Moving Upstream Becoming a PublicHealth Nurse, Part 2Lee .docx

Moving Upstream: Becoming a Public
Health Nurse, Part 2
Lee SmithBattle, R.N., D.N.Sc.,
Margaret Diekemper, R.N., M.S.N.,
and Sheila Leander, R.N., M.S.N.
Abstract This article extends the argument in Part 1 that stand-
ards, protocols, textbook knowledge, and other external guide-
lines, while important for beginners, must yield to the ‘‘real
world’’ of practice. Additional narratives document how the
development of practical reasoning, perceptual skills, and
responsiveness to clients supplants the beginner’s reliance on
external guidelines and promotes a situated understanding of
practice. This growth in understanding and clinical know-how,
cultivated by frontline experience with individuals and families,
fosters a perceptual grasp of the ‘‘big picture’’ and makes it
possible for the nurse to learn the community through the eyes
of clients. Experiences from home visiting and community-
based

activities provide critical lessons that inform and inspire nurses
to
act and think upstream. This interpretation provides add-
itional evidence for legitimating clinical practice as a rich
source
of situated knowledge and clinical reasoning.
Key words: clinical knowledge, community health nursing,
population-based care, public health nursing.
When I first came out of school, we had ideas that we
were going to get everybody to stop smoking, lose
weight, exercise, see the doctor, take your medicine
on time, just because we talk to them. I mean that
was unrealistic. We thought the whole world was just
waiting to hear the word. They weren’t. And if you’re
trying to measure your success and nothing shows up,
then you start getting depressed because [it seems that]
you’re not doing anything. Then you realize you better
start counting your successes by a whole lot of smaller
increments, according to the real world.

The above excerpt supports the argument developed in
Part 1 (see SmithBattle, Diekemper, & Leander, 2004),
namely, that the beginner’s reliance on external guidelines
and classroom principles and theories, while important,
must yield to the ‘‘real world’’ of practice. In Part 2,
additional exemplars highlight how the development of
practical reasoning, perceptual skills, and responsiveness
to clients supplants inexperienced public health nurses’
theoretical understanding and promotes a situated under-
standing of practice (SmithBattle, Drake, & Diekemper,
1997). This growth in understanding and clinical know-
how, cultivated by frontline experience with individuals
and families, fosters a perceptual grasp of the ‘‘big
picture’’ and makes it possible for the nurse to learn
the community through the eyes of clients. This natural
outgrowth of experiential learning inspired several
inexperienced public health nurses to move upstream
and to become involved in population-focused care.
GAINING A SITUATED UNDERSTANDING OF
PRACTICE
After gaining considerable experience, the practice of the
less-experienced public health nurses began to shift from
a predetermined, nurse-directed agenda that was theory
based or driven by the original referral, agency protocols,
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 November 14,
2000 in
Boston, Massachusetts.
Lee SmithBattle is Associate 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. 2, pp. 95–102
0737-1209/04
# Blackwell Publishing, Inc.
95
or documentation systems to a situated understanding of
practice. With the refinement of perceptual and relational
skills, public health nurses began to ‘‘see’’ larger patterns
and subtle cues in individual and family responses that
had eluded them earlier. Their early reliance on scientific

evidence and practice guidelines for defining clinical suc-
cess was refined or supplanted by a more nuanced under-
standing of clients’ social embeddedness and a greater
respect for clients’ practical reasoning. As a result, under-
standing of clinical success was redefined and directly
linked to the specifics of a clinical situation. This growth
in understanding made the public health nurses less likely
to blame clients for their circumstances. As one nurse
reported: ‘‘The biggest danger of working is getting
burned out and blaming people for their problems . . . But
the more I understand, the less I have a desire to blame.’’
Another nurse confirmed that her understanding of
practice changed dramatically as she became more open
and flexible:
I’m sure early on I was naive enough to believe I could
change the world, but that certainly has changed. [Int:
How has your understanding changed?] . . . I’ve been
working with a lot of sick families for a couple of
years. . . Sometimes I think that my whole role in com-
munity health nursing—the social service stuff is bene-
ficial to these families, helping them get their children
immunized and into appointments, that’s important
too—but I really think in some ways my main role is
just to be a presence for people who haven’t had some-
one consistent in their lives and who is committed to

who they are and committed to their family. And so
that’s my primary role and this other stuff just comes
with it. I think that’s probably the most important thing
that I can offer these families—is being a consistent
person in their lives. When they’re not in crisis, they
know I’m still gonna be there. And when they are in
crisis, they trust and know that there’s somebody out
there who is some sort of safety net . . . [Int: Now was
there a situation that changed your understanding from
saving the world [to being present with families?] I don’t
know if it was one particular experience. I think it was
two, three, four, five different experiences that [taught
me] the same thing . . . I’ve been working with [many]
families for two years now. And they’re really in no
different place than they were two years ago. And that
made me stop and evaluate. Because when I started
working with them, you have that energy and enthu-
siasm. OK, I’m gonna get them into school and help

them get a degree, and better their lives, and go to work,
and value health care and all that kind of stuff. And two
years later, these families are still on welfare, relocating
every six months, and health care is still lower on the
rung because there are other things they’re paying atten-
tion to. And so these families have not adopted my
priorities (laughter). And the things that I was told as
a CHN you do for people. You could get discouraged.
But for me, what happened was reframing it in a way
that lets me stay with families over the long haul and to
realize that their lives are their lives and my priorities
may not be theirs. And you kind of know this but it’s
not until you have the experience . . . I’m still not OK that
these families are in the situations that they’re in. But I
think what I realized is that it’s bigger than they are.
That it’s much more [a result] of the political and the
social system . . . There’s so much out there that keeps
them where they’re at. So rather than expecting

dramatic changes to happen in their lives and lifestyles,
that’s what shifted for me, maybe it’s just about offering
a presence . . .
Similar to the public health nurse whose comments
began this paper, this nurse reflects on how the ‘‘real
world’’ moved her away from trying to achieve the
utopian, norm-based outcomes of health-promotion
theories supported by population-based epidemiological
findings with the families on her caseload. Experiential
learning led both nurses to question the prevailing ideol-
ogy in which health and lifestyle choices are promoted in
a vacuum, regardless of a person’s or family’s history,
resources, and understandings of what are worthy ends
and commitments. Rather than becoming demoralized or
blaming families for their dire circumstances and lack of
clinical progress in meeting predetermined outcomes, the
public health nurses’ understanding broadened to incorp-
orate an insider perspective that led to clinically based
notions of success. This clinical reasoning diverged from
classroom and textbook theory and was better attuned to
the possibilities and impossibilities of specific clinical
situations.
So then, what constitutes ‘‘success’’ with a family? The
above nurse was quick to elaborate with an example:
My idea of success with a family is what happened to
me last week. Here’s a mom with six kids. I’ve been
following them a year and a half. My first encounter

with them was when the children were lead poisoned
and I knocked on the door. I asked for the mom and
the woman told me she wasn’t there. So I left a mes-
sage. Did this about three different times. And I finally
met mom in the doctor’s office and it was the woman
who answered the door who told me that she wasn’t
there! (laughter) [Int: And you had no suspicion?] I had
no suspicion. You think it would have dawned on me.
But it didn’t. I was new. And so it went from that to
meeting with mom on the porch. And then there was
the day she invited me into the living room. And last
week, I got a telephone call from her saying, ‘‘Did you
read in the newspaper about the woman who was
killed and put in a fridge?’’ It happened to be her
96 Public Health Nursing Volume 21 Number 2 March/April
2004
next door neighbor. ‘‘Can you come over?’’ So it went
from this woman not even acknowledging who she

was, to calling me and saying, ‘‘I’m nervous and
scared, can you come over?’’ And when I went over, I
didn’t do anything. She couldn’t articulate that she
needed anything from me . . . ‘‘I just wanted you to
know.’’ To me that’s success. Her life is still the same.
This is the third address she’s been at since I’ve known
her. Their heat bills are up and all that kind of stuff.
And there’s not a lot of difference, per se, [in her
situation] . . .
This nurse’s growth in understanding and responsive-
ness was based on cumulative experience and the ethical
concern that this woman be seen and acknowledged. Like
other public health nurses, she learned to value presence
as a good in itself, much like the nurse in Part 1 who
challenged the detachment promoted by her colleagues and
formal education (SmithBattle, Diekemper, & Leander,
2004, p. 8).
Other public health nurses similarly referred to ‘‘experi-
ences that mentored’’ and led them to follow the family’s
lead and receptivity, rather than imposing a nurse-directed
agenda. In detailing her care of an elderly man and his
terminally ill wife earlier in her career, one nurse recalled
how ‘‘I probably had a thousand little experiences that led
me to the place where . . . I didn’t have to tell the couple
things they didn’t want to hear and I didn’t have to push

things.’’ ‘‘Learning not to force myself’’—as she described—
involved engaged reasoning and learning to situate herself
in clinical situations in ways that were respectful of clients’
concerns, priorities, experiences, and understandings: ‘‘I
learned not to force [my way] just because I have the knowl-
edge and knew I was right. We always think that because
we’re right, we need to share that right away, and so I think
I learned to be patient, to time and pace information . . . ’’
This greater flexibility and responsiveness brought the dis-
covery that ‘‘communicating is not the same as listening.’’
Active listening involved a dialogue that allowed her to
understand people’s lives, actions, and health status as
always embedded in specific contexts.
The practical, engaged reasoning that informs and
organizes action cannot be spelled out in rules, proced-
ures, or theory, yet is necessary for tailoring interven-
tions to the client’s world and possibilities. The following
nurse described learning this very lesson from clinical
practice:
I was going to close this client because I just hadn’t
had any success with her and I just kept missing the
clues, which I shouldn’t have. But I discovered that
when I just stopped talking and let her talk, she just
spilled her beans on everything that’s going on in the
family and all kind of social issues. And I’m like,
hmmm, I need to do this more often. And she was
giving me suggestions on ways to help her through her

talking, and I don’t think she realized that.
As this nurse discovered, her initial interventions failed
because they were ill-suited to the client’s situation. In
becoming more receptive, she was led by the client’s story
to envision more effective care. We also suspect that
the nurse’s growth in openness affirmed the client’s
strengths and power to define and act in the situation
that could not occur as long as the nurse imposed her
own agenda, without understanding the client’s world.
Learning that clients’ stories provide relevant guides to
action is an advance in clinical reasoning that informs
‘‘big picture’’ thinking and action.
GRASPING THE BIG PICTURE
Moving beyond a predetermined agenda and developing
skills of responsiveness allow the public health nurse to
hone in on the relevant details of a clinical situation and
to see the ‘‘big picture.’’ Grasping the ‘‘big picture’’ occurs
at many levels and becomes increasingly sophisticated as
the public health nurse moves from an individual to a
family focus and begins to notice how families face issues
that are best addressed with systemic changes. The fol-
lowing excerpt details a public health nurse’s skill at
structuring a student nurse’s experience at an appropriate
level, so that early successes encourage learning, percep-
tual awareness, and clinical reasoning that attend to the
relevant aspects of the situation:
An expert would be someone who can sit in a home
and listen to their needs and then say, ‘‘Oh, well you
need to call so and so at this agency.’’ Someone who

already knows the community resources doesn’t even
have to think. It’s almost automatic. I think a huge
difference is being able to see the total picture [whereas]
a beginner really deals with much more specific issues
in a particular family and then once they master those,
then they broaden out. I’m hooking a nursing student
up with a family of eight children. And she’s just so
overwhelmed. So we said, ‘‘Look, start with the two
youngest children. Don’t worry about the rest of the
family. Just start with the two youngest children and
when you’ve figured out what they might need and
how to help the mom with that, then open it up and
maybe add two more children to the picture.’’ We
knew she was gonna have a can of worms right when
she went in the door. What we said is, ‘‘Focus it.’’
While this mother with her eight children overwhelm
me, it overwhelms me in a way that is more empower-
ing and energizing than frightening. (Laughter). A

person who is experienced can tackle more of the
SmithBattle et al.: Moving Upstream, Part 2 97
bigger issues than a beginner could. [Int: Well they
need to find out the big picture.] Right. Because the
mother would probably be telling her but she
wouldn’t pick up on it. I mean, there’s a way that
without even asking questions, you get answers from
people. My interaction with somebody is much more
conversational whereas [for beginners], it’s the yes
and no questions and it’s trying to gather specific
data. Now I know how to ask one question that’s
gonna get me about seven different answers (laugh)
while before I had to ask seven different questions to
get that.
Precisely because the relevant features of a clinical
situation go beyond their perceptual abilities, less-
experienced public health nurses benefit from guidance
that orients them to aspects of the clinical situation, as
the nurse above does for a student. With experience, the

clinical world begins to show up as more differentiated so
that subtle aspects, discrepancies, and gray issues can be
noticed, as the next story highlights. The nurse recalls
how she was assigned to follow a 10-year-old child who
was referred because she smelled of mold. Somewhat
skeptical of the mother’s story because the interactions
in the home were so unsettling, she engaged in skillful
‘‘detective’’ work to uncover sexual abuse. While several
other seasoned professionals were involved with this
family, it was this less-experienced nurse who followed
her ‘‘gut instincts’’ and marshaled the evidence that led
to the child’s removal from the home. Here is her account
of what she learned from this ambiguous clinical
situation:
Oh God. I learned to not take people at face value. A
lot of time you’ve got to really listen and discern and
really look at the whole picture. It’s really easy to
pretty much believe everything people say. For me it
was. Why would a person lie to me about something?
But I really learned in that experience to take in the
whole picture and really look and watch and sometimes
even read between the lines. [Int: Had you not done
that before?] I don’t know. I felt like I was really doing
it even more so in that family for some reason. Cause
even with the first visit, I felt something wasn’t right.

But when I was brand new, it seems like you pretty
much believe whatever they say. Why would they lie to
the nurse?
This nurse aptly claimed that her skills of ‘‘discernment’’
were enhanced as her perceptual field expanded beyond
the beginner’s naivete and narrow range of vision. Grasp-
ing the bigger picture signaled a leap in skill development
and provided the experiential cushion for engaging in
increasingly complex clinical situations, which may include
seeing patterns that require a community response.
LEARNING THE COMMUNITY OR POPULATION
THROUGH THE EYES OF CLIENTS
Sometimes, public health nurses ‘‘stumbled’’ into unmet
community needs by virtue of their presence in the com-
munity. This serendipity occurred when a fairly inexperi-
enced nurse was asked to trim an elderly man’s toe nails.
Her humorous story revealed how the subsequent
onslaught of phone calls requesting a visit by the ‘‘foot
lady’’ eventually led to the inclusion of podiatric services
in the mostly volunteer health center that employed her:
There was this gentlemen who had really bad toenails.
And one of the family members asked if I could trim
his toenails. I was like, ‘‘Well I guess I can. I don’t
know why I can’t.’’ (Laughter) So I did, after soaking

his feet. And they were really bad. Turns out that after
I trimmed them, he stood up and started tap dancing.
And this was a really old guy who had tap danced in
another life. Well, of course, word got around. They
would call, ‘‘Is the foot lady there?’’ [Laughter] It was
actually kind of a nightmare. All these people needed
nailcare . . . [Eventually] we started a foot clinic and got
real podiatrists in. [Int: So what happened to your role
as the foot lady then?] Well, I still did a little on the
side, for the people who couldn’t make it in. (Laughter)
Once a foot lady, always a foot lady.
While not downplaying the value of sophisticated data
gathering and analytic skills, this serendipitous identifica-
tion of an unmet community need emerged ‘‘naturally’’
from the nurse’s organic relationship to the community.
Other public health nurses told similar accounts of how
being ‘‘the eyes and ears’’ of the community with their
quasi-insider status in a neighborhood, school, or parish
led to the discovery of patterns and needs that were
eventually addressed by new programs, policy changes,
or advocacy efforts. As the above nurse added, ‘‘Some of
it was just need. It’s like you take a step and you keep
taking the next step.’’ This practical knowledge of public
health nurses, based on their work with individuals and
families, often escaped more formal community assess-

ments. For example, one nurse described how the grants
that were written by the agency’s grant-writer, who had a
wealth of data at his disposal but no community-based
experience, were not well tailored to the community’s
perceived needs. The nurse’s input, based on her presence
in the community, was invaluable in developing grants
that were better attuned to the community’s priorities.
Experienced public health nurses commented on the
importance of becoming skilled in home visiting before
sharpening their focus on community- and population-
level activities (Diekemper, SmithBattle, & Drake,
1999b). In fact, by learning the community through the
98 Public Health Nursing Volume 21 Number 2 March/April
2004
eyes of the families they visited and through multiple
community contacts, public health nurses developed an
insider perspective and clinical know-how about specific
populations that other public health professionals often
lacked. Several public health nurses described discerning
clinical issues from home visiting and other community
activities that moved them upstream to participate
in population-level activities. Because the following
nurse had extensive community-organizing experience
prior to becoming a public health nurse, her account is
particularly instructive regarding the foundation needed
for aggregate-focused care. While the health department
for which she worked was adopting core functions into
public health nursing (PHN) practice, she was reluctant
to move into that area before developing some compe-
tence in individual and family care:

[Int: Has your practice changed in any significant
way?] Yeah, just more community stuff than when I
first started. And that might be just my comfort
level . . . or it could be that I have more time, but I
don’t feel like that I have more time. It just seems
like I’m running into different people in the commu-
nity than I did before. There’s a parish nurse that I just
ran into at a meeting. She’s having a health fair at her
church tomorrow, so I’m going to go and work at the
health fair so I can get to know more about that area,
because it’s in my visiting area. Just things like that
seem to keep popping up. [Int: And that’s from just
being there and getting more familiar with the
community.] It seems like when I first started, I did
go to community things but it was more [about] getting
comfortable with the prenatal and mom-baby visits, so
I felt like I knew what I was doing before I moved
on [to community aspects]. It was more a matter of

meeting the right people and figuring out what to
become involved in. I knew how to do it [from prior
job experience]. I just had to get the time to be able to
figure out where I wanted to plug myself in.
Other public health nurses confirmed that individual-
and family-level experience was a crucial foundation for
aggregate-level practice. The next excerpt is especially
relevant not only because the nurse is quite articulate
about her development of skill and passionate about her
practice, but because she was quoted earlier about the
importance of presence (p. 96). The practical know-how
gained from visiting families provided the groundwork
and the impetus for the community advocacy work that
is part and parcel of her PHN practice:
Individuals in a community are as healthy as their
community is, and vice versa. The community is only
as healthy as the individuals are. You can’t address
one without addressing the other. It’s real basic, but
it’s like totally fundamental and essential. Students
want to see patients and visit with people and they
don’t really grasp the magnitude of the community
piece. And I don’t think I grasped the magnitude of
it until a few years into my practice . . . When I started

in public health, I needed to learn the foundation and
the home visiting part. Now that that’s developed, I
have the time and the energy [to devote to the com-
munity piece]. If I didn’t have the whole home visiting
aspect, [I wouldn’t know] how to determine who needs
to be seen when and what are the priorities . . . But, for
me, I think you have to start with the individual to
understand the community. And if you started with
the community, I think you’d find yourself going
back to the individuals and trying to catch up. So I
think you have to start with the individuals, because
that tells you what the community is . . . I probably
could have started out in the community, but I
wouldn’t have been focused on this particular commu-
nity for its particularities. I think I would have been
able to take from my practice the fundamentals of
community education. But, it wouldn’t have become
particular to that community until I became familiar

with the individuals. [Int: And so it’s a natural out-
growth of having developed the expertise with individuals
and understanding the community.] Right. And that’s
probably why my practice now has moved in the direc-
tion of a lot of community advocacy. Like with lead
poisoning. I have done case management for two and a
half years. And I’ve been doing a lot of education, and
I used to believe that education was the thing. And I
believe in education. I’m a firm believer in that. But
I’ve also been in this practice enough to know that
after two and a half years of educating families about
lead poisoning, the percentage of children that are
poisoned in this area is the same now as it was two
and a half years ago. Now I could look at that as a
personal failure, that my program has not done
anything to impact the percentage of children that
are poisoned. And I’ve considered that. So is it that
education doesn’t seem to be making a difference? Or

is it that education makes a difference, but you don’t
really see the results until five or 10 years later? I’m at
a point where I’m saying, okay we’re doing what we
can education-wise. So then, what next? I can do as
much education as I want, but if people remain in their
environments, it’s not going to change. So now I’m at
the point that I need to start focusing more on how do
we clean up the environment . . . So, I need to try and
move the efforts of this coalition I’m involved in to
remediate housing. [Int: That’s a wonderful example of
being in practice with individuals and families that led
you to see the big picture and realizing what needs to be
the next step.] And that happens all kinds of times
along the way. I mean, initially it started out where
I was doing education with people about diet and all of
SmithBattle et al.: Moving Upstream, Part 2 99
a sudden I’m going, these people don’t have the money

to buy the food. High iron food is meat. It’s expensive.
They don’t have the money for that or phosphate
cleaners and buckets and mops [for the prevention of
lead exposure]. If they can’t pay their electric bill,
they’re not going to buy mops. So then it was like,
okay, we need to write a grant and get money to help
provide the means for parents.
This nurse highlights the central role of experiential
learning in generalist practice and its logical extension
into the development of population-focused skills. Her
extensive experience in case managing families with lead
poisoning allows her to see the limitations of patient
education and moves her into a leadership position in a
lead coalition to address systemic issues. She has moved
beyond the beginner’s unqualified, technical understand-
ing of patient education as a magic bullet to improve
health (see Part 1, p. 8). She articulates a refined under-
standing and, indeed, a sense of inquiry about what it
takes to improve the health of individuals, families, and
communities. This more situated understanding includes
an appreciation for how the family’s concerns, …

Moving Upstream Becoming a PublicHealth Nurse, Part 2Lee .docx

Recommended

Recommended

More Related Content

More from griffinruthie22

More from griffinruthie22 (20)

Recently uploaded

Recently uploaded (20)

Moving Upstream Becoming a PublicHealth Nurse, Part 2Lee .docx