that in me. I’ve really
stopped a lot of the, let me do this for you.
Some beginning public health nurses were fortunate to
have an experienced colleague to point our their over-
involvement:

I can tell you about the little thirteen-year old. Boy oh
boy. I got her midway in her pregnancy and she was
having problems and her home life was totally
unstable. [relates extensive details] So early on, I’m
thinking, how can I get you out of this house and
take you home with me? Seriously, I’m thinking
those things. But then reality set in and I’m talking
to [my mentor] about it, and she’s saying, ‘‘That’s a
no-no. You cannot take on everybody’s problems. You
cannot be codependent. You can’t live their lives for
them and you can’t go in and fix everything. You can
only do what you can do as a nurse and that’s the
bottom line.’’ I think my nursing practice has
SmithBattle et al.: Becoming a Public Health Nurse. Part 1 7
improved because of that lesson. As a matter of fact,
I know it has.
While this nurse learns not to rush in and rescue

families, the nurse quoted below confronts the risks of
becoming detached and doing too little. This issue was
heightened for her because of her patient’s recent death
from a crack overdose. After relating an emotional story
of her 2-year involvement with this mother of seven chil-
dren, she reflected on the nurse–patient relationship and
the struggle to remain open to vulnerability and suffering:
There was times where I felt very overwhelmed and
I felt like I needed to pull out. One time she called me.
She had just got beat up. And it came to a point where
it was really hard to emotionally detach from this case,
because it was in my face all the time, and I went home
crying because she was beat up. And it’s making me
tear up now. [Int: Should you have been emotionally
detached?] H-m. [Int: What a gift you gave to that
woman.] I think it was a two-way street, though,
because I learned a lot from her. Like not to judge.
That was a big part. One of the nurses said to me, you
got so involved with her that you ended up at the
patient’s funeral. But I thought the family needed me
there. They asked me to be there. [Int: So what did the

nurse mean by that?] Why are we helping these people
that don’t want to be helped type of thing. She’s been a
PHN for a long time and I think she is kind of burned
out. [Int: And you had no question about being there at
the funeral?] Oh, no. Not at all. [Int: Anything else you
learned from the situation?] I knew I was really import-
ant to her. …

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