The Henry Street Consortium Population-Based Competencies for Educating Public Health Nursing Students

Public Health Nursing Vol. 28 No. 1, pp. 78 90 0737-1209/r 2010 Wiley Periodicals, Inc. doi: 10.1111/j.1525-1446.2010.00900.x SPECIAL FEATURES: EDUCATION The Henry Street Consortium Population-Based Competencies for Educating Public Health Nursing Students Marjorie A. Scha er, Sharon Cross, Linda O. Keller, Pamela Nelson, Patricia M. Schoon, and Pat Henton ABSTRACT The Henry Street Consortium, a collaboration of nurse educators from universities and colleges and public health nurses (PHNs) from government, school, and community agencies, developed 11 population-based competencies for educating nursing students and the novice PHN. Although many organizations have developed competency lists for experts, the Consortium developed a set of competencies that clearly define expectations for the beginning PHN. The competencies are utilized by both education and practice. They guide nurse educators and PHNs in the creation of learning experiences that develop population-based knowledge and skills for baccalaureate nursing students. Public health nursing leaders use the competencies to frame their expectations and orientations for nurses who are new to public health nursing. This paper explains the meaning of each of the 11 population-based competencies and provides examples of student projects that demonstrate competency development. Strategies are suggested for nurse educators and PHNs to promote effective population-based student projects in public health agencies. Key words: collaboration, partnerships, population-based nursing, public health nursing competencies, public health nursing education. Marjorie A. Scha er, Ph.D., R.N., is Professor, Bethel University, St. Paul, Minnesota. Sharon Cross, M.S.P.H., B.S.N., is Public Health Nurse Clinician, Department of Public Health,St. Paul Ramsey County,St. Paul, Minnesota. Linda O. Keller, D.N.P., R.N., F.A.A.N., is Clinical Associate Professor, School of Nursing, University of Minnesota, St. Paul, Minnesota. Pamela Nelson, M.S., R.N., is Assistant Professor, Bethel University, St. Paul, Minnesota. Patricia M. Schoon, M.P.H., R.N., P.H.N., Retired, Maternal Child Health, Family Health, Chisago County Public Health Department, St. Catherine University, St. Paul, Minnesota and Distance Clinical Instructor, University of Wisconsin, Oshkosh, Wisconsin. Pat Henton, R.N., P.H.N., Maternal Child Health, Family Health, Chisago County Public Health Department, North Branch, Minnesota. Correspondence to: Marjorie A. Scha er, Bethel University, 3900 Bethel Drive, St. Paul, MN 55112. E-mail: m-scha er@bethel. edu The Henry Street Consortium, established in 2001, is a group of five baccalaureate schools of nursing and the 13 local health departments in the state of Minnesota that developed a model for collaboration between public health nursing education and practice. One of their most important outcomes was the development of the Entry Level Population-Based Public Health Nursing Competencies (Minnesota Department of Health, 2004), a set of entry-level competencies that met the needs of both education and practice, and was easily understood by students and novice nurses in public health nursing. The overarching goal of the Consortium was to redesign clinical experiences to be populationbased, which meant that they: (1) focused on entire populations, (2) were guided by assessment of the community s health, (3) incorporated the determinants of health, (4) addressed all levels of prevention, and (5) included all levels of practice (Keller, Strohschein, Lia- Hoagberg, & Schaffer, 2004) (Table 1). Existing competency sets defined competencies for expert public health nurses (PHNs). The complexity 78

TABLE 1. Entry-Level Public Health Nursing Competencies Schaffer et al.: Population-Based Public Health Nursing Competencies 79 1. Applies the public health nursing process to communities, systems, individuals and families 2. Utilizes basic epidemiological principles (the incidence, distribution, and control of disease in a population) in public health nursing practice 3. Utilizes collaboration to achieve public health goals 4. Works within the responsibility and authority of the governmental public health system 5. Practices public health nursing within the auspices of the nurse practice act 6. Effectively communicates with communities, systems, individuals, families, and colleagues 7. Establishes and maintains caring relationships with communities, systems, individuals, and families 8. Shows evidence of commitment to social justice, the greater good, and the public health principles 9. Demonstrates nonjudgmental and unconditional acceptance of people different from self 10. Incorporates mental, physical, emotional, social, spiritual, and environmental aspects of health into assessment, planning, implementation, and evaluation 11. Demonstrates leadership and detail of these competency sets created a barrier for nursing students in understanding the fundamentals of public health nursing. The Henry Street Consortium was challenged to translate abstract competencies into specific, achievable goals for undergraduate nursing students. The Henry Street Consortium competencies are clear, action-oriented, and integrate important values and attitudes needed to promote the health of populations. These competencies engage nursing students and novice PHNs in learning the essential expectations for public health nursing practice. Background on Existing Competencies, Essentials, and Standards Competencies are expectations that guide public health nursing practice (Carter, Kaiser, O Hare, & Callister, 2006). They integrate the skills, knowledge, and attitudes needed by a PHN for effective practice (Council on Linkages Between Academia and Public Health Practice, 2001). The Quad Council of Public Health Nursing Organizations (2004) adopted the Core Competencies for Public Health Professionals developed by the Council on Linkages Between Academia and Public Health Practice in 2001 and revised in 2009 (Public Health Foundation, 2009). The Core Competencies provide a structure for the training needs of public health professionals, development of job descriptions and performance review criteria, and assessment of knowledge gaps. The Quad Council (American Nurses Association [ANA], American Public Health Association, Association of Community Health Nursing Educators [ACHNE], and the Association of State and Territorial Directors of Nursing) identified the applicability of the competencies to generalist and expert PHNs (Association of State and Territorial Directors of Nursing, 2003). While this competency framework is effective in guiding the work of expert public health professionals, many of the competencies are beyond the basic knowledge and skills expected of undergraduate nursing students. Several educational organizations have established essentials for baccalaureate education that define the foundational knowledge and skills necessary for the education of nurses. The Essentials of Baccalaureate Education for Professional Nursing Practice, developed by the American Association of Colleges of Nursing (AACN) (2008), identifies the curricular elements and framework for building the baccalaureate nursing curriculum for the 21st century (p. 3). One of these elements focuses on clinical prevention and population health. The ACHNE developed educational essentials that many academic programs use for developing curricula and teaching-learning strategies to prepare PHNs (2000). Although both the AACN Baccalaureate Essentials and the ACHNE Core Knowledge areas are very useful guides for determining the content to include in the public health nursing curriculum, their use is not easily translated for either practicing PHNs in the field or public health nursing students in their clinical experiences. ANA (1999, 2007) developed standards of practice for public health nursing that outline the expectations of the professional role within which all public health registered nurses should practice (2007, p. vii). Important public health nursing concepts include determinants of health, epidemiology, partnership, policy development,

80 Public Health Nursing Volume 28 Number 1 January/February 2011 population, and social justice. The Public Health Nursing Scope and Standards of Practice incorporates recommendations from Institute of Medicine (IOM) reports for educating the public health workforce (IOM, 1988, 1995, 2003a, 2003b). Several of these reports emphasize the linkages and relationships among multiple factors (or determinants) affecting health (ANA, 2007, p. 42). Although these important standards provide a framework for public health nursing practice, they do not clearly identify the activities that PHNs routinely perform or the basic skills that public health nursing students are expected to master. Development of Competencies Consortium members reviewed existing sets of public health nursing competencies and other sources that reflected public health nursing activities (ACHNE, 2000; Allegrante, 2001; ANA, 1999; Core Public Health Functions Steering Committee, 1994; Council on Linkages Between Academia and Public Health Practice, 2001; Cross, Block, & Josten, 2003; Deiman, 1988; Gebbie, n.d.; Knox, 1985; Missouri Department of Health Council of Public Health Nursing, n.d.; North Dakota State University, n.d.; U.S. Department of Health and Human Services, 1997). Additional sources included public health nursing position descriptions from counties represented in the Consortium, public health nursing course syllabi, and Minnesota law related to public health nursing. Articles written by public health nursing experts were also reviewed for the skills, knowledge, and attitudes that underlie public health nursing practice (Gebbie & Hwang, 2000; Kaiser & Rudolph, 1996; Kenyon, Smith, Hefty, Bell, & Martaus, 1990; Nickel, 1995; Snow, Hefty,Kenyon,Bell,&Martaus,1992;Zerwekh,1990). Consortium members divided into four workgroups consisting of equal numbers of public health nursing educators and public health nursing staff. The groups analyzed the following practice frameworks for the skills, knowledge, and attitudes needed by PHNs: Core Competencies for Public Health Professionals (Council on Linkages Between Academia and Practice, 2001), Essentials of Baccalaureate Nursing Education for Entry Level Community/Public Health Nursing (ACHNE, 2000), Scope and Standards of Public Health Nursing Practice (ANA, 1999), and Essential Public Health Services (Core Public Health Functions Steering Committee, 1994). In order to meet the needs of both practice and education, existing documents were reviewed through dual lenses. From the practice perspective, the workgroups analyzed health department job descriptions, performance evaluations, interview questions, and job advertisements and compared them with the skill, knowledge, and attitudes identified from the existing frameworks. From the education perspective, the workgroups examined public health nursing course syllabi, clinical student performance evaluation tools, learning activities, and assignment guidelines and conducted a similar analysis. The resulting competency lists from each of the four workgroups were compiled and synthesized to create a single list of competencies. The entire membership reviewed numerous iterations and refinements of the list, ultimately yielding the desired set of competencies that represented both practice and education. Table 2 provides a comparison of the Henry Street Consortium competencies with competency and three other practice frameworks in use at the time of competency development. Competency Use by Educators and Public Health Nurses Public health nursing educators have used the Henry Street Competencies to both frame learning and assess baccalaureate nursing students accomplishment of the population-based public health nursing competencies. Public health nursing educators at one university in the Consortium developed a portfolio assignment that asked students to reflect on learning experiences consistent with the competencies, identify relevant population-based public health concepts, and evaluate their growth and preparation for future nursing practice (Schaffer, Nelson, & Litt, 2005). The competencies also provide a clear and straightforward guide for PHN managers and supervisors in health departments to frame expectations for entry-level performance for the beginning PHN. In partnership with educators, PHNs use the competencies as a guide to create student-learning experiences that are consistent with key expectations of both nursing faculty and health department staff. This article explains the essence of each competency and presents student pro-

Schaffer et al.: Population-Based Public Health Nursing Competencies 81 TABLE 2. Comparison of Henry Street Entry-Level PHN Competencies to Other Public Health Practice Frameworks Entry-Level Population- Based PHN Competencies Henry Street Consortium, 2003 11 competencies #1 Applies the public health nursing process to communities, systems, individuals and families #2 Utilizes basic epidemiological principles (the incidence, distribution, and control of disease in a population) in public health nursing practice #3 Utilizes collaboration to achieve public health goals #4 Works within the responsibility and authority of the governmental public health system #5 Practices public health nursing within the auspices of the nurse practice act #6 Effectively communicates with communities, systems, individuals, families, and colleagues #7 Establishes and maintains caring relationships with communities, systems, individuals, and families #8 Shows evidence of commitment to social justice, the greater good, and the public health principles #9 Demonstrates nonjudgmental and unconditional acceptance of people different from self Core Competencies for Public Health Professionals Council on Linkages, 2001; Quad Council [ANA, APHA, ACHNE, ASTDN] competencies, 2003 18 domains Analytic/assessment skills Policy development and program planning skills Cultural competency skills Community dimensions of practice skills Analytic/assessment skills Community dimensions of practice skills Basic public health sciences skills Communication skills Leadership and systems thinking skills Policy development and program planning skills Cultural competency skills Community dimensions of practice skills Financial planning and management skills Leadership and systems thinking skills Analytic/assessment skills Policy development and program planning skills Community dimensions of practice skills Communication skills Cultural competency skills Financial planning and management skills Communication skills Cultural competency skill Leadership and systems thinking skills Analytic/assessment skills Communication skills Leadership and systems thinking skills Communication skills Cultural competency skills Leadership and systems thinking skills Scope and Standards of Public Health Nursing American Nurses Association, 1999 6 standards of care; 8 standards of professional performance Standards of care Assessment; diagnosis; outcome identification; planning; assurance; evaluation Standards of care Assessment; diagnosis; outcome identification; planning; assurance; evaluation Collaboration Collegiality Quality of care Performance appraisal Resource utilization Standards of care Assessment; diagnosis; outcome identification; planning; assurance; evaluation Education Quality of care Education Ethics Quality of care Ethics Ethics Essential Public Health Services Core Public Health Functions Steering Committee (1994) 10 core functions Monitor health Diagnose and investigate Inform, educate, and empower Link to/provide care Evaluate System management and research Diagnose and investigate Mobilize community partnerships Link to/provide care Develop polices Enforce laws Assure competent workforce Link to/provide care Inform, educate, and empower Mobilize community partnerships Link to/provide care Inform, educate, and empower Mobilize community partnerships Develop polices Inform, educate, and empower Mobilize community partnerships

82 Public Health Nursing Volume 28 Number 1 January/February 2011 TABLE 2. Continued. Entry-Level Population- Based PHN Competencies Henry Street Consortium, 2003 11 competencies #10 Incorporates mental, physical, emotional, social, spiritual, and environmental aspects of health into assessment, planning, implementation, and evaluation #11 Demonstrates leadership Core Competencies for Public Health Professionals Council on Linkages, 2001; Quad Council [ANA, APHA, ACHNE, ASTDN] competencies, 2003 18 domains Analytic/assessment skills Cultural competency skills Policy development and program planning skills Communication skills Community dimensions of practice skills Financial planning and management skills Leadership and systems thinking skills Scope and Standards of Public Health Nursing American Nurses Association, 1999 6 standards of care; 8 standards of professional performance Standards of care Assessment; diagnosis; outcome identification; planning; assurance; evaluation Quality of care Performance appraisal Education Collegiality Ethics Collaboration Resource utilization Essential Public Health Services Core Public Health Functions Steering Committee (1994) 10 core functions Inform, educate, and empower Link to/provide care Mobilize community partnerships Develop polices Assure competent workforce jects that illustrate learning experiences for building skill in and understanding each competency. Evidence for Population-Based Student Projects Henry Street Consortium members from health departments submitted written descriptions of collaborative projects. All of the projects were populationbased and engaged public health nursing students in aspects of assessment, planning, implementation, or evaluation. Traditional undergraduate students often worked on projects in groups, while R.N. to B.S.N. students generally worked one on one with a preceptor or staff team. Although a specific project is ascribed for each competency, the projects often represented more than one competency. All population-based student projects are grounded in actual community assessments and community plans completed by public health staff in local health departments. Brownson (2003) declares that evidence-based public health must include data and scientific evidence, input from community members, input from other stakeholders, and professional experience. The community health plans are based on public health data that health department staff analyze to determine priority health needs. The decisions about priority needs are influenced by input or preferences from community members and leaders. Local health departments then develop an action plan to respond to the identified needs (Minnesota Department of Health, 2009). They use published research when available and expert opinion developed from professional practice experience to determine the action plan. Local health department staff used community health data and priorities from the community health plans to select and guide student projects. In addition, the interventions featured in the project are supported by the Public Health Intervention Wheel (Keller et al., 2004), a practice-based, evidence-supported model. In 2001, the evidence base of the Wheel was validated by a rigorous critique by hundreds of regional and national PHN experts. The Wheel depicts how PHNs improve population health through interventions with communities, identified individuals within communities, and the systems that impact health. It includes 17 interventions: surveillance, disease and other health threat investigation, outreach, screening, case-finding, referral and follow-up, case management, delegated functions, health teaching, counseling, consultation, coalition building, collaboration, community organizing, advocacy, social marketing, and policy development and enforcement (see Table 3).

Schaffer et al.: Population-Based Public Health Nursing Competencies 83 TABLE 3. Evidence Supporting Student Projects All of these student projects were based in actual community need and contributed to meeting the health improvement goals of the local health departments Public health interventions and practice level Project Asthma tool kit for parish nurses Health teaching and faith-based communities (community) Best practices for head lice management Teen labor and delivery classes Natural disaster preparedness Dental health screening Consultation (community and systems) Policy development and enforcement (community) Collaboration (community) Health teaching (community) Community organizing (community) Outreach (community) Policy development (systems) Health teaching (individual) Outreach (community) Policy development (systems) Screening (community) Surveillance (community) Teen program satisfaction survey Collaboration (community) Policy development (systems) Surveillance (community) Revision of pregnancy free club survey Latino health survey Early childhood screening outreach Walkability project Analysis of state survey on students Source: Keller et al. (2004). Advocacy (community) Collaboration (community) Counseling (individual) Advocacy (community) Collaboration (community) Health teaching (community) Outreach (community) Surveillance (community) Collaboration (community) Outreach (community) Screening (community) Community organizing (community) Policy development (systems) Social marketing (community) Outreach (community) Policy development (systems) Surveillance (community) Entry level population-based public health nursing competencies Competency 1: Applies the public health nursing process. This competency addresses PHN use of the nursing process in their work in public health settings. PHNs expand the nursing process to apply to communities and systems in addition to individuals and families. One of the most important skills for this competency is conducting a community assessment and determining community priorities. Assessment of populations includes analysis of the health determinants that contribute to the health status of populations. Determinants of health include the social, economic, perinatal, nutritional, behavioral, and environmental factors that influence the health status of population groups (Novick & Mays, 2001). Health statistics and health program evaluation data are analyzed to help determine priority population health needs. PHNs use existing partnerships and develop new partnerships in planning evidence-based interventions that have the greatest potential for improving the health of the population. PHNs, in partnership with others, select all applicable levels of practice (community, systems, and individual/family) and all relevant levels of prevention (primary, secondary, and tertiary). The Public Health Intervention Wheel (Keller et al., 2004) provides a framework for selecting population-based public health interventions. The evaluation step of the nursing process involves measuring the outcomes of public health nursing interventions and documenting both process and outcome. An R.N. to B.S.N. degree student applied the public health nursing process when working on the development of an asthma tool kit. Together with health department staff, the student contributed to assessing the need for education about asthma, planning the project, and creating the tool kit for parish nurses to use in faith-based communities. The student searched the Internet, reviewed existing resources for information about asthma and asthma tool kits, and developed and assembled a comprehensive tool kit, which included the symptoms, triggers, and management of asthma. The tool kit was tailored for faith-based communities and represents a community-level intervention for the asthma population in faith-based settings. Competency 2: Utilizes basic epidemiological principles. This competency focuses on PHNs utilization of the science of epidemiology to identify

84 Public Health Nursing Volume 28 Number 1 January/February 2011 and control health problems in populations. Through application of the epidemiological process, public health nursing programs and services respond to health concerns identified in the community assessment. PHNs use epidemiological evidence to identify interventions that increase protective factors for health and reduce risk factors that contribute to disease, illness, and injury. Application of epidemiological principles requires knowledge about the incidence and distribution of disease in a population and strategies for reducing disease. Analysis of the interactions of the host, agent, and environment (the epidemiological triangle) is necessary to plan interventions for protecting health and reducing the risk factors that contribute to the incidence of disease. A student group used the epidemiological process to respond to a growing head lice problem in a community; they surveyed clinics, school nurses, and pharmacies to determine community norms for head lice treatment. Health department staff used the survey findings to develop pediculosis treatment and prevention guidelines based on best practices. Students disseminated the guidelines to community providers; many providers changed their recommendations for the treatment of pediculosis. The health department became known as a helpful and reputable source for information and the community benefited through increased knowledge of tools for safe and effective head lice treatment (Monsen & Keller, 2002). The practice change in head lice treatment focused on both community- and systems-level interventions for populations affected by pediculosis. Competency 3: Utilizes collaboration. An essential skill for PHNs is the ability to collaborate with colleagues, community organizations, and clients to deliver effective public health services. PHNs collaborate with interdisciplinary community partners to achieve common public health goals for individuals, families, and communities. Individuals representing a broad range of disciplines, organizations, and services collectively come together for joint action to respond to community needs and enhance community assets. The ability to initiate and maintain partnerships is essential to the effective practice of population-based public health nursing. Nursing students partnered with a health department, school district, childbirth educators, and faculty to provide labor and delivery classes for a teen population. A group of students met with health department staff and community partners to discuss expectations for program content. Students developed class outlines and lesson plans, facilitated five labor and delivery classes, engaged and interacted with teens, and presented the project to public health staff at the end of the practicum. The student-developed curriculum was integrated into the school district program. This population-based, community-focused project assisted the health department to meet its community health priority of reducing the risk of premature births and low-birth-weight babies. Competency 4: Works within the governmental public health system. PHNs who work in official health departments must consider the governmental scope of their work. PHNs understand the relationship among the federal, state, and local levels of the public health system and identify their organization s responsibilities within the context of the Essential Public Health Services and Core Functions (assessment, policy development, and assurance). Critical to PHN practice is the nurse s understanding of the independent public health nursing role as described in the Scope and Standards of Public Health Nursing (ANA, 2007) and legal issues such as public health nuisance, quarantine, commitment laws, data privacy, and mandated reporting. Additionally, the PHN must be knowledgeable and adept at using multiple funding sources and community resources. A student learned about the organization and responsibilities of governmental systems though working on an emergency preparedness project. The student developed a resource manual that included state health department emergency preparedness resources, natural weather disaster risk maps, common weather-related trauma and injury risks, and mental health resources. The student s work culminated in the Disaster Event Injury and Needs Assessment Tool. This tool was used to document the needs, injuries, client complaints, and plan of care for evacuees. When Hurricane Katrina evacuees moved into the county, the tool was used to assess the needs of this population. The project addressed communityfocused interventions and assisted health department staff to efficiently and effectively assume their governmental responsibility to meet the needs of a relocated population following a natural disaster. Competency 5: Practices within the nurse practice act. This competency addresses the legal requirements for the practice of public health nursing.

Schaffer et al.: Population-Based Public Health Nursing Competencies 85 All PHNs practice under the provisions of the nurse practice act in their individual states. PHNs distinguish between actions delegated to them, such as giving immunizations or distributing contraceptives, and many of the independent functions identified on the Public Health Intervention Wheel, such as health teaching, counseling, and community organizing (Keller et al., 2004). Their scope of practice requires ensuring confidentiality for all clients and meeting the ethical, legal, and professional requirements outlined in the nursing practice act. The establishment of professional boundaries is particularly important in a community environment in which the boundaries between professional and personal relationships can be more easily blurred. For those states that have PHN certification or registration, the PHN also needs to understand the requirements and scope of practice specific to that state. Students learned about independent public health nursing functions that are covered in the state nurse practice act through their work on an oral health project (focusing on the interventions of surveillance, outreach, screening, health teaching, and policy development). They collaborated with PHNs who had the goal of increasing the detection of and interventions for poor oral health of pregnant teens served by the health department. Students completed an assessment through key informant interviews and an analysis of health determinants, developed an oral assessment tool for PHNs to use in their practice, and created a brochure about oral health practices for pregnant teens. The PHNs now routinely include assessment questions on dental health for pregnant teens and the oral assessment tool has been modified for use with all family health client populations. This project is consistent with a community-level intervention and resulted in a systems change in the oral health assessment for families. Competency 6: Effectively communicates with communities, systems, and individuals. Public health nursing practice requires excellent communication skills, not only to work with individuals and families but with multiple community partners and organizations. PHNs are required to disseminate health messages on numerous topics to diverse populations. They work with the entire community, including clients, county board members, legislators, educators, social workers, environmental health experts, health educators, nutritionists, researchers, physicians, and many others. This competency requires the ability to effectively communicate demographic, statistical, programmatic, and scientific information in an understandable, professional, respectful, culturally sensitive, and accurate manner that promotes desired outcomes. PHNs must also demonstrate competence in utilizing computerized documentation systems and programs for data analysis and reporting. Students learned to effectively communicate evaluation data to decision makers in a project that involved reporting data from a high-risk teen population, which was a resurvey of teen satisfaction with the changes in the services offered. Health department staff, school faculty, and PHNs met with students to review previous survey questions and revise them to address program changes. Nursing students conducted 86 random phone interviews, analyzed and reported data to staff, and recommended program changes. The teen data were combined with other program evaluation data for submission to the county board of commissioners and other program funders. The report provided valuable insights into the factors that influence pregnant and parenting teen behavior and implications for public health nursing practice, contributing to the design of effective community and systems-level interventions. Competency 7: Establishes and maintains caring relationships. Similar to all nurses, PHNs develop relationships with individuals and families. However, PHNs must also be skilled in establishing caring relationships with communities and systems. Important components of a caring relationship include the demonstration of trust, respect, and empathy in interactions. Maintaining effective relationships with community partners and organizations requires following through with commitments and being tactful and diplomatic in all communication. Nursing students learned about the importance of building caring relationships with teen mothers in an alternative school that serves pregnant and parenting teens. Teen mothers in the school have the option of participating in the Pregnancy Free Club, which focuses on delaying a repeat pregnancy while in school (Schaffer, Jost, Pederson, & Lair, 2008). Focus groups revealed that the teen mothers felt that some of the program survey questions were intrusive. In collaboration with PHNs, four nursing students worked together to revise the questionnaire based on

86 Public Health Nursing Volume 28 Number 1 January/February 2011 focus group feedback. This is an individual-level intervention for an adolescent parent population. Through their interactions with the teen mothers, the nursing students were able to establish empathetic and respectful relationships with the teen mothers. Competency 8: Shows evidence of commitment to social justice. PHNs seek health equity for everyone in their communities. PHNs diligently work to reduce the many health disparities that exist. Social justice and respect for the worth of all people, especially the vulnerable, are core values in public health nursing. For this competency, PHNs differentiate between social justice and market justice and are acutely aware of the impact of market justice on health. They promote social justice in all of their interactions, with the goal of contributing to the well-being of populations and ultimately to the greater good. A key public health nursing skill for this competency is advocating for those who do not have a strong voice in making their health needs known. Students addressed health disparities in a Latino population by seeking out the perspectives of the population group. Latino immigrants in a suburban community attended a Catholic Church and sought services from a Latino resource center. The initial group of senior nursing students worked with a public nursing supervisor and resource center staff to develop a culturally sensitive health survey in Spanish. The resource center staff reviewed the translation for quality and accuracy and the health department communication specialist formatted the survey using a culturally appealing design. The survey was administered to the Latino population after church services. In the following semester, a student group from a different school of nursing analyzed the survey and created a report. Later student groups created poster displays that addressed important health needs identified in the survey, including appropriate discipline for children and dental health. Interventions involved community-level assessment and planning educational presentations that targeted the Latino population to increase their access to health care and health education. Competency 9: Demonstrates nonjudgmental/unconditional acceptance of people. PHNs respect other cultures and ways of thinking. Population-based public health nursing practice requires nurses to explore the influence of cultural, social, spiritual, religious, and behavioral factors in all their interactions. PHNs consider and integrate diverse opinions and perspectives into their practice. They interact sensitively and respectfully with populations that are different from self, including differences in culture, socioeconomic status, education, race, ethnicity, gender, sexual orientation, religious background, or age. Nursing students had the opportunity to respect the perspectives and experiences of African American parents in a program improvement project for a child health program. School staff had identified a need to increase the participation of African American families in early childhood screening. In collaboration with the student wellness administrator, nursing students studied state law, reviewed program information, and analyzed community data. They observed the early childhood screening process, surveyed parents, and conducted key informant interviews with the parents. Findings indicated a variety of ways in which parents accessed the program. Students recommended outreach methods to increase parent knowledge and participation in the program, a community-level intervention. As a result of the student recommendations, an additional 15 families enrolled in the program. Competency 10: Incorporates the mental, physical, emotional, social, spiritual, and environmental aspects of health. PHNs integrate the mental, physical, emotional, social, spiritual, and environmental aspects of health into their assessment, planning, implementation, and evaluation. Integrating this holistic approach to health is especially important in PHNs work with community neighborhoods and family environments. Strategies for improving health through addressing environmental issues are particularly applicable to communities and systems. Nursing students completed a project that considered the holistic nature of health in a community through increasing safe and pleasant walking opportunities for community residents. Students collaborated with health promotion staff and their nursing instructor to complete an analysis of walking paths in a city surrounded by rural countryside. A student group divided the city into walking routes of 1.5 2 miles; they rated and scored each route using a checklist and also took photos. Students compiled the data, organized photos, and presented their findings to health department and city officials. Residents and city officials became more aware of safe walking

Schaffer et al.: Population-Based Public Health Nursing Competencies 87 opportunities. As a result, the town received a grant to improve walking paths as part of the Safe Routes to School Program. The project resulted in a community level change for community residents at risk for a sedentary lifestyle. Competency 11: Demonstrates leadership. PHN leaders look for leadership opportunities to initiate strategies that improve the health status of communities. They both engage and build the capacity of others to contribute knowledge and expertise to accomplish needed change. PHN leaders meld their ability to work collaboratively and in partnership with others with their independent and autonomous practice in unstructured environments. PHNs demonstrate leadership when they identify a populationbased issue and seek community solutions to the issue. The effective PHN leader tolerates ambiguity, adapts to change, and maintains flexibility while assuring quality standards. An important leadership strategy for PHNs is creating opportunities to communicate information to key decision makers for the allocation of public health dollars. Students worked with the adolescent health coordinator and a local health department to identify 10 key youth risk-taking behaviors in the Minnesota Student Health Survey. They examined school district data and compared the results with other county and state data. The students then graphed the comparative data and wrote a summary report. The health department incorporated the report into the community assessment they were conducting. The report was also used to inform staff about specific youth risk-taking behavior and assist in establishing adolescent program priorities. The project resulted in communityand systems-focused change. Summary of Henry Street Entry-Level Population-Based Competencies The Henry Street Competencies provide a clear framework for preparing nursing students and novice PHNs for public health nursing practice. The competencies are grounded in the essential content of existing public health nursing competency sets and standards. The Henry Street Competencies provide a refined, focused, and simplified competency list that was developed in partnership between faculty and PHNs from local health departments who actually hire new PHNs. The competencies provide a balanced set of expectations and common language for faculty, students, and PHNs in the practice community. The opportunity for students to share their assessments and projects with professionals, community leaders, and legislators gives them a unique insight into their future professional role. The students demonstrate leadership and receive recognition for real work that contributes to promoting the health and well-being of populations. Strategies for Effective Nursing Student Projects Henry Street members have learned to identify relevant student projects that meet the service-learning requests from local health departments, interests of the students, and educational goals. Although the projects described in this article represent collaboration between schools of nursing and local health departments, many of the projects could be adapted and implemented in nonofficial agencies. Henry Street Consortium members disseminate innovative project ideas and lessons learned at their consortium meetings. Promoting effective student projects required role clarification and a willingness to discuss tensions and conflicts. Through ongoing dialogue, local health departments realized that they are partners in designing effective student-learning experiences. Faculty members became skilled in negotiating projects that are feasible in scope for student learning and also meet the expectations of health departments. Behind the scenes actions contributed to assuring effective student projects. The educator must be involved in all stages of projects, beginning with initial contact of PHNs to identify potential projects 2 months or more ahead of time. Student groups versus a single student broaden the scope of feasible projects and provide the opportunity to learn collaboration skills. In areas where there are multiple schools of nursing that utilize health departments for clinical sites, projects may be divided into components and shared between schools. This allows schools to take on long-term projects based on priority health needs of the community. For example, a student group from one school of nursing can conduct the assessment, a student group from another school of nursing can provide the intervention in the following semester, and a third student group can evaluate the effectiveness of the project. Frequent communication between faculty and nurses in the health department who

88 Public Health Nursing Volume 28 Number 1 January/February 2011 TABLE 4. Strategies for Promoting Effective Nursing Student Projects in Public Health Agencies Public health nurse health department actions Nursing faculty actions Become familiar with student educational level and course objectives Explain projects are determined by community and health department needs Communicate value and usefulness of past student projects Appoint a consistent staff liaison with availability and contact information Explain connection of project goals to public health outcomes Reflect with students on application of public health nursing concepts during project planning and/or implementation Facilitate student presentation of projects Publicize student involvement in public health of community through local media Emphasize population focus of project versus individual focus Match projects to needs of health department and student learning needs Begin collaboration with health department staff early for adequate development time for project ideas and planning logistics Clarify project goals and health department staff and faculty expectations for outcomes of project and contribution to public health Provide health department staff and students with needed contact information Provide direction and consultation to students for project development and implementation Communicate regularly with health department staff about any concerns and student progress Provide information about relevant resources related to project such as Web sites or community agencies

Schaffer et al.: Population-Based Public Health Nursing Competencies 89 coordinate student experiences is essential. For example, faculty should make the course syllabus available to nurses who precept students. In addition, nursing faculty should arrange to meet with health department staff following the completion of the clinical to evaluate projects. Both PHNs and faculty members should seek opportunities to help students reflect on how their activities are population-based. Students are often grounded in a world of acute care to individuals; public health experiences can spur their growth in systems thinking. Finally, celebrate the success of student projects. Publishing the activities in local newsletters and newspapers validates the importance of student work to the public. See Table 4 for a detailed list of suggested strategies that health department staff and nursing faculty members can implement to ensure greater success in collaborative projects. The Henry Street Consortium members, representing nursing practice and education, collaborated to develop the Henry Street Public Health Nursing Competencies. The competencies have been instrumental along with the Public Health Intervention Wheel in guiding nursing students learning experiences. The competencies provide a concise and concrete framework that has engaged nursing students in learning the expectations for public health nursing practice. References Allegrante, J. P. (2001). Continuing-education needs of the currently employed public health education workforce. American Journal of Public Health, 91(8), 1230 1234. American Association of Colleges of Nursing [AACN]. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/education/ pdf/baccessentials08.pdf American Nurses Association [ANA]. (1999). Scope and standards of public health nursing practice. Silver Spring, MD: Author. American Nurses Association [ANA]. (2007). Public health nursing: Scope and standards of practice. Silver Spring, MD: Author. Association of Community Health Nursing Educators [ACHNE]. (2000). Essentials of baccalaureate nursing education for entry level community/ public health nursing. Pensacola, FL: Author. Association of State and Territorial Directors of Nursing. (2003). Quad council PHN competencies. Retrieved from http://www.astdn.org/publication_ quad_council_phn_competencies.htm Brownson, R. C. (2003). Evidence-based public health. Oxford, U.K.: Oxford University Press. Carter, K. F., Kaiser, K. L., O Hare, P. A., & Callister, L. C. (2006). Use of PHN competencies and ACHNE essentials to develop teaching-learning strategies for generalist C/PHN curricula. Public Health Nursing, 23(2), 146 160. Core Public Health Functions Steering Committee. (1994). Essential public health services. Retrieved from http://www.cdc.gov/od/ocphp/nphpsp/ essentialphservices.htm Council on Linkages Between Academia and Public Health Practice. (2001). Core competencies for public health professionals. Washington, DC: Public Health Foundation. Retrieved from https://www.train.org/competencies/ corecompetencies.aspx?tabid=94 Cross, S., Block, D., & Josten, L. (2003). Competencies in public health nursing practice instrument. Minneapolis, MN: University of Minnesota School of Nursing. Retrieved from http:// www.nursing.umn.edu/ccfhpr/resources/ Competencies/home.html Deiman, P. A. (1988). BSN education and PHN practice: Good fit or mismatch? Nursing Outlook, 36(5), 231 233. Gebbie, K., & Hwang, I. (2000). Preparing currently employed public health nurses for changes in the health system. American Journal of Public Health, 90(5), 716 721. Gebbie, K. (n.d). Advance materials for synthesis meeting. New York, NY: Center for Health Policy and Health Services Research, Columbia University School of Nursing. Institute of Medicine [IOM]. (1988). The future of public health. Washington, DC: National Academy Press. Institute of Medicine [IOM]. (1995). Nursing, health, and the environment. Washington, DC: National Academy Press. Institute of Medicine [IOM]. (2003a). The future of the public s health in the twenty-first century. Washington, DC: National Academy Press. Institute of Medicine [IOM]. (2003b). Who will keep the public healthy? Washington, DC: National Academy Press. Kaiser, K. L., & Rudolph, E. J. (1996). In search of meaning: Identifying competencies relevant to evaluation of the community health nurse

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