Becoming a Public Health Nurse,

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: smithli@slu.edu

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, priorities, actions, and resources are embedded within larger social- structural conditions and resources. She has gained an insider understanding that mitigates against blaming families and that moves her to think and act upstream.

This nurse’s story also reveals how ‘‘knowing the com- munity’’ is grasped in its particularities. While admitting that she could have applied theoretical reasoning about community education—‘‘the fundamentals of community education’’—without an experiential base, she argues that her population-focused skills are improved by her gener- alist PHN experience with individuals and families. Other excerpts from her three interviews confirm how she con- tinuously brings her knowledge of this community, not only to the families she visits, but also to other forums and community groups. As a member of a community- development board, she brings the missing voices of marginalized neighborhood residents and articulates their concerns to non-community dwelling stakeholders. She has also become very experienced in refugee health from visiting families relocated into the neighborhood and has worked to address this population’s unrecognized mental health needs. These are only some of the ‘‘particularities’’ she knows firsthand from her generalist practice.

DISCUSSION

While public health nurses enter the field equipped with theories from the classroom and agency guidelines, the development of their expertise rests on the clinical know- how that comes from being ‘‘schooled’’ by ‘‘the real world.’’

The ‘‘real world’’ is too complex, unpredictable, inscrutable, and ‘‘messy’’ to be captured in formulas or theories (Benner & Wrubel, 1989; Dreyfus, 1991; Schon, 1983/ 1994). Clinicians’ actions in the world must therefore inevitably rely on experience, perceptiveness, judgment, improvisation, and ‘‘the kind of insight demanded by concrete cases’’ (Dunne, 1993, p. 273). The accounts of both less-experienced and more-experienced public health nurses confirm how the knowledge and analytical reasoning of the classroom are revised, filled in, or supplanted with the ‘‘real world’’ of practice. This experiential background is precisely what new public health nurses lack when they enter the field and why each clinical situation is described as a learning experience (Chesla, 1996). Their practical learning from the ‘‘real world’’ often confirmed and ‘‘par- ticularized’’—as one nurse aptly noted—the PHN theory taught in their formal education. Although the public health nurses had learned about the relationship between the community and its members in theory, it was their practical experience that made sense of the theory. Cumu- lative experience with individuals and families from a neighborhood or population deepened their understanding of the social embeddedness of objectively defined health indicators.

As public health nurses become conversant with the realities of clients’ lives, they learn to see how health beliefs and practices are shaped, reinforced, or under- mined within complex webs of meaning and material resources, from the family and neighborhood up to the state and nation. This situated knowledge replaces utopian, objective norms for health and teaches nurses to be realistic about outcomes with ‘‘a view of the whole context,’’ as one nurse commented. Outcomes based on aggregate data and textbook interventions hide the con- text and the particularities of the specific case and are therefore an insufficient guide for clinical reasoning. In expert practice, scientific reasoning remains in the background for successful practice and yields to experi- ence, judgment, and clinically based notions of success (Benner, 1984; Benner, Hooper-Kyriakidis, & Stannard, 1999; Benner, Tanner, & Chesla, 1996; Dunne, 1993; SmithBattle & Diekemper, 2001).

Our data confirm how experiential learning, habits of responsiveness, and a community of seasoned colleagues and supervisors are crucial for supporting rank beginners and for extending their perceptual grasp to the big picture and practical knowing of the community. These skills are evident in their increased powers to notice how clients on their caseload face issues that require a community response. Knowing the community was also fundamental to the aggregate skills of advocacy, policy formation, and program development that several of the less-experienced

100 Public Health Nursing Volume 21 Number 2 March/April 2004

nurses had dove into by the third year of practice. This natural development in upstream thinking recalls the practice wisdom handed down in first-person accounts of PHN practice (Wald, 1915; Milio, 1970) and supports conclusions from our first study (Diekemper, SmithBattle, & Drake, 1999a,b).

Situated understanding and seeing the big picture rely upon engagement with clients and connection to the com- munity that have received little attention in the theories and principles for population-focused practice. The focus on nursing and public health theory overlooks the import- ance of knowing the community over time and how the public health nurse’s presence in the community leads to the identification of patterns that may escape more for- mal community assessments (Conley, 1995; Diekemper et al., 1999a,b). In light of these findings, we believe that it is a serious mistake in undergraduate curricula to emphasize population-focused care without including individual and family clinical experiences. Of course, nursing students will need experienced public health nurses as instructors to help them develop beginning perceptual and relational skills in home visiting and to see connections between individuals, families, and the broader community in which they practice. But meeting this challenge is far better for our specialty than graduat- ing students who enter PHN practice without clinical preparation in generalist PHN practice.

While we applaud the inclusion of population-focused clinical experiences in PHN undergraduate education, and believe that moving upstream is a natural outgrowth of the public health nurse’s cumulative experience and connections to the community (Conley, 1995), we resist efforts that dichotomize individual and family care from aggregate care at the undergraduate or graduate levels. As our data suggest, the broad scope of PHN practice is promoted when nurses begin to grasp the big picture and skills of responsiveness from first being engaged with individuals and families. Unless the public health nurse is constrained from moving upstream (e.g., due to large caseloads, funding and reimbursement systems, etc.), the public health nurse’s integral connection to the com- munity and experiential learning from individuals and families often pulls the nurse into advocacy efforts, com- munity development, program planning, and policy for- mation, sometimes with great passion. Of course, sound mentoring by experienced colleagues and supervisors helps less-experienced public health nurses to recognize the connections and relationships between the health and well-being of individuals and communities. This practical acumen does not replace formal education in public health, but public health principles are perhaps ideally employed when melded to the clinical know-how that

arises in real-world practice. When public health nurses have the flexibility and administrative support to respond to the needs they identify in the field from their quasi- insider status in dialogue with other public health col- leagues and the communities they serve, clinical practice is enriched and enriching. The experiential learning that occurs from being the eyes and ears of the community over time deserves to be validated, strengthened, rein- forced, and studied for its contributions to the health and well-being of individuals, families, communities, and populations.

This study was designed to reveal patterns and transi- tions in PHN skill development as expressed in the text. Because the interpretive method does not claim an objec- tive world distinct from our concerns and engagements, the realist assumptions and methodological procedures of empirical–rational research cannot be used to judge the validity of interpretive work (Angen, 2000; Benner, 1994; Kvale, 1995; Leonard, 1989). Certainly, the quality of the text is an important consideration to assure that conclu- sions are not based on ‘‘thin’’ data, spurious comments, or trivial meanings and patterns. In this study, the large sample size, the inclusion of public health nurses with varied levels of experience, the supplementation of inter- views with observations and field notes, and repeated interviews with less-experienced public health nurses not only provided a dense text but also created multiple avenues for moving in the hermeneutic circle, analyzing the text, and refining our interpretation. For example, multiple data sources made it possible to contrast and compare patterns and shifts in meaning among individual public health nurses as they gained experience and to look for similarities and differences between public health nurses with varying levels of experience. In addition to the volume and quality of the data, our interpretive sessions were invaluable for exploring nuances in the text, for contesting our positions and preconceptions with evidence and counter-evidence in narrative data, and for documenting our understanding in detailed case summaries.

Because the process of understanding a text involves a dialogue between the text and the interpretive questions brought to it, evaluating an interpretation necessarily involves judgment regarding the plausibility, coherence, and practical significance of the study (Angen, 2000; Kvale, 1995). Members of the PHN community, includ- ing the reader, participate in the process of validation by considering the following questions: Is the interpretation convincing? Does it make sense of the data presented and perhaps illuminate experiences the reader may have had with students or public health nursing staff? Does it cultivate an appreciation for how clinical know-how unfolds with experience? Is the reader reminded of the

SmithBattle et al.: Moving Upstream, Part 2 101

struggles and excitement, inevitable blind spots, and awkward flat-footedness of early career experiences? Have readers also experienced how the development of skill moved them upstream? With respect to the signifi- cance of the study, do study findings suggest practical implications for how staff should be oriented, mentored, supervised, and evaluated? Finally, do study conclusions legitimate clinical practice as a source of reasoning and know-how? In presenting our findings to several audi- ences, including the study participants, we have found that public health nurses often identify with the clinical vignettes and are prompted by the narratives and dis- cussion to share some of their own, demonstrating the communicative validity of the study (Kvale, 1995).

Although we collected a large amount of data, the relatively small cohort of less-experienced public health nurses precluded making more refined distinctions between nurses of varied levels of experience. This limit- ation could be addressed by pooling greater numbers of public health nurses with similar levels of experience with a regional or national study. A larger study would refine our conclusions and could identify additional distinctions in the practical learning that occurs among public health nurses over their careers. We welcome such clarification and look forward to the time when experiential know- how is examined as the rich source it is for articulating the practical reasoning and ethos of PHN practice.

ACKNOWLEDGMENTS

We thank the nurses who participated in this study, the Beaumont Faculty Development Fund of Saint Louis University for funding this research, and two anonymous reviewers who offered thoughtful suggestions.

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