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Public Health Nursing Vol. 29 No. 4, pp. 330–342
0737-1209/© 2012 Wiley Periodicals, Inc.
doi: 10.1111/j.1525-1446.2011.00989.x
SPECIAL FEATURES:METHODS
A Public Health Nursing Research
Agenda
1 2 3
L. Michele Issel, Ph.D., R.N., Betty Bekemeier, Ph.D., M.P.H., R.N., and Shawn Kneipp, Ph.D., A.R.N.P.
1 2
University of Illinois at Chicago, School of Public Health, Chicago, Illinois; University of Washington, School of Nursing, Seattle,
Washington; and 3University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, North Carolina
Correspondence to:
L. Michele Issel, University of Illinois at Chicago School of Public Health, 1603 W. Taylor Street (MC 923), Chicago, IL 60612.
E-mail: issel@uic.edu
ABSTRACT Public health nurses (PHNs) use many interventions to prevent illness and promote the
health of populations. Unfortunately, generating evidence regarding PHN practice is not explicitly identi-
fied as a research priority area of the major national funding agencies. Nor has PHN, as a profession, had
a strong enough research agenda to drive practice improvement on a population-level and to drive funding
to support such areas of research. To further advance the science needed to guide PHN practice, a
national conference to set the research agenda was held in October 2010 with grant support from the
Agency for Healthcare Research and Quality. The conference was part of a multimethod, participatory,
multistage approach taken to generate the final research priority themes and corresponding priority
research questions. The process yielded four high priority PHN research themes: PHN intervention mod-
els, Quality of population-focused PHN practice, Metrics of/for PHN, and comparative effectiveness and
PHNoutcomes. As the agenda is adopted by funding agencies, researchers, and practice-based partners, a
more focused program of research will produce evidence that can guide population-focused PHN practice.
Key words: models, public health nursing, quality, research priorities, safety.
Public health nursing (PHN) is recognized as a (Association of Community Health Nursing Educa-
nursing specialty, with a professionally established tors [ACHNE], 2010) that would support and
scope and standards of practice (American Nurses advance the PHN specialty focus. To further these
Association [ANA], 2007) and competencies (Quad priorities in advancing the science needed to guide
Council, 2003). The key defining characteristic of PHN practice, a national research agenda setting
PHN is population- and systems-level practice conference was held in October 2010 with grant
(American Nurses Association [ANA], 2007). Many support from the Agency for Healthcare Research
of the types of interventions and contributions and Quality (AHRQ). In this article, we report on
made by public health nurses to prevent illness and the process by which a set of high priority research
promote health across populations are not, how- themes were identified, as well as describe corre-
ever, explicitly identified as research priority areas sponding key research directions within each
of major national funding agencies which focus on theme. We conclude by providing recommendations
individual level outcomes. Nor has PHN as a pro- for advancing the scientific agenda.
fession had a strong enough research agenda to
drive practice improvement on a population level Challenges to Public Health Nursing
and to drive funding in support of priority areas of Scholarship
research. The Association of Community Health
Nursing Educators (ACHNE) has worked to estab- Fourmainchallengesexistforadvancingpublichealth
lish and advance a research agenda related to PHN nursing as a population-focused, evidence-based
330
Issel et al.: Public Health Nursing Research Agenda 331
practice. These challenges are artifacts of history, but individual/family focused practice to a more popu-
are not insurmountable with conscious effort. Briefly, lation/systems focused practice (Zahner & Gredig,
each challenge is described in relationship to its role 2005). This shift is consistent with the tone of the
in advancing evidence in support of PHN practice American Nurses Association [ANA] (2007) PHN
focused on the population and systems levels of scope and standards, and requires a corresponding
practice. shift in PHN scholarship and research. The shift to
One challenge is that public health nursing a population-focus requires conceptualizing and
practice is predominately situated in the public measuring both the nature and quality of PHN prac-
health system, not the medical care system. Being tice at a population level, as well as the population-
part of the public health system de facto gives PHN level outcomes the practice intends to affect (Issel &
practice less visibility than the much larger num- Bekemeier, 2010). The current environment of link-
bers of their nursing counterparts in other individ- ing acute care reimbursement to a minimum quality
ually oriented health care specialties (Bureau of of clinical care and denial of payments for adverse
Labor Statistics, 2011) and less status, as reflected events has created a strong incentive for hospitals
in lower salaries (Edwards, Wattoff, & Issel, 2010). and hospital-based clinicians to develop a broad
The PHN researchers (or potential researchers) research agenda focused on safety and quality and
therefore, need to find colleagues with whom to —more specifically—generate data sets with out-
create empirical synergies, such as scholars in pub- comes sensitive to nursing care. There is not yet a
lic health systems research and practitioners inter- PHN counterpart to the programs of research on
ested in practice-based research. The promising nursing’s role in providing safe acute care in a hos-
field of public health services and systems research pital setting (Friese, Lake, Aiken, Silber, & Sochal-
is still emerging as a relatively new area of research ski, 2008; Van den Heede et al., 2009).
along with its even newer development of formal A fourth challenge is that public health nursing
public health practice-based research networks has been relatively invisible as a specialty among
(Scutchfield, Mays, & Lurie, 2009). Unfortunately, funding agencies. A review of membership lists for
being part of a nascent field of study means that various advisory committees that set funding priori-
there are fewer research supports in place, whether ties reveals a dearth of PHN scholars on those com-
intellectual, financial, or methodological, especially mittees. Being inactive among key decision making
in comparison to research related to clinical treat- bodies has the consequence of further invisibility of
ment or other areas of health services. PHN in the larger system of research funding and
A corresponding second challenge is that public priority-setting and exacerbates difficulties in
health nursing practice is deeply embedded within accessing intellectual, financial, or methodological
a multidisciplinary and collaborative context. This research support. Contributing to this challenge is
embeddedness refers to a PHN practice that natu- the general paucity of research that would reinforce
rally functions through interdisciplinary collabora- the value of funding population level research. The
tions and community coalitions and that is based scarcity of population-level or population-focused
in organizations broadly encompassing a diverse set PHN research makes it difficult to break the cycle
of workers–including those not overtly considered of invisibility and generate support for funding in
health professionals, such as sanitarians. Most, if this area.
not all, public health nurses would argue in support A key step toward overcoming these challenges
of the benefits of this reality. Yet, representing one and addressing the issue of minimal national
health discipline among a diverse team of public understanding of PHN practice and workforce
health professionals can cloud and confound empir- issues as an important avenue of empirical scholar-
ical issues. The interdisciplinary nature of PHN ship is the development of consensus on a research
work makes it difficult to link the knowledge base, agenda which can be adopted by funding agencies
skill set, and other characteristics unique to PHN and can establish an iterative program of PHN
practice with specific outcomes of actions focused research. Similar work was done through the AHRQ
on populations. in setting a research agenda related to hospital
Another challenge is that public health nursing acquired infections (Stone et al., 2010). ACHNE
practice has been increasingly shifting from an was thoughtful in its approach to developing the
332 Public Health Nursing Volume 29 Number 4 July/August 2012
most recent research agenda for PHN and reinvigo- a set of eight priority areas. In doing so, duplicate
rated the need for additional focus on further questions were eliminated, and a few were com-
developing an evidence base for practice. The ACH- bined based on their similarities. For each priority
NE process, however, was internal to its member- area, a brief theme statement was developed by
ship and was derived exclusively from a PHN participants as a whole.
perspective. Given the multidisciplinary nature of To maintain, but continue to refine, the spirit
PHN, involvement of members from the broader of the suggestions from the October 2010 confer-
public health services and systems research com- ence participants, a round table session at the
munity—including nurses, health professionals and November 2010 annual meeting of the American
scientists from other disciplines—would be benefi- Public Health Association (APHA) was held. The
cial to further advance the scientific agenda of roundtable was devoted to obtaining further input
PHN. This was accomplished via a national, invita- from public health nurse researchers and practitio-
tional conference held in October 2010 and ners. The session started with a 20-min summary
described below. of the consensus conference and the themes from
the consensus conference that were discussed. The
Process to Develop the Agenda approximately 35 participants, then self-selected
into five groups, each led by a predesignated facili-
A multimethod, participatory, multistage approach tator. Facilitators were asked to assist each table
was taken to generating the final research priority group in reaching consensus on the relevance and
themes and corresponding priority research ques- importance of the identified themes and generating
tions. The process began by hosting an invitational additional key research questions, as desired. At the
conference bringing together 50 multidisciplinary end of this session, there was widespread support
experts from around the United States for a struc- for the themes identified in the AHRQ process, and
tured, working consensus conference focused on suggestions for how to proceed in meeting the pri-
the relationship of the quality, safety, and costs of orities identified in the themes.
population-focused PHN interventions to popula- Following the APHA session, the last step in
tion health outcomes. Conference planning was the process consisted of inviting the October 2010
conducted through participation of an eight mem- consensus conference participants to rank the eight
ber advisory committee made up of experts in the themes with regard to priority of addressing the
field of PHN research and public policy making. research topics and conceptually clarifying ques-
The focal areas of quality, safety, and cost were tions falling under each theme. All consensus con-
chosen for their relationship to the trends in health ference participants were electronically sent a
services and public health services and systems ranking survey. A total of 15 surveys were returned
research. The goal of the consensus conference was (32%), all from senior nursing faculty in attendance
to outline a set of research questions which would at the consensus conference. The rankings were
stimulate population-level and population-focused used to drop themes and corresponding research
research, leading to evidence-based PHN interven- questions that received the lowest rank. This
tions that improve population health outcomes. resulted in retaining the four highest priority
The conference design included invited papers themes, each with a subset of high priority research
reviewing state-of-the art research and methods in question foci. These themes and topics make up the
PHN and areas applicable to advancing PHN identified research agenda intended to guide PHN
research (Table 1). In facilitated small discussion researchers and research funding priorities related
groups, participants explored gaps in existing to PHN population-focused practice.
research, barriers and issues. At the end of the con- Various factors and circumstances may have
ference, an all-participant consensus-building pro- influenced both the process by which the research
cess was used to generate a draft set of research agenda was developed and the agenda itself. Most
agenda priorities in terms of research themes and notably, there are period effects in terms of when
their related topics or research questions. Following the conference was timed. Specifically, the date of
the conference, the themes and questions generated the conference coincided with both the National
by the participants were condensed and refined into Institute of Nursing Research holding a celebration
Issel et al.: Public Health Nursing Research Agenda 333
TABLE 1. Matrix of Topics Addressed at the Conference
Presentation titles Presenter Affiliation
Introduction Kristine Gebbie, Dr PH, RN, Hunter-Bellevue SON
FAAN Hunter College CUNY
Joan Hansen Grabe Dean
Outcomes focus
Outcomes from PHN Pamela Mitchell, Ph.D., RN, FAHA, SON, U of WA, Seattle,
Population-focused Interventions: FAAN
State of the Art Professor
Conceptual models for Jeri Bigbee, Ph.D., RN, FNP-BC, Department of Nursing
population-focused PHN FAAN Boise State University
interventions and outcomes Jody DeMeyer Endowed Chair
Existing nursing intervention Karen Monsen, Ph.D., MS, RN SON, U of MN
and outcome databases Assistant Professor
Existing non-nursing databases Doug Scutchfield, MD SPH, U of KY
for studying PHN processes & Professor
outcomes
Quality focus
Quality of care for AmyRosen, Ph.D., MSW SPH, Boston U
population-patients from PHN Professor
Interventions: State of the Art
Existing conceptual models Linda Olson Keller, DNP, RN, SON, U of MN
for understanding quality of BC, FAAN
PHNcare Clinical Associate Professor
PHNinterventions and Rita Munley Gallagher, Ph.D., RN National Center for
quality of PHN care Independent Contractor Nursing Quality,
American Nurses’
Association,
Methods/databases for studying quality of Robin Newhouse, RN, Ph.D., SON, U of MD at
population-focused PHN care NEA-BC, CNOR Baltimore
Associate Professor and Assistant
Dean
Safety focus
Safety for population-patients William Riley, Ph.D. SPH, U of MN
from PHN Interventions: State Professor, Associate Dean
of the Art
Conceptual models for Pat Stone Ph.D., MPH, RN, SON, Columbia U
understanding FAAN
safety of PHN care Professor
PHNinterventions and safety Shawn Kneipp, Ph.D., ARNP SON, U of NC at Chapel
for population-patients Visiting Associate Professor Hill
Databases/methods for studying safety Ron Bialek, MPP Public Health
of PHN population-focused care Executive Director Foundation
Contexts focus
Costs and PHN Interventions: Jack Needleman, Ph.D. SPH, U of CA at Los Angeles
State of the Art
PHNResearch and L. Michele Issel, Ph.D., RN SPH, U of IL at Chicago,
Health Care Reform
Current Priorities and Mary Hand, MSPH, RN Agency for Healthcare
Setting Agencies: AHRQ’s Process Health Scientist Administrator Quality and Research
Strategizing to Get Where Glen Mays, MPH, Ph.D. Fay W. Boozman
we Want to Be Chair, Department of Health College of Public Health,
Policy and Management UofAR
Medical Sciences
Note. SON=School of Nursing; SPH=School of Public Health.
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