Getting Your Feet Wet: Becoming a Public Health Nurse, Part 1

Abstract While the competencies and theory relevant to public health nursing (PHN) practice continue to be described, much less attention has been given to the knowledge derived from practice (clinical know-how) and the development of PHN expertise. A study was designed to address this gap by recruiting nurses with varied levels of experience and from various practice sites. A convenience sample of 28 public health nurses and seven administrators/supervisors were interviewed. A subsample, comprised of less-experienced public health nurses, were followed longitudinally over an 18-month period. Data included more than 130 clinical episodes and approximately 900 pages of transcripts and field notes. A series of interpretive sessions focused on identifying salient aspects of the text and comparing and contrasting what showed up as compelling, puzzling, and meaningful in public health nurses’ descriptions. This interpretive analysis revealed changes in understanding of practice and captured the development of clinical know-how. In Part 1, we describe the sample, study design, and two aspects of clinical knowledge development—grappling with the unfamiliar and learning relational skills—that surfaced in nurses’ descriptions of early clinical practice. In Part 2, which is to be published in the next issue of Public Health Nursing (SmithBattle, Diekemper, & Leander, 2004), we explore gradual shifts in public health nurses’ understanding of practice that led to their engagement in upstream, population-focused activities. Implications of these findings for supporting the clinical learning of public health nurses and the development of expertise are described. Key words: clinical knowledge, community health nursing, home visiting, public health nursing. While the competencies and theory relevant to public health nursing (PHN) practice continue to be described (Kenyon et al., 1990; Bramadat, Chalmers, & Andrusyszyn, 1996; Block et al., 2001), much less attention has been given to the knowledge derived from practice (clinical know-how) and the development of PHN expertise. This study was designed to address this gap and to draw on scholarship regarding the role of experience, perception, embodiment, and engaged reasoning in the development of expertise (Schon, 1983/1994; Dunne, 1993; Benner, Tanner, & Chesla, 1996; Dreyfus & Dreyfus, 1996; Benner, 1999, 2000a; Benner, Hooper-Kyriakidis, & Stannard, 1999). In describing the experiential gains, ethical discernment, and perceptual acuity central to clinical expertise in acute care settings, Benner and her colleagues (1984, 1996, 1999, 2000b) have articulated crucial distinctions between theoretical, applied knowledge (knowing-that) and the practical, engaged reasoning (knowing-how) that responds to the salient particulars of a clinical situation. This research program has led Benner to conclude that ‘‘practice is a way of knowing in its own right that must be in dialogue with science and technology’’ (2000b, p. 32). Several researchers have adopted Benner’s approach in examining PHN expertise (McMurray, 1992; Zerwych, We use the terms public health nursing and community health nursing interchangeably. An earlier draft of this paper was presented at the annual meeting of the American Public Health Association Meeting on October 22, 2001 in Atlanta, Georgia. Lee SmithBattle is Professor, Saint Louis University, St. Louis, Missouri. Margaret Diekemper is Associate Professor, Maryville University, St. Louis, Missouri. Sheila Leander is Adjunct Clinical Instructor, Saint Louis University, St. Louis, Missouri. Address correspondence to Lee SmithBattle, Saint Louis University, 3525 Caroline Street, St. Louis, MO 63104. E-mail: Public Health Nursing Vol. 21 No. 1, pp. 3–11 /04 # Blackwell Publishing, Inc. 3 1992a,b; SmithBattle, Drake, & Diekemper, 1997; Diekemper et al., 1999a,b; SmithBattle, Diekemper, & Drake, 1999; SmithBattle & Diekemper, 2001). Although we described several aspects of PHN expertise in our previous study (SmithBattle et al., 1997; Diekemper et al., 1999a,b; SmithBattle & Diekemper, 2001), the small cohort of less-experienced nurses in that study provided limited data from which to generate a fine-grained analysis of skill development. Two years later, upon learning that new public health nurses had been hired in various positions across the metropolitan area, we returned to the field to conduct a second study that would capture patterns and transitions in the skill acquisition of public health nurses. In this article, we describe the sample, study design, and two aspects of beginning practice—grappling with the unfamiliar and learning relational skills—that surfaced in the public health nurses’ early clinical practice. In Part 2, we address additional aspects of clinical learning that led public health nurses to think and act ‘‘upstream.’’ STUDY DESIGN This study was designed within the interpretive phenomenological tradition (Leonard, 1989; Benner, 1994; Benner et al., 1996; Angen, 2000). Because this approach places priority on understanding human action in its own terms, the perspectives of participants are privileged over prevailing theories or methodological procedures. Understanding of varied meanings and patterns is sought, rather than the discovery of unvarying ‘‘essences’’ or an underlying structure of the phenomenon. Participants’ accounts and actions are carefully examined to uncover the taken-for-granted aspects and meanings of a phenomenon that ‘‘reside’’ in human activities. In embarking on this study, we used our professional networks to identify public health nurses employed by schools, parishes, public health departments, neighborhood health centers, and social service agencies in the metropolitan area. Letters were sent to all public health nurses who had completed at least a baccalaureate nursing degree and who had not participated in our earlier study. Thirty-five nurses agreed to participate. Those who had been in PHN practice for less than 3 years were identified as less-experienced public health nurses for study purposes. Among this cohort of public health nurses, four began the study with less than 1 year of PHN experience, six had less than 2 years of experience, and three had been in PHN practice between 2 and 3 years. The 15 public health nurses who had been in practice for more than 3 years were referred to as experienced public health nurses. We also interviewed seven public health nurse supervisors or nursing administrator