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Swider_et_al-2017-Public_Health_Nursing1.pdf
POPULATIONS AT RISK ACROSS THE LIFESPAN: POPULATION STUDIES
Evidence of Public Health Nursing Effectiveness: A Realist Review Susan M. Swider, PhD, APHN-BC, FAAN Pamela F. Levin, PhD, APHN-BC, and Virginia Reising, MSN, APHN-BC Community, Systems and Mental Health Nursing, College of Nursing, Rush University, Chicago, Illinois
Correspondence to:
Susan M. Swider, Community, Systems and Mental Health Nursing, College of Nursing, Rush University, 600 S. Paulina #1080, Chicago, IL 60612.
E-mail: [email protected]
ABSTRACT Objectives: The purpose of this realist review was to examine PHN interventions and their outcomes during the period preceding the Affordable Care Act (1990–2010), to deter- mine what types of interventions demonstrated effectiveness, and whether these were related to target population or setting. Design and Sample: The review focused on PHN interventions with data support documented over 20 years. A search of the published literature using CINHAL, PubMed, and ancestry methods resulted in 64 articles meeting the search criteria. The researchers reviewed each article for the relevant variables; achieved consensus for each variable; and summa- rized results using descriptive statistics. Results: Documented PHN interventions targeted vulnera- ble populations. Interventions included health education, behavior change, and screening. There was evidence of effectiveness of PHN interventions in a number of studies; however, the study limitations and variety of intervention types make overall conclusions about PHN effectiveness challenging. Conclusions: Despite the long history of PHN working in communities to promote and maintain the health of vulnerable populations, practice outcomes have not been well documented. Further work is needed to: strengthen the methods for documenting effectiveness of PHN practice; focus on promising PHN interventions via multisite studies; and translate evidence-based PHN interventions to practice settings.
Key words: community health nursing, Public Health Nursing effectiveness, Public Health Nursing interventions, Public Health Nursing practice.
Background Public health nursing is one of the oldest nursing roles in the United States, dating back to the 19th cen- tury. Nursing care in the home was an early type of health care intervention, when people did not go to the hospital for illness unless they were dying or indi- gent (Kulbok, Thatcher, Park, & Meszaros, 2012). Pioneer Lillian Wald was an early proponent of addressing what are now called the social determi- nants of health in her practice by focusing on housing and the environment for her patients (Buhler-Wilker- son, 1993). In the early 20th century, hospitals proliferated and the care of the sick shifted to institu- tions; only the very poor were cared for at home.
The evolving role of the public health nurse was often financed by charitable organizations, and focused on vulnerable mothers, infants and follow- up care to adults after hospitalization. By the mid- 20th century when germ theory was fully adopted, specific public health measures became more com- mon and public health nurses (PHN) assumed additional roles focused on population health and wellness including: immunizations, family planning clinics, and disease outbreak investigations. The role encompassed both care for vulnerable popula- tions and care for the public as a whole. To reflect this integration of public health and nursing, the PHN section of the American Public Health
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Public Health Nursing Vol. 34 No. 4, pp. 324–334
0737-1209/© 2017 Wiley Periodicals, Inc. doi: 10.1111/phn.12320
Association (APHA) adopted the following defini- tion of practice in 1996, and reaffirmed it in 2013 (American Public Health Association, Public Health Nursing Section, 2013):
Public health nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences.
In the 21st century, PHN often serve as the backbone of government funded public health agencies (Beck, Boulton, & Coronado, 2014) because they can provide both disease-focused care and population-focused prevention. However, due to recent budget cuts, such agencies have begun to utilize less expensive providers for the services pre- viously provided by PHN. PHN salaries, while less than registered nurses (RNs) in acute care, are often higher than for public health workers without a clinical background (Robert Wood Johnson Foun- dation, 2013). Defining the scope of practice and overall effectiveness of PHN presents a challenge because they work in an array of community set- tings, including schools, worksites, homecare agen- cies, and ambulatory care, with varying duties.
A recent survey of PHNs in government funded public health agencies in the United States showed that they remain the largest group in the public health workforce, even as their roles shift and their numbers decrease. Over 40% of the PHNs surveyed (N = 2,697) reported that they continued to provide individual, clinic-based services in their state, including primary and specialty care. In addition, PHNs said they were working in outreach, commu- nity engagement, population-level prevention, qual- ity improvement, workforce development, and administrative roles (University of Michigan Center of Excellence in Public Health Workforce Studies, 2013). The survey documents that the services pro- vided by PHNs span the components of the Min- nesota Public Health Nursing Intervention Wheel, including population-based practice delivered across individual, community, and system-focused spheres (Keller, Strohschein, Lia-Hoadberg, & Schaffer, 2004). While no similar data exist for nurses practicing in nongovernmental community health agencies, there is reason to believe the roles/ functions would be similar.
With the 2010 passage of the Affordable Care Act (ACA), the health system is shifting focus from
services provided to individuals to those focused on population health outcomes. This shift recognizes that the medically driven health care system is expen- sive and only moderately effective in improving health outcomes. The ACA focuses on increasing insurance coverage to those previously uninsured and addressing disease prevention and health promo- tion needs, including the social determinants of health (Center for Medicare and Medicaid Services, 2016). This shift in focus should strengthen PHN practice, with its focus on the combination of nursing and public health knowledge and skills in practice.
Despite these recent changes, the future of PHN practice is in question as PHN are decreasing in number (University of Michigan Center of Excel- lence in Public Health Workforce Studies, 2013) due to better-paying opportunities for nurses; changes in public health financing; and limited documentation of effectiveness for PHN interven- tions. The critical question in this era of increas- ingly strained public health resources is what is the added value of bringing clinical nursing knowl- edge and public health expertise to practice? To address this question, we need to know what PHN interventions are most effective. The overall ques- tion for this realist review was: what types of PHN interventions in the United States, performed in what settings and with what populations, have demonstrated effectiveness and are worthy of fur- ther testing, implementation, and dissemination?
Purpose The purpose of this realist review was to examine PHN interventions and their outcomes during the 20 year period preceding the ACA, to determine what types of interventions demonstrated effective- ness, and whether these were related to target pop- ulation or setting. The results of this review can guide research to further delineate where PHN are most effective in practice and to promulgate these roles in community/public health agencies.
Methods
Design and Sample The study used a realist review methodology begin- ning with a search of the literature for the 20 year period preceding the ACA, using the PubMed and CINAHL databases. A medical reference librarian,
Swider et al.: Public Health Nursing Effectiveness 325
in consultation with authors, conducted the search using Medical Subject Headings (MeSH) of public health nursing and community health nursing. As there were no adequate MeSH headings for the additional terms of interest and to be as inclusive as possible, the “all fields” approach was used. Key search words were:
• public health nursing/community health nursing AND
○ role ○ effectiveness ○ intervention ○ evidence ○ outcome
The review focus was on articles presenting data on the effectiveness, outcomes and/or impacts of health interventions provided by PHN. PHN roles differ across settings and populations, hence we chose a realist review approach because it pro- vides a rationale and tools for synthesizing com- plex, multivariate studies across different settings. A realist review method aids in looking at the con- text, mechanisms, and outcomes for PHN interven- tions; that is, what outcomes (evidence of effectiveness) were triggered by what mechanisms (PHN interventions) in what contexts (settings and populations) (Pawson, Greenhalgh, Harvey, & Walshe, 2005).
The initial search resulted in 5,052 abstracts. Reviewing these abstracts for data on the effective- ness of PHN-implemented interventions, the sam- ple was narrowed to 119 relevant articles, which were reviewed for applicability to the study. The authors excluded systematic reviews, as the realist approach focuses on primary studies (Pawson et al., 2005), which reduces bias from use of other meth- ods. We also excluded dissertations for reasons of parsimony and access; as well as excluding studies conducted outside of the United States, as our focus was on roles in the U.S. health care system before the ACA, and roles in other countries would not be easily comparable. Thirty-nine articles met the study criteria and were coded for the relevant vari- ables. As we reviewed these articles, we recognized that authors were citing studies that had not appeared in our original search of electronic data- bases, so we expanded our focus via an ancestry search on the reference list for the initial 39 articles
and found an additional 25 articles which met our criteria for inclusion. The investigators coded a total of 64 articles; see Figure.
Measures Each article was reviewed by two of the three inves- tigators, using the following variables:
• Context
○ Setting of the intervention ○ Target Population
• Mechanism
○ Type of Intervention: function of the PHN in this intervention
○ PHN background: educational background/ad- ditional training required
• Outcome
○ Outcomes measured and significant findings ○ Methodological rigor
■ Study design ■ Psychometrics of measures and tools used
Analytic Strategy Investigators met after reviewing the first 20 arti- cles separately; in cases of disagreement about cod- ing, the team came to consensus and refined the variable definitions. This process was repeated for the remaining articles. Table 1 provides an example of the data-coding table used for the study.
Results
Context The majority of the PHN interventions in the review were conducted in urban settings (59.4%), with 21.9% conducted in rural settings or a combi- nation of settings (4.7%), and 14.1% not specifying setting. The majority of PHN interventions were delivered in the home (74.5%), with a few being clinic-based (5.1%), and the remainder unspecified (20.4%).
In terms of the populations served, the major- ity of interventions were designed to serve high risk maternal/child health needs (64.1%). More than a quarter of the studies addressed the health needs of at-risk adults (28.1%) and a small number of
326 Public Health Nursing Volume 34 Number 4 July/August 2017
T A B L E
1. S a m p le
D a ta
D is p la y
F ir st
au th o r
S tu d y d es ig n
T ar ge t p o p u la ti o n
P H N
le ve l
In te rv en
ti o n
O u tc o m es
P sy ch
o m et ri cs
S et ti n g
A m m er m an
et al . (2 0 0 3 )
R an
d o m iz ed
cl in ic al
tr ia l
2 0 –7 0 ye ar s o ld s,
w it h to ta l
ch o le st er o l 4 .7 /
m m o l/ L
N = 4 6 8 ; 71 %
fe m al e,
av er ag
e ag
e = 6 5 , 8 0 %
w h it e
C o n tr o l: n = 2 5 2
T re at m en
t: n = 2 16
L o ca l h ea lt h
d ep
ar tm
en t P H N
w it h 2 h r
ad d it io n al
tr ai n in g;
tr ea tm
en t P H N s
h ad
m o re
ye ar s
ex p er ie n ce
C o n tr o l: d ie ta ry
ri sk
as se ss m en
t T re a tm
en t: d ie t
co u n se li n g (3
se ss io n s) ,
n u tr it io n is t
re fe rr al , fo ll o w -u p
D ie ta ry
ri sk
a ss es sm
en t: se lf -,
si g d if fe re n ce
at 3
an d 12
m o n th s
B lo o d ch
o le st er o l:
n o si g d if fe re n ce
W ei g h t: si g at
3 , 6 ,
an d 12
m o n th s
R is k as se ss m en
t re p o rt ed
/c it ed
; n o
p sy ch
o m et ri cs
o n
w ei gh
ts an
d la b o ra to ry
te st s
R u ra l
A n d re w s
(2 0 0 5 )
C o h o rt , w it h
re p ea te d
m ea su re s
N o n p re gn
an t
A fr ic an
-A m er ic an
w o m en
o ve r
18 ye ar s w h o ar e
sm o k er s;
8 0 %
le ss
th an
$ 10
0 m o n th
in co m e
N u rs e b ac k gr o u n d
n o t sp ec if ie d ; u se d
C o m m u n it y H ea lt h
W o rk er s (C
H W s)
N u rs e le d gr o u p
ed u ca ti o n ,
in d iv id u al
b eh
av io ra l
co u n se li n g;
w ee k ly
fo r 6 w ee k s,
b o o st er
at w ee k 12 ;
n ic o ti n e
re p la ce m en
t th er ap
y; p ar ti ci p an
ts re ce iv ed
m o n et ar y
in ce n ti ve ; fo ll o w -
u p b y C H W s
P a rt ic ip a ti o n : 12 /1 5
at te n d ed
10 0 %
se ss io n s
R et en
ti o n : 10
0 %
S m o k in g
ce ss a ti o n : si g
d ec re as e in
ci ga
re tt es
p er
d ay
an d m ea n C O
le ve ls ; ab
st in en
ce fo r 2 4 h r fr o m
re p o rt in g at
6 0 %
at 2 m o n th s
S ta g es
o f ch
a n g e:
si g p ro gr es si o n
al o n g st ag
es S o ci a l su p p o rt : si g
in cr ea se
fo r
af fe ct io n at e
su p p o rt
at 6 an
d 12
w ee k s
S el f- ef fi ca
cy : si g
in cr ea se
ac ro ss
al l
3 su b sc al es
P ro p er ti es
re p o rt ed
fo r al l m ea su re s
u se d
U rb an
N o te
S ig
= si gn
if ic an
t.
Swider et al.: Public Health Nursing Effectiveness 327
studies addressed solely the needs of at-risk chil- dren (7.8%). Most of the target populations were defined as having multiple risk factors.
Mechanism We examined the type of intervention offered. The majority of PHN interventions were focused on education and behavior change for mothers, infants, and children (67.2%). The next most com- mon intervention was behavior change for adults or children with chronic illnesses (21.9%). Smaller numbers of interventions were screening (6.3%) or preventive in nature (4.7%).
We then proceeded to look at the qualifications of the PHNs who delivered the interventions. Speci- fic definitions of PHN practice were not commonly provided, but we looked for specified educational background or training for the PHN role being described in the study. Almost half of the studies described the nurse as a PHN generalist (48.4%), with a few studies describing the PHN as graduate prepared (3.1%) or as part of an intervention team (6.3%). Additional studies presented the interven- tionist as an RN (32.8%), with no further specifica- tion about background or experience. The remainder specified various nursing backgrounds: Clinical Nurse Specialist (3.1%) or nursing students with faculty (6.3%). The studies reviewed provided little detail on the background of the PHN conduct- ing the intervention.
Outcomes We examined Outcomes in several ways. First we looked at methodological rigor of the studies them- selves, including study design and psychometric properties of the outcomes measured. We then looked at the types of outcomes measured for PHN interventions, and for which outcomes the PHN interventions made a statistically significant improvement. Tables 2 and 3 illustrate this.
The investigators coded Physiological outcomes as including: blood cholesterol, weight, blood lead levels, health problems, blood pressure, addiction severity, depression, urine loss, anemia, infant birth weight, pregnancy-induced hypertension, yeast infec- tions, second pregnancies, live births, asthma diagno- sis, premature births, infant mortality, neonatal morbidity, morbidity at 12 months, miscarriages, preg- nancy complications, prenatal health, mental develop- ment, intellectual functioning, verbal ability, and
cotinine levels. These outcomes were measured quanti- tatively in 25% of all studies reviewed, demonstrating statistically significant improvement after the PHN intervention in almost half of those studies (Table 3).
Behavioral outcomes, often measured via self- report or observation, were included in over 33% of the studies reviewed, and included: dietary risk assessment, smoking cessation, smoking reduction, observed housekeeping, pet dander, parent–child interaction, parenting competencies, emotional problems, behavioral problems, child custody/ abuse, incidence of breast feeding, health behavior change, goal attainment, health promoting lifestyle, injuries/ingestions, home environment, substance use, dust lead level, life skills, domestic violence experience, employment, educational outcomes, cockroach allergen levels, social competence, disease self-management, car seat use, arrests/con- victions/jail time/probation, running away from home, lifetime sex partners, relationship stability, and psychosocial risk. PHN interventions signifi- cantly improved these outcomes in 60% of all inter- ventions in which they were measured.
The next category of outcomes was Client atti- tudes toward such things as smoking cessation, stress, perceived severity of illness, and social sup- port. These were largely self-reported measures, assessed in 13% of all studies reviewed, and were significantly impacted by the PHN intervention in half of those studies. Access to care/care utilization outcomes included: visit compliance, number of visits, program access/enrollment, hospitalization/ use of emergency services, and immunization rates. These outcomes were measured quantitatively in 25% of the studies reviewed, and were significantly improved by the PHN intervention in almost half of the studies in which they were measured.
Health knowledge was measured in few stud- ies, and related to caregiver or client’s knowledge of the disease/condition. This measure was signifi- cantly improved by the PHN intervention in two thirds of the studies where measured. The last cate- gory of outcome measures – Other – included mea- sures of client problem solving and family-provider relationship. These measures occurred in a small number of studies with the PHN intervention related to significant improvement about one third of the time.
In the review, we also looked at methodological rigor, including the type of study design and
328 Public Health Nursing Volume 34 Number 4 July/August 2017
T A B L E
2 . S u m m a ry
o f S tu d y D es ig n a n d E ff ec ti v en
es s o f P u b li c H ea
lt h N u rs in g O u tc o m es
(N = 6 4 )
R ef er en
ce S tu d y d es ig n
R es ea rc h o u tc o m es
an d le ve l o f st at is ti ca l si gn
if ic an
ce
P h ys io lo gi ca l
B eh
av io ra l
A tt it u d in al
A cc es s/ u ti li za ti o n
H ea lt h k n o w le d ge
O th er
A m m er m an
et al . (2 0 0 3 )
R C T
+ /�
+ A n d re w s (2 0 0 5 )
C o h o rt
+ +
+ /�
N A
B al d w in
et al . (1 9 9 8 )
C as e– C o n tr o l
+ �
B ar n es -B
o yd
, N o rr , an
d N ac io n (1 9 9 6 )
C as e– C o n tr o l
� B ar n es -B
o yd
, N o rr , an
d N ac io n (2 0 0 1)
C as e– C o n tr o l
� +
B ea r,
D w ye r,
B en
ve n es te , J et t, an
d D o u gh
er ty
(1 9 9 7)
R C T
+
B ro w n , M cL
ai n e,
D ix o n , an
d S im
o n (2 0 0 6 )
R C T
� +
� B u tz , L ea rs , O ’N ei l, an
d L u k k (1 9 9 8 )
C as e st u d y
N A
N A
B u tz
et al . (2 0 0 1)
R C T
+ �
C la rk , C u rr an
, an
d N o ji (2 0 0 0 )
C o h o rt
+ �
C o rr ar in o et
al . (2 0 0 0 )
C o h o rt
� N A
N A
C o u lt as
(2 0 0 5 )
R C T
� �
+ /�
� C ra d d o ck , A d am
s, U su i, an
d M it ch
el l (1 9 9 9 )
R C T
+ /�
D av
is et
al . (2 0 0 2 )
C as e– C o n tr o l
+ D av
is et
al . (2 0 0 6 )
C o h o rt
+ /�
+ D eJ o n g an
d V ei tm
an , 2 0 0 4
C as e st u d y
+ D o u gh
er ty
et al . (2 0 0 2 )
R C T
+ /�
+ E ck en
ro d e et
al . (2 0 0 0 )
R C T
+ /�
F et ri ck , C h ri st en
se n , an
d M it ch
el l (2 0 0 3 )
C o h o rt
+ +
F ly n n , B u d d , an
d M o d el sk i (2 0 0 8 )
C as e– C o n tr o l
� +
G ib so n , M ar ti n , J o h n so n , B lu e,
an d M il le r
(1 9 9 4 )
C as e– C o n tr o l
+ +
G o n za le z- C al vo
, J ak
so n , H an
sf o rd , W o o d m an
, an
d R em
in gt o n (1 9 9 7)
C o h o rt
N A
K ai se r,
F ar ri s,
S to u p a,
an d A gr aw
al (2 0 0 9 )
R C T
+ /�
� +
K an
g et
al . (1 9 9 5 )
R C T
+ K ei n tz , F le u sh
er , an
d R im
er (1 9 9 4 )
C o h o rt
+ K it zm
an et
al . (1 9 9 7)
R C T
+ +
+ +
K li n n er t et
al . (2 0 0 5 )
R C T
+ /�
+ /�
+ /�
+ /�
+ K li n n er t et
al . (2 0 0 7)
R C T
+ K o n ia k -G
ri ff in , V er ze m n ie k s,
an d C ah
il l (1 9 9 2 )
R C T
+ �
K o n ia k -G
ri ff in , M at h en
ge , A n d er so n , an
d V er ze m n ie k s (1 9 9 9 )
R C T
+ /�
� +
K o n ia k -G
ri ff in , A n d er so n , V er ze m n ie k s,
an d
B re ch
t (2 0 0 0 )
R C T
� + /�
+ /�
K o n ia k -G
ri ff in
et al . (2 0 0 2 )
R C T
+ /�
+ /�
+ +
K o n ia k -G
ri ff in
et al . (2 0 0 3 )
R C T
� + /�
� + /�
K o rf m ac h er , O ’B ri en
, H ia tt , an
d O ld s (1 9 9 9 )
R C T
+ �
+
(c o n ti n u ed
)
Swider et al.: Public Health Nursing Effectiveness 329
T A B L E 2 . (C
o n ti n u ed
)
R ef er en
ce S tu d y d es ig n
R es ea rc h o u tc o m es
an d le ve l o f st at is ti ca l si gn
if ic an
ce
P h ys io lo gi ca l
B eh
av io ra l
A tt it u d in al
A cc es s/ u ti li za ti o n
H ea lt h k n o w le d ge
O th er
L an
e, M ar ti n , U h le r,
an d W o rk m an
(2 0 0 3 )
C as e st u d y
N A
N A
L ar so n , M cG
u ir e,
W at k in s,
an d M o u n ta in
(1 9 9 2 )
C o h o rt
� +
L as h le y (2 0 0 7)
C as e– C o n tr o l
N A
M ar ce n k o an
d S p en
ce (1 9 9 4 )
R C T
� + /�
� M ar te n s an
d M el lo r (1 9 9 7)
C as e st u d y
+ M ay o , W h it e,
O at es , an
d F ra n k li n (1 9 9 6 )
C as e st u d y
N A
M az zu
ca , F ar ri s,
M en
d en
h al l, an
d S to u p a
(1 9 9 7)
R C T
� + /�
+ �
M o n se n et
al . (2 0 10
) C o h o rt
+ M o o re
et al . (1 9 9 8 )
R C T
+ /�
N av
ai e- W al is er , M is en
er , M er sm
an , an
d L in co ln
(2 0 0 4 )
C o h o rt
+
N gu
ye n , C ar so n , P ar ri s,
an d P la ce
(2 0 0 3 )
R C T
+ N o rr
et al . (2 0 0 3 )
R C T
+ /�
+ /�
+ O ld s,
H en
d er so n , an
d K it zm
an (1 9 9 4 )
R C T
� + /�
+ /�
O ld s,
H en
d er so n , K it zm
an , an
d C o le
(1 9 9 5 )
R C T
� + /�
+ O ld s et
al . (1 9 9 7)
R C T
+ + /�
+ /�
O ld s et
al . (1 9 9 8 )
R C T
+ /�
O ld s et
al . (2 0 0 2 )
R C T
+ + /�
� O ld s et
al . (2 0 0 4 a)
R C T
+ /�
+ /�
+ /�
O ld s et
al . (2 0 0 4 b )
R C T
+ /�
+ /�
� �
P ri d h am
, K ro li k o w sk i et
al . (2 0 0 6 a)
R C T
� �
� P ri d h am
, L im
b o , S ch
ro ed
er , K ro li k o w sk i, an
d H en
ri q u es
(2 0 0 6 b )
C as e– C o n tr o l
�
R o se , B ai gi s- S m it h , S m it h , an
d N ew
m an
(1 9 9 0 )
C o h o rt
+
S ch
af fe r,
J o st , P ed
er so n , an
d L ai r (2 0 0 8 )
C o h o rt
N A
N A
S ch
m it z an
d R ei f (1 9 9 4 )
C o h o rt
N A
N A
S id o ra -A
rc o le o et
al . (2 0 10
) R C T
+ +
S ta rn
(1 9 9 2 )
R C T
+ + /N
A T h o m p so n , C u rr y,
an d B u rt o n (1 9 9 8 )
C as e– C o n tr o l
+ /�
V in es
(1 9 9 4 )
C as e– C o n tr o l
+ + /�
+ W h ee le r an
d W at er h o u se
(2 0 0 6 )
C as e– C o n tr o l
� Z o tt i an
d Z ah
n er
(1 9 9 5 )
C as e– C o n tr o l
� �
S u b to ta l
3 8
3 7
2 2
3 6
3 4
N o te
R C T = R an
d o m iz ed
C li n ic al
T ri al ; + = st u d y
re p o rt ed
st at is ti ca ll y
si gn
if ic an
t fi n d in gs ; �
= st u d y
fi n d in gs
n o t st at is ti ca ll y
si gn
if ic an
t; + /�
= st u d y
re p o rt ed
b o th
st at is ti ca ll y si gn
if ic an
t an
d n o n st at is ti ca ll y si gn
if ic an
t fi n d in gs ; N A
= st u d y re p o rt ed
m ea su re s w h ic h w er e n o t te st ed
fo r si gn
if ic an
ce , su ch
as in
d es cr ip ti ve
st u d ie s.
330 Public Health Nursing Volume 34 Number 4 July/August 2017
psychometric properties of the measures, to assess the credibility of the data presented. Of the 64 studies reviewed, half were randomized clinical tri- als; another 25% were case–control studies; 20% were cohort studies; and the remainder were case
studies, with limited descriptions of outcomes (Table 2). Half (52%) of the studies reported the psychometric properties of all of the measures or referred the reader to relevant information pub- lished previously. However, many studies (31%) provided no discussion of the psychometrics of the measures or tools used. Thus, although a variety of PHN interventions demonstrated statistically signif- icant effectiveness, the rigor of the studies was of moderate quality, as assessed by design and psy- chometric properties of measures.
Overall, PHN interventions were targeting vul- nerable populations in primarily urban, community settings. The review demonstrated little documenta- tion of the intervention details, including the skills/ background of the PHN conducting the interven- tion. A variety of outcomes were measured, although methodological rigor was only moderate.
TABLE 3. Prevalence and Statistical Significance of Measured Outcomes
Research outcomes Outcomes measured
across studies (n = 290) Significant findingsa
Physiological/clinical 77 (26.6%) 48.0% Behavioral 102 (35.2%) 59.8% Attitudinal 38 (13.1%) 50.0% Access/utilization 66 (22.8%) 47.0% Health knowledge 3 (1.0%) 66.0% Other 4 (1.4%) 33.0%
Notes aEach study measured more than one outcome; therefore percentages do not equal 100%.
PubMed/CINAHL (1990-2010)
Keywords: Public health nursing/community health nursing AND
• Role • Effectiveness • Interventions • Evidence • outcomes
Abstract review conducted for relevance and outcome data
5052 articles from keyword search
NO 4933
Yes 119
No 80
Yes 39
TOTAL meeting study criteria
64
Ancestry Search
25
Assessed for meeting additional criteria in terms of methods and location of studies
Figure 1 Literature Search Results
Swider et al.: Public Health Nursing Effectiveness 331
However, PHNs demonstrated statistically signifi- cant outcomes across interventions designed to improve physiological, behavioral, and attitudinal client outcomes.
Discussion
The study had several limitations. Because of the lack of a standard role for PHN, nurses involved in the interventions had widely different functions, which made comparisons challenging. In addition, given the large number of studies identified via the ancestry method, the investigators cannot attest that our data collection included all of the relevant work from the time period. However, the realist approach guides literature search to sufficient arti- cles to help inform program theory development to address the research question; the authors are con- fident that they reviewed sufficient studies for this purpose. The authors did not search reports, white papers or other documents not formally published. The authors contend, however, that while such lit- erature is often conceptually important, it is unli- kely to contain research that was not published in journals. Similarly dissertations were not searched assuming that significant findings would be pub- lished in peer-reviewed journals.
While there was clear evidence of the effective- ness of PHN interventions in many reviewed stud- ies, the study limitations and the variety of interventions make conclusions about PHN effec- tiveness challenging. Contributing to this challenge was the lack of detail presented in the articles regarding the nature of the interventions. The study authors provided little description of the nursing role, protocols used in the intervention, or the training/background required of the interventionist, making replication difficult. This lack of detail makes comparison across types of interventions dif- ficult, so general conclusions about intervention effectiveness are not consistently supported by data.
The PHN interventions studied here focused predominantly on maternal-child populations; the remainder addressed adults with chronic illness or those unable to access care. This is consistent with the history of PHN practice with vulnerable popula- tions. Such interventions could be expanded to other vulnerable populations, including those with
long-term chronic illness, or the socially high risk, to further test the value of the PHN role.
The majority of the studies reviewed were not replicated across different racial/ethnic groups, set- tings, or times. Studies replicating PHN models and interventions would provide a more robust evi- dence base for practice across sites, populations, and time. Strong support for the current definition of the PHN role can be inferred from the variety of out- comes measured for PHN practice. However, given the state of current research, this variety may dilute the evidence base for specific PHN interventions. PHN researchers need to look at the existing research and develop interventions for the most promising outcomes, as defined by their uniqueness to the PHN scope of practice and potential impact on health status. This helps build the evidence base of PHN interventions and provides data for policy decisions about providers best suited to specific outcomes. From a policy perspective, PHN should focus efforts in those interventions where the evi- dence is strongest and where PHN practice adds value to the desired health outcomes. Results in these areas indicate that PHN practice demon- strates the definition provided earlier of the prac- tice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences.
Acknowledgments
This study was partially supported by HRSA AEN Grant D09HP03144-6-03.
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