EBP

Getting Your Feet Wet: Becoming a Public Health Nurse, Part 1 Lee SmithBattle, R.N., D.N.Sc.,

Margaret Diekemper, R.N., M.S.N., C.S.,

and Sheila Leander, R.N., M.S.N.

Abstract While the competencies and theory relevant to public

health nursing (PHN) practice continue to be described, much

less attention has been given to the knowledge derived from

practice (clinical know-how) and the development of PHN

expertise. A study was designed to address this gap by recruiting

nurses with varied levels of experience and from various practice

sites. A convenience sample of 28 public health nurses and seven

administrators/supervisors were interviewed. A subsample, com-

prised of less-experienced public health nurses, were followed

longitudinally over an 18-month period. Data included more

than 130 clinical episodes and approximately 900 pages of tran-

scripts and field notes. A series of interpretive sessions focused

on identifying salient aspects of the text and comparing and

contrasting what showed up as compelling, puzzling, and mean-

ingful in public health nurses’ descriptions. This interpretive

analysis revealed changes in understanding of practice and cap-

tured the development of clinical know-how. In Part 1, we

describe the sample, study design, and two aspects of clinical

knowledge development—grappling with the unfamiliar and

learning relational skills—that surfaced in nurses’ descriptions of

early clinical practice. In Part 2, which is to be published in the

next issue of Public Health Nursing (SmithBattle, Diekemper, &

Leander, 2004), we explore gradual shifts in public health nurses’

understanding of practice that led to their engagement in

upstream, population-focused activities. Implications of these

findings for supporting the clinical learning of public health

nurses and the development of expertise are described.

Key words: clinical knowledge, community health nursing,

home visiting, public health nursing.

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

Several researchers have adopted Benner’s approach in examining PHN expertise (McMurray, 1992; Zerwych,

We use the terms public health nursing and community health nursing

interchangeably.

An earlier draft of this paper was presented at the annual meeting of the

American Public Health Association Meeting on October 22, 2001 in

Atlanta, Georgia.

Lee SmithBattle is Professor, Saint Louis University, St. Louis,

Missouri. Margaret Diekemper is Associate Professor, Maryville

University, St. Louis, Missouri. Sheila Leander is Adjunct Clinical

Instructor, Saint Louis University, St. Louis, Missouri.

Address correspondence to Lee SmithBattle, Saint Louis University,

3525 Caroline Street, St. Louis, MO 63104. E-mail: [email protected]

Public Health Nursing Vol. 21 No. 1, pp. 3–11

0737-1209/04 # Blackwell Publishing, Inc.

3

1992a,b; SmithBattle, Drake, & Diekemper, 1997; Diekemper et al., 1999a,b; SmithBattle, Diekemper, & Drake, 1999; SmithBattle & Diekemper, 2001). Although we described several aspects of PHN expertise in our previous study (SmithBattle et al., 1997; Diekemper et al., 1999a,b; SmithBattle & Diekemper, 2001), the small cohort of less-experienced nurses in that study pro- vided limited data from which to generate a fine-grained analysis of skill development. Two years later, upon learning that new public health nurses had been hired in various positions across the metropolitan area, we returned to the field to conduct a second study that would capture patterns and transitions in the skill acqui- sition of public health nurses. In this article, we describe the sample, study design, and two aspects of beginning practice—grappling with the unfamiliar and learning rela- tional skills—that surfaced in the public health nurses’ early clinical practice. In Part 2, we address additional aspects of clinical learning that led public health nurses to think and act ‘‘upstream.’’

STUDY DESIGN

This study was designed within the interpretive phenom- enological tradition (Leonard, 1989; Benner, 1994; Benner et al., 1996; Angen, 2000). Because this approach places priority on understanding human action in its own terms, the perspectives of participants are privileged over prevailing theories or methodological procedures. Understanding of varied meanings and patterns is sought, rather than the discovery of unvarying ‘‘essences’’ or an underlying structure of the phenomenon. Participants’ accounts and actions are carefully examined to uncover the taken-for-granted aspects and meanings of a phenom- enon that ‘‘reside’’ in human activities.

In embarking on this study, we used our professional networks to identify public health nurses employed by schools, parishes, public health departments, neighbor- hood health centers, and social service agencies in the metropolitan area. Letters were sent to all public health nurses who had completed at least a baccalaureate nur- sing degree and who had not participated in our earlier study. Thirty-five nurses agreed to participate. Those who had been in PHN practice for less than 3 years were identified as less-experienced public health nurses for study purposes. Among this cohort of public health nurses, four began the study with less than 1 year of PHN experience, six had less than 2 years of experience, and three had been in PHN practice between 2 and 3 years. The 15 public health nurses who had been in practice for more than 3 years were referred to as experi- enced public health nurses. We also interviewed seven

public health nurse supervisors or nursing administrators from the same agencies as the staff participants.

The 13 less-experienced public health nurses were followed longitudinally over an 18-month period. They participated in a group interview at the beginning of the study and were re-interviewed individually at 6-month intervals. They were also observed in clinical activities for a maximum of 6 hours and debriefed. Field notes were recorded as soon as possible after leaving the field. The 15 experienced public health nurses were interviewed once individually to refine our understanding of clinical expertise. During group and individual interviews, public health nurses were asked to describe clinical situations in which they had ‘‘made a difference’’ or which were espe- cially difficult in promoting the health and well-being of an individual, family, or community. Interviews were tape recorded and transcribed verbatim. Data included more than 130 clinical episodes and approximately 900 pages of transcripts and field notes. The individual, tape-recorded interviews with the seven supervisors/administrations provided background for understanding how agencies organized, supervised, and funded PHN services.

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

4 Public Health Nursing Volume 21 Number 1 January/February 2004

abilities, skills of responsiveness, and clinical reasoning. When different interpretations surfaced among the team members, we returned to the text to review, clarify, and argue for our different understandings until consensus was reached.

Codes were then identified for entering data into Ethnograph (Seidel, 1998). While this qualitative software package allowed for easy retrieval of clinical vignettes, our interpretive summaries proved indispensable in recovering the details, nuances, variations, and similarities that we had noted in the text. After the study was com- pleted, all participants were invited to a public health nurse or a supervisor/administrator session to discuss the findings. Two dimensions of early practice—grap- pling with the unfamiliar and learning relational skills— are now described with clinical vignettes and interpretive commentary.

GRAPPLING WITH THE UNFAMILIAR

Narratives from inexperienced public health nurses cap- tured their effort, anxiety, and excitement as well as their limited perceptual abilities and practical know-how. For example, the first interview conducted with the least experi- enced nurse in our sample, who had been hired 3 months earlier after a year of hospital experience, revealed an over- riding self-consciousness in making telephone calls and scheduling visits, entering the home and interacting with clients, understanding and describing her role to others, and acting in clinical situations. In her next interview 6 months later, the clinical world was no longer so utterly foreign:

[Int: Now that you’ve been here almost a year, does it

still feel new to you?] No, it’s feeling more familiar.

I’ve kind of developed standard approaches [from my

colleague] for different situations…I have my standard

lines for when I call patients to set up appointments.

The standard things that I go through when I go for a

prenatal appointment, or lead, or hypertension, or

problems with medications. So while each one is dif-

ferent, I’ve kind of developed my standard approaches,

which I then modify for each patient. [Int: So that feels

a lot more comfortable to you now?] Much. Much.

[Int: And what about visits? Which ones are you feeling

more comfortable with?] I’m feeling a lot more

comfortable with the postpartum and prenatals.

I know more of what I need to ask, what I need to

assess, what’s important to address, and ways to lead

the conversation into it, so it doesn’t feel and seem so

awkward for me and the patient. [Int: Does it still feel

pretty effortful to you at this point?] Kind of half and

half. It depends on the situation. Some are very effort-

ful…At first, doing newborn and postpartums were

kind of effortful. I didn’t have a whole lot of experi-

ence with them…It’s getting better. My knowledge

base is improving and I’ve been developing my whole

spiel and system for those home visits. But, when I get

into more complicated [ones], that’s when it gets more

effortful…Generally, any of my first visits of a certain

type have been really effortful, but the more my

knowledge base tends to grow and the resources I’m

aware of, it’s gotten better.

As this nurse suggests, repetition with similar clinical situations is required for beginners to grasp what is rele- vant and to gain skill in knowing how to assess, address, and ‘‘lead the conversation.’’ A sense of competence emerges as she gains familiarity with typical parameters and responses and is thus able to modify ‘‘standard’’ approaches. While she becomes less self-conscious in dealing with ‘‘typical’’ situations, she is confronted by her inexperience and limited understanding when entering novel clinical situations.

In her second year of practice, the novelty of the clin- ical world remained prominent in a school nurse’s inter- view. As a solo health provider in an educational setting, she necessarily relied on textbooks for making many nursing and medical judgments:

I’m learning every day from these children. Every time

you think you’ve heard it all, you hear something

else…There’s always something new coming in that I

don’t know all the answers to. I have all my anatomy

books, dictionaries, physiology, and skin condition

books at my school, because I want to know what’s

wrong…I feel that if I can steer the parent in the right

direction, or not send a kid home because the kid has

allergies…And I’m doing really good at identifying

ringworm from eczema. And child abuse has reared

it’s ugly head which I’m real uncomfortable with.

Similar to the beginning nurses in acute care settings described by Chesla (1996), novice public health nurses relied on external guidelines for structuring their actions. In addition to the borrowed standards and textbook knowledge described by the above nurses, the referral, agency protocols and forms, standardized care plans, and documentation systems played this crucial role. For example, in making three home visits with a less- experienced public health nurse, the first author observed the nurse as she closely followed agency forms to complete an initial family assessment and to teach a parent about infant care and development. The next excerpt highlights how referrals also provided this necessary structure for less-experienced public health nurses:

It was about four o’clock in the evening. And a hospi-

tal nurse called and said that there was a baby whose

SmithBattle et al.: Becoming a Public Health Nurse. Part 1 5

mother had no prenatal care and the baby was dis-

charged a day before the test results were back and she

was positive for Hepatitis B. And they didn’t give the

baby the H Big, but they did give the baby her first

Hepatitis B. So I was like, oh, God. This had never

happened [to me] before. We’re trying to figure out how

we can get this baby H Big…So, I called my regional

manager who’s over the vaccine program, and she says,

‘‘I’ll call the hospital and see if they can supply us with

one vial of HBig for the baby, and then you can do the

home visit on Friday.’ So we were playing with time

because the baby was born on a Monday, and after

seven days, H Big is no good. So I was thinking, I have

to get this baby injected by Friday or I’ll be crazy all

weekend. So we got it all together. Got the H Big from

the hospital. When I was on my way to work, I was

thinking, I should draw the father’s blood while I’m

there. So I did the H Big on the baby and I drew

his blood. And it was like an adrenaline type rush, like,

I got two things done at the same time.

Like other beginners in our study, this nurse decided what to do on a home visit, largely based on the referral alone. To her credit, she went beyond the single task identified by the referral—to vaccinate the infant—and relied on her knowledge of communicable disease trans- mission to realize that the boyfriend might be infected. While the story captured a beginner’s excitement in trans- lating theory into practical situations—‘‘an adrenaline rush type of thing’’—her learning does not progress to include follow-up and interventions beyond the one visit. She lacked the skill, support, and clinical reasoning to assess the situation beyond the immediate health threat and to provide follow-up to the family.

Although referrals provided needed direction to launch the inexperienced public health nurse on a home visit, they did not help a nurse to discern what was salient in the situation. Upon receiving referrals for the chronically ill, less-experienced public health nurses often presumed, based on the referral, that the goal was to promote patient ‘‘compliance’’ with medical management. In maternal–child cases, health-promotion guidelines were closely followed. In all cases, health teaching was highly nurse directed. Inexperienced public health nurses had not yet learned the lesson related by an experienced nurse: ‘‘Basically you may go in for one thing when you get the referral, but it turns out that it may be other things; it’s never the way it appears.’’

Inexperienced public health nurses’ lack of perceptual skills and practical experience made it difficult for them to translate theoretical knowledge or clinical guidelines into skillful clinical judgments. In the next excerpt, a nurse described learning to make clinical judgments about the progress of labor:

[My patient] was thirteen at the time and pregnant,

and the night before, I went by just to see how she was

doing, and she wasn’t feeling so well. So we talked

about contractions and labor. This is what you need

to look for, and you’ll time them, and stuff like that.

So the next day, I was telling [my mentor] about the

visit, and I said, ‘‘Something is just not right.’’ She

said, ‘‘Well, we can just drive by and see how she’s

doing.’’ Jane would always tell me, ‘‘Follow your gut

instinct.’’ So we went by the house, she was laying in

bed, she’s not feeling well, and I asked her what was

wrong. She said that she’d been in pain all night long.

‘‘Do you think you’re in labor?’’ ‘‘I don’t know, but

I’m really in pain.’’ So I was kind of evaluating her and

it sounded like she was in labor. And I said, ‘‘I’ve got

another nurse in the car. I’d like for her to just give me

a second opinion if you don’t mind.’’ And Jane came

in and assessed her. ‘‘Yes, she’s in labor.’’ So, we called

911 and she delivered the next day. So Jane was right

there for me, because that was the first time that ever

happened to me. And I was really kind of nervous

about it because my patient was young and had had

some complications. But Jane, with her ‘‘You’ve

always got to follow your gut feeling. And that was

just such a good call.’’ And just on and on with the

encouragement.

This excerpt illustrates how a novice nurse clearly bene- fits from an experienced colleague who translates formal theory (e.g., the progress of labor) into practical situ- ations and who reinforces the beginner’s practical learning. Less-experienced public health nurses also relied on patient educational pamphlets to make up for their lack of experience. For example, in describing a visit to a child with asthma, a nurse said:

[The visit] gave me an opportunity to continue learning

more asthma management. I’ve got a little bit of

knowledge about a lot of things, but I don’t have

in-depth knowledge about enough. [Int: So what did

you do about that?] I did some reading, research on

things. As I gathered educational materials and tools for

the family, I also read them myself, so that I would know

what I was giving them and I could learn from them

as well.

Families themselves provide an important resource for teaching the inexperienced public health nurse. Consider the following example of how a nurse learns to refine her assessment of neonatal jaundice:

In the beginning, jaundice was really hard for

me…because of all the different skin tones in African

Americans. You will get some that are more yellow by

nature and to me it was, ‘‘Oh my God, that’s jaun-

dice?’’ So I’ve really relaxed a lot. You’ll see it. If it gets

this bad, it’s gonna show up in other places. And, I’ll

6 Public Health Nursing Volume 21 Number 1 January/February 2004

ask questions, ‘‘What’s the father of the baby’s skin

tone like? Is it darker or is it the same as yours? Is it

lighter?’’ And a lot of my patients will just say, ‘‘I have

a lot of yellow in my skin tone and so the baby is very

similar to me.’’ [Int: Did anybody coach you in that?

Did you sort of learn that on your own?] I think a lot of

times, the moms really were the ones that taught me.

Cause I would say, ‘‘Your baby looks a little yellow. I

wonder if this could be some jaundice.’’ And they

would say, ‘‘No, no. I’m yellowy skin color too and

so’s my boyfriend. I think it’s just that he looks like

us.’’ And then we’d take him over to the window and

look at his eyes and everything. A lot of times, it would

turn out they were right.

Coping with unfamiliar aspects of clinical practice was also noted in the many ways the inexperienced public health nurses were caught off-guard and embarrassed by social worlds that differed quite radically from their middle- class backgrounds. The difficulty in soliciting psycho- social information from families was quite pronounced among several public health nurses who felt they were prying into sensitive or private issues. As one nurse explained, ‘‘I really don’t feel I have a right to know all of that stuff.’’ During an observation of a home visit, another nurse introduced an agency form to the patient by saying, ‘‘This is the nosy form, mostly about family composition and financial status. If you don’t want to answer any questions, just tell me.’’ A third nurse reported that she eventually broached financial issues but only after a full year as a public health nurse:

When I first started having to fill out the socioeco-

nomic sheet, I just dreaded it. And half the time

I wouldn’t even ask. I would just kind of look. I hear

water running. Roof’s not leaking. There’s a smoke

detector. And I didn’t even ask. It took me a while to

get up to the point that, okay, I can ask these [ques-

tions] and it even got to, there probably are really good

reasons why we’re asking these questions. Because

nobody really gave me good reasons why we’re asking

all this stuff.

Inexperienced public health nurses were not only reluc- tant to ask families about their income, but they were often embarrassed and loathe to address roach problems or to assess family violence. As an experienced nurse made clear, an experiential cushion is required to go beyond one’s comfort level: ‘‘In the beginning, I wasn’t comfortable raising some issues. Like violence…I’ve got- ten more confidence in how to broach the subject better, what’s the right way to ask and when to ask, and that type of thing. Whereas when you’re new, you have your agenda, I have to do this and this and you don’t really listen to the client.’’

Public health nurses early in their careers enter situ- ations with an agenda and focus on accomplishing those tasks (‘‘I have to do this and this’’) that are largely dic- tated by external guidelines and prior education. As the above nurse explained, going beyond a predetermined agenda requires listening, being in partnership with cli- ents, and creating ‘‘common ground’’ (Kristjanson & Chalmers, 1990). Creating this shared understanding pre- sumes a set of highly developed relational skills atypical of less-experienced public health nurses.

LEARNING RELATIONAL SKILLS

Many stories from less-experienced public health nurses detailed the challenges of developing relational skills [see Benner et al. (1996) for similarities in acute-care settings]. Our study confirmed Zerwych’s (1992a) conclusion that newer public health nurses ‘‘tend to overshoot one way or the other’’ (p. 102) by doing too much or too little for families. The inclination to rescue families and ‘‘fix’’ prob- lems is a hallmark of beginning public health nurses:

[Int: When you think back on this last year, has your

practice changed in any way?] Yeah, I think that I’ve

been able to be less enabling (laughter). All of us have

talked about this being a trademark of brand new

CHNs. I will save you all. I will do everything for

you. I will make your appointments. I will drive you

there if I need to. (laughter) Not quite that bad, but it

gets pretty bad. You just want to help them so much.

And over time, you get frustrated at the times you

make these appointments and they blow them off.

You just get a little bit wiser and more street savvy.

It’s like, hey, wait a minute, why am I making this

appointment for you? If this really mattered to you,

you’d make your own appointment. You stop hand

holding so much. And I can see that in me. I’ve really

stopped a lot of the, let me do this for you.

Some beginning public health nurses were fortunate to have an experienced colleague to point our their over- involvement:

I can tell you about the little thirteen-year old. Boy oh

boy. I got her midway in her pregnancy and she was

having problems and her home life was totally

unstable. [relates extensive details] So early on, I’m

thinking, how can I get you out of this house and

take you home with me? Seriously, I’m thinking

those things. But then reality set in and I’m talking

to [my mentor] about it, and she’s saying, ‘‘That’s a

no-no. You cannot take on everybody’s problems. You

cannot be codependent. You can’t live their lives for

them and you can’t go in and fix everything. You can

only do what you can do as a nurse and that’s the

bottom line.’’ I think my nursing practice has

SmithBattle et al.: Becoming a Public Health Nurse. Part 1 7

improved because of that lesson. As a matter of fact,

I know it has.

While this nurse learns not to rush in and rescue families, the nurse quoted below confronts the risks of becoming detached and doing too little. This issue was heightened for her because of her patient’s recent death from a crack overdose. After relating an emotional story of her 2-year involvement with this mother of seven chil- dren, she reflected on the nurse–patient relationship and the struggle to remain open to vulnerability and suffering:

There was times where I felt very overwhelmed and

I felt like I needed to pull out. One time she called me.

She had just got beat up. And it came to a point where

it was really hard to emotionally detach from this case,

because it was in my face all the time, and I went home

crying because she was beat up. And it’s making me

tear up now. [Int: Should you have been emotionally

detached?] H-m. [Int: What a gift you gave to that

woman.] I think it was a two-way street, though,

because I learned a lot from her. Like not to judge.

That was a big part. One of the nurses said to me, you

got so involved with her that you ended up at the

patient’s funeral. But I thought the family needed me

there. They asked me to be there. [Int: So what did the

nurse mean by that?] Why are we helping these people

that don’t want to be helped type of thing. She’s been a

PHN for a long time and I think she is kind of burned

out. [Int: And you had no question about being there at

the funeral?] Oh, no. Not at all. [Int: Anything else you

learned from the situation?] I knew I was really import-

ant to her. It’s really hard not to take that home and

not let it hurt you. I think I probably learned that it

was okay to love clients for who they are. [Int: Do you

think she shaped your practice in any way?] I think she

has. I always felt that in nursing school, you’re sup-

posed to come in and be the nurse and be professional

and keep your feelings hidden. And now I know that

you don’t have to do that. And I’ve cried with many

clients before. I have a client whose baby just came

home. The baby was one pound seven ounces at birth,

and we just didn’t think this baby would make it. And

the mom came to the clinic and was just really thrilled.

And everybody at the clinic, their faces dropped when

she said, ‘‘My baby’s going to be okay.’’ And when he

came home, she wanted me there, and we both hugged

him and we were crying. And I think that’s okay…But,

I think the client who died is the one that made me

realize that we’re all human, and we’re only human.

[Int: So, that whole thing about professional distance,

how do you view that now?] I think maybe there’s a

time and place for it, but I don’t know when it is.

These critical learning experiences challenged this nurse’s formal education and the advice of colleagues. In becoming a witness to patients’ joys, concerns, and

suffering, she resisted detachment and abandonment and received a deeper understanding of presence, perse- verance, and respect for human vulnerability. She learned that there are no fast rules for nurse–patient relationships and that the right kind of involvement is best judged on a case-by-case basis.

Less-experienced public health nurses had difficulty in developing responsive relationships with vulnerable parents and more often than not focused on correcting parenting deficits. The following tragic story is a good example:

This family was actually the first one to receive a

crib from the program with the birth of their first

child…[The mother] talked about how she didn’t want

to put her new baby in a crib, thinking that that caused

crib death. So we had our work cut out for us. So me

and another colleague talked at great length about

how to place the child safely in a crib, what to do,

and what not to do…Anyway, I closed the family

when the baby was a year old and the family seemed

to be doing pretty well…Eighteen months later, mom

showed up in the clinic with a newborn infant. So

I started to redevelop a relationship with the family and

a month later the baby died. I don’t know if they still

had the crib. [Mother was not home for two scheduled

visits.] [Int: How did you learn the baby died?] The

mother called the day the baby died and left a message

on my answering machine. She told me that it was

probably SIDS. A day later I went to the child fatality

review meeting and the [medical examiner] indicated

that it might not have been SIDS [possibly positional

asphyxia, as a result of being smothered while sleeping

next to her mother.] I saw the family the next day in

clinic. Both dad and mom were in because they felt like

maybe they needed some medication to help them

through this grieving period…They showed me pic-

tures of the baby and her first four months of life

and pictures of the funeral, pictures of the baby in

the casket. That was really hard to see. And in the

little photo album there was a picture. I just can’t

forget this. It sort of haunts me because one of the

pictures was the two year old asleep on the couch with

the infant sleeping next to her on the outside of the

couch. I’m thinking who’s watching those kids? So it

was really hard because they’re doing all the things

you’re not supposed to do. And I talked and talked

and talked and worked with this family for a long

time, and it just doesn’t seem like anything sunk in.

Like many inexperienced public health nurses, the above nurse naively subscribed to health-promotion the- ory and patient education to correct risky practices and unhealthy lifestyles. Suspecting that the mother might resist such advice because of her understanding of crib death, the nurse ‘‘talked and talked and talked’’ in hopes

8 Public Health Nursing Volume 21 Number 1 January/February 2004

that repetition would convince the mother to adopt recommended infant sleep practices. When the baby tra- gically died, the nurse’s original agenda continued to frame the story and led her to the conclusion that the parents were responsible for the death. The parents’ culp- ability absorbed her attention, not their grief.

The previous excerpt illustrates a child-focused agenda that preempts ‘‘seeing’’ or responding to the parents beyond the needs of the child. Several inexperienced nurses made the shift from this child focus to a broader person- and family-centered practice over the study period. An experienced nurse described making this very transition in visiting a mother whose children were removed for neglect early in her career:

I was fairly new [as a PHN] when I first got involved

with this mother and I focused so much on the kids

and her staying in [drug] treatment. That was my focus

with her…After the kids were removed, I kind of got

to know her more as a person and as a mom that now

doesn’t have the kids. I’ve always kept in mind, you

need to keep doing things that help mom feel good,

instead of pointing out what they didn’t do. Point out

what she is doing right. And I don’t know if I did

enough of that. [Int: So, that notion of being mother-

centered.] And the whole family…[Instead] I was so

focused on her responsibility to take care of the kids.

Even though I knew she had a substance abuse prob-

lem, I approached it more from you need to get in

treatment. Have you kept your appointments? But I

never addressed what was leading her to substance

abuse. Or the interaction with her boyfriend…

I didn’t get to know him at all. What was his role?

The kids were bonded to him as a father. But I didn’t

make any effort [to get to know him.] [Int: Do you do

anything differently now?] Just make sure I get to know

the parents, let them feel like I care about them as a

person beyond being a mother or a father, and what’s

going on in the family. Not just focusing on the kids.

Perceptual and relational skills improved as public health nurses became more engaged, less directive and judgmental, and more respectful of client difference. As experience broadened their understanding, they talked of removing their ‘‘professional hat,’’ ‘‘breaking through the professional edge,’’ or ‘‘going in with expertise but not as the expert’’ (SmithBattle et al., 1997, p. 80). In giving up sole authority for determining clients’ needs, they were more likely to ‘‘see’’ clients’ strengths that, in turn, pro- moted client receptivity, trust, and disclosure.

DISCUSSION

Because inexperienced public health nurses enter the field with great gaps between theoretical knowledge and prac-

tical know-how, they orient themselves to clinical situ- ations by external guidelines. While such guidelines provide a valuable cushion for the beginner, they do not map well onto the clinical world of particular individuals, families, and populations. As we have previously pointed out (SmithBattle & Diekemper, 2000, 2001), external guidelines cannot make up for the lack of experience, because it is experience that makes it possible to grasp what is most important in a particular clinical situation. For example, the nurses quoted above knew the scientific basis for the progress of labor and the epidemiology of domestic violence, but they needed practical experience to ‘‘see’’ how clinical conditions would show up in specific cases and how to ‘‘lead’’ and follow conversations to tackle clinical issues with tact and skill. Less-experienced public health nurses were absorbed in learning these prac- tical skills, very much like the inexperienced nurses in acute care described by Chesla (1996). In observing that ‘‘clinical knowledge development is primarily about learn- ing the concrete, practical exigencies of clinical situations that were earlier studied only in the abstract’’ (p. 77), Chesla concluded that clinical learning is enhanced when specific experiences are shared informally with more experienced colleagues.

Relational skills are honed over time as inexperienced public health nurses begin to appreciate the daily strug- gles of clients’ lives and learn to judge what works and what does not work, with increasing refinement. As skills improve, they begin to rely on their ‘‘gut instincts’’ and to meld, tailor, or supplant professional, theoretical know- ledge with clinical know-how and with clients’ practical reasoning and language (Reutter & Ford, 1997). Cumu- lative experience provides the foundation for becoming more responsive, for appreciating the strengths as well as the vulnerabilities and suffering of clients, for becoming more open and attentive to clients’ needs and concerns, and for moving beyond a practice focused on the index case. The importance of these qualities is often seen when the index case is a child referred to PHN services. Because children are so dependent on family care, it is no surprise that public health nurses focus on children’s health and welfare, particularly in high-risk, chaotic family circum- stances. But identifying with children’s plight and identi- fying parents’ deficits without addressing the personhood of the parent do not build on the parent’s and family’s strengths or develop a partnership that promotes perso- nal identity and family self-help (Zerwych, 1992a). Not all experienced public health nurses make the transition from a child to a person and family focus, as evident in Byrd’s (1999) case study of an experienced public health nurse. Although that nurse had over 10 years in practice, she maintained a child-focused practice, appraising each

SmithBattle et al.: Becoming a Public Health Nurse. Part 1 9

mother’s caregiving and providing interpersonal support for mothers judged to be competent caregivers. Mothers judged to be inadequate received less support as the nurse used her personal and legal authority to demand changes. This child-centered focus was in stark contrast to the expert nurses described by Zerwych (1992b) and Smith- Battle et al. (1997), who developed a caring relationship with vulnerable mothers. In withholding judgment while affirming the mother’s strengths, experts demonstrated the responsive use of self that preserves personhood. Even in cases of child neglect or abuse, expert public health nurses often framed the situation in such a way that promoted the child’s safety without excluding or blaming the family (SmithBattle et al., 1997, p. 82). That many nurses make the shift from a child focus to the person and family deserves further study, including its role in achieving positive outcomes and sensitizing the nurse to the bigger picture in which children and families are embedded (SmithBattle, Diekemper, & Leander, 2004).

Numerous stories related how experienced colleagues promote clinical learning and skill development when they point out aspects of the clinical situation that are beyond the beginner’s experience. This ‘‘pointing out’’ responds directly to the specific learning needs of the beginner and how she or he is absorbed in learning prac- tical skills. Beginners were eager to share gratifying experiences with colleagues who appreciated their suc- cesses and dilemmas and could draw out aspects of the clinical situation that went beyond the beginner’s percep- tual skills. This helped new public health nurses to improve their perceptual skills and to translate theory into practice, while extending their focus beyond the original referral, nursing theories, borrowed standards, and other external guidelines.

Unfortunately, the lack of seasoned colleagues and the limited PHN experience of some supervisors dampened the clinical learning of inexperienced public health nurses in this study and mitigated against their going beyond a task-based focus and reliance on external guidelines. The difficulty of retaining public health nurses in the absence of colleagueship and good supervision was demonstrated by the resignation of three of the 13 less-experienced nurses over the 18 months of the study. The three nurses were clearly demoralized by the lack of sound supervision and a positive culture for learning and collaboration. Their demoralization demonstrated how the beginner relies on the community of clinicians for understanding what practice entails and how the culture of an agency profoundly shapes the beginner’s experience of practice and development of skill. Promoting a culture of colla- boration and clinical learning supports skill development for beginners while simultaneously validating the exper-

tise of experienced public health nurses. To support posi- tive outcomes for families and communities, it is therefore incumbent on supervisors and administrators to promote an agency culture that is conducive to clinical inquiry and collaborative learning (Benner et al., 1996; SmithBattle et al., 1999).

In entering the field, beginners confront the ‘‘messy complexities’’ (Schon, 1983/1994) of the practice world and the discrepancies between practice and external guidelines. The development of perceptual skills, habits of responsiveness, and engaged reasoning with particulars eventually supplants their preoccupation with protocols, narrowly defined outcomes, a nurse-directed agenda, and a task-oriented approach. This growing openness to clin- ical situations cultivates the public health nurse’s under- standing of the situation and guides his/her specific actions. The development of these relational and percep- tual skills sets the stage for seeing the ‘‘big picture’’ and for thinking and acting upstream.

ACKNOWLEDGMENTS

We thank the nurses who participated in this study, the Beaumont Faculty Development Fund of Saint Louis University for funding this research, and the two anony- mous reviewers who provided helpful suggestions.

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