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Moving Upstream: Becoming a Public Health Nurse, Part 2 Lee SmithBattle, R.N., D.N.Sc.,

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

Abstract This article extends the argument in Part 1 that stand-

ards, protocols, textbook knowledge, and other external guide-

lines, while important for beginners, must yield to the ‘‘real

world’’ of practice. Additional narratives document how the

development of practical reasoning, perceptual skills, and

responsiveness to clients supplants the beginner’s reliance on

external guidelines and promotes a situated understanding of

practice. This growth in understanding and clinical know-how,

cultivated by frontline experience with individuals and families,

fosters a perceptual grasp of the ‘‘big picture’’ and makes it

possible for the nurse to learn the community through the eyes

of clients. Experiences from home visiting and community-based

activities provide critical lessons that inform and inspire nurses to

act and think upstream. This interpretation provides add-

itional evidence for legitimating clinical practice as a rich source

of situated knowledge and clinical reasoning.

Key words: clinical knowledge, community health nursing,

population-based care, public health nursing.

When I first came out of school, we had ideas that we

were going to get everybody to stop smoking, lose

weight, exercise, see the doctor, take your medicine

on time, just because we talk to them. I mean that

was unrealistic. We thought the whole world was just

waiting to hear the word. They weren’t. And if you’re

trying to measure your success and nothing shows up,

then you start getting depressed because [it seems that]

you’re not doing anything. Then you realize you better

start counting your successes by a whole lot of smaller

increments, according to the real world.

The above excerpt supports the argument developed in Part 1 (see SmithBattle, Diekemper, & Leander, 2004), namely, that the beginner’s reliance on external guidelines and classroom principles and theories, while important, must yield to the ‘‘real world’’ of practice. In Part 2, additional exemplars highlight how the development of practical reasoning, perceptual skills, and responsiveness to clients supplants inexperienced public health nurses’ theoretical understanding and promotes a situated under- standing of practice (SmithBattle, Drake, & Diekemper, 1997). This growth in understanding and clinical know- how, cultivated by frontline experience with individuals and families, fosters a perceptual grasp of the ‘‘big picture’’ and makes it possible for the nurse to learn the community through the eyes of clients. This natural outgrowth of experiential learning inspired several inexperienced public health nurses to move upstream and to become involved in population-focused care.

GAINING A SITUATED UNDERSTANDING OF PRACTICE

After gaining considerable experience, the practice of the less-experienced public health nurses began to shift from a predetermined, nurse-directed agenda that was theory based or driven by the original referral, agency protocols,

We use the terms public health nursing and community health nursing

interchangeably.

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

American Public Health Association Meeting on November 14, 2000 in

Boston, Massachusetts.

Lee SmithBattle is Associate Professor, Saint Louis University, St

Louis, Missouri. Margaret Diekemper is Associate Professor, Maryville

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

Instructor, Saint Louis University, St Louis, Missouri.

Address correspondence to Lee SmithBattle, Saint Louis University,

3525 Caroline Street, St Louis, MO 63104. E-mail: smithli@slu.edu

Public Health Nursing Vol. 21 No. 2, pp. 95–102

0737-1209/04 # Blackwell Publishing, Inc.

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or documentation systems to a situated understanding of practice. With the refinement of perceptual and relational skills, public health nurses began to ‘‘see’’ larger patterns and subtle cues in individual and family responses that had eluded them earlier. Their early reliance on scientific evidence and practice guidelines for defining clinical suc- cess was refined or supplanted by a more nuanced under- standing of clients’ social embeddedness and a greater respect for clients’ practical reasoning. As a result, under- standing of clinical success was redefined and directly linked to the specifics of a clinical situation. This growth in understanding made the public health nurses less likely to blame clients for their circumstances. As one nurse reported: ‘‘The biggest danger of working is getting burned out and blaming people for their problems . . . But the more I understand, the less I have a desire to blame.’’ Another nurse confirmed that her understanding of practice changed dramatically as she became more open and flexible:

I’m sure early on I was naive enough to believe I could

change the world, but that certainly has changed. [Int:

How has your understanding changed?] . . . I’ve been

working with a lot of sick families for a couple of

years . . . Sometimes I think that my whole role in com-

munity health nursing—the social service stuff is bene-

ficial to these families, helping them get their children

immunized and into appointments, that’s important

too—but I really think in some ways my main role is

just to be a presence for people who haven’t had some-

one consistent in their lives and who is committed to

who they are and committed to their family. And so

that’s my primary role and this other stuff just comes

with it. I think that’s probably the most important thing

that I can offer these families—is being a consistent

person in their lives. When they’re not in crisis, they

know I’m still gonna be there. And when they are in

crisis, they trust and know that there’s somebody out

there who is some sort of safety net . . . [Int: Now was

there a situation that changed your understanding from

saving the world [to being present with families?] I don’t

know if it was one particular experience. I think it was

two, three, four, five different experiences that [taught

me] the same thing . . . I’ve been working with [many]

families for two years now. And they’re really in no

different place than they were two years ago. And that

made me stop and evaluate. Because when I started

working with them, you have that energy and enthu-

siasm. OK, I’m gonna get them into school and help

them get a degree, and better their lives, and go to work,

and value health care and all that kind of stuff. And two

years later, these families are still on welfare, relocating

every six months, and health care is still lower on the

rung because there are other things they’re paying atten-

tion to. And so these families have not adopted my

priorities (laughter). And the things that I was told as

a CHN you do for people. You could get discouraged.

But for me, what happened was reframing it in a way

that lets me stay with families over the long haul and to

realize that their lives are their lives and my priorities

may not be theirs. And you kind of know this but it’s

not until you have the experience . . . I’m still not OK that

these families are in the situations that they’re in. But I

think what I realized is that it’s bigger than they are.

That it’s much more [a result] of the political and the

social system . . . There’s so much out there that keeps

them where they’re at. So rather than expecting

dramatic changes to happen in their lives and lifestyles,

that’s what shifted for me, maybe it’s just about offering

a presence . . .

Similar to the public health nurse whose comments began this paper, this nurse reflects on how the ‘‘real world’’ moved her away from trying to achieve the utopian, norm-based outcomes of health-promotion theories supported by population-based epidemiological findings with the families on her caseload. Experiential learning led both nurses to question the prevailing ideol- ogy in which health and lifestyle choices are promoted in a vacuum, regardless of a person’s or family’s history, resources, and understandings of what are worthy ends and commitments. Rather than becoming demoralized or blaming families for their dire circumstances and lack of clinical progress in meeting predetermined outcomes, the public health nurses’ understanding broadened to incorp- orate an insider perspective that led to clinically based notions of success. This clinical reasoning diverged from classroom and textbook theory and was better attuned to the possibilities and impossibilities of specific clinical situations.

So then, what constitutes ‘‘success’’ with a family? The above nurse was quick to elaborate with an example:

My idea of success with a family is what happened to

me last week. Here’s a mom with six kids. I’ve been

following them a year and a half. My first encounter

with them was when the children were lead poisoned

and I knocked on the door. I asked for the mom and

the woman told me she wasn’t there. So I left a mes-

sage. Did this about three different times. And I finally

met mom in the doctor’s office and it was the woman

who answered the door who told me that she wasn’t

there! (laughter) [Int: And you had no suspicion?] I had

no suspicion. You think it would have dawned on me.

But it didn’t. I was new. And so it went from that to

meeting with mom on the porch. And then there was

the day she invited me into the living room. And last

week, I got a telephone call from her saying, ‘‘Did you

read in the newspaper about the woman who was

killed and put in a fridge?’’ It happened to be her

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

next door neighbor. ‘‘Can you come over?’’ So it went

from this woman not even acknowledging who she

was, to calling me and saying,…