Public Health Nursing Competency 1

Running Head: Public Health Nursing Competency Tools

Public Health Nursing Competency

A Review of Literature

Michelle D. Kelly

Instructional Design N 704

Dr. Prion

June 21, 2008

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Public Health Nursing Competency:

A Review of Literature

Background

Is there a lack of consistency in clinical evaluation among Bachelors of Science in

nursing (BSN) programs in California to assure up to date PHN competencies in their graduates?

There is a wide and seemingly unconnected variety of educational outcomes among the 28

schools of nursing (SON) in California providing PHN coursework approved by the California

Board of Registered Nursing (BRN). California is one of two states in the United States that

offers PHN certification and specifies the use of title “public health nurse” as advanced practice

in a bachelors prepared RN. With completion of a BSN in California and registered nurse (RN)

licensure, candidates are eligible for California PHN certification. BSN programs in California

have a wide variety of clinical and evaluative methods in PHN courses. What does the literature

indicate as themes in PHN competencies and are there effective tools to measure PHN

competencies by educators?

Introduction

This paper will briefly describe the impact of poorly prepared PHN graduates as well as

contemporary themes identified in the literature on PHN competencies and the evaluation of

PHN competencies in BSN programs. The author used a broad approach to search the literature

with the intention of being more inclusive in this preliminary review of literature related to PHN

competencies. For example, non-research articles, editorials and looking at community health

competencies in non-BSN programs outside of California may possess useful information and

are therefore included. This review presents five recent articles (2004 to 2006) on PHN
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competencies with the arrangement of first general then progressively to specific themes. PHN

competency themes presented are:

1. Specialty competencies as a guide to course development,

2. Practice recommendations,

3. Competency self-rating,

4. Faculty knowledge, and use of PHN competency tools,

5. PHN competency tool.

Impact and Scope

The public deserves entry level PHN’s with minimal competency, and the need for health

promotion and disease prevention from BSN’s have never been higher (Public Health

Foundation [PHF], 2005). BSN’s need to be adequately prepared for population based practice

to deal with anything from disaster response, chronic disease prevention, violence to policy

making. Impact on the overall health status of populations with less than fully capable PHN’s is

vast. The need for well-educated and clinical prepared PHN’s along with other public health

workers is widely documented in the literature. Population based services moved from

communicable disease control to environmental and behavioral root causes over the last 50

years. Failure to prepare BSN graduates has a costly impact as described in a 2005 Public Health

Foundation Press Release:

“Lack of Performance Tools and Measures Undermines

Preparedness Efforts. In response to today's release of the Trust for

America's Health report card on our Nation's preparedness, the

Public Health Foundation (PHF) calls on Congress to make new

investments to eliminate the chaos and confusion that contributed

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to our woefully inadequate response to disasters like Hurricane

Katrina.”

(PHR, 2005, pp. 1)

Review of Literature

In the article Using Professional Specialty Competencies to Guide Course Development,

Foss, Janken, Langford and Patton (2004), described the reformulation of a RN to BSN

community health (CH) course at the University of North Carolina and introduce a new clinical

evaluation tool. The CH course evolved from a traditional precepted clinical rotation with a

required number of clinical hours to a series of modules with performance-based competencies.

CH faculty choose competencies from the Association of Community Health Nursing Educators

(ACHE) which were described as critical knowledge, values, and clinical skills needed to

demonstrate mastery of specific competencies. The article described a new CH course evaluation

tool of six learning modules covering all thirty–six ACHE competencies. Students completed a

series of self-directed online activities and provided written reports as evidence of mastery to

faculty. The strengths of the course and clinical tool were that faculty directly evaluated students

work rather than relying on preceptor feedback and faculty spent their time on evaluating student

work versus non-scholarly work such as setting up placements and dealing with contracts.

A few limitations in translating Foss’s (et al) work on specialty competencies to PHN-BSN

programs in California are worth noting. The students in their course were all RN’s and it is

unknown how the ACHNE tool would work with generic students, the performance based

education was evaluated solely on written reports, and self-directed activities did not take place

in a actual CH work setting. Curriculum based on competency is one concept in PHN education.
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However, do competencies from ACHNE and other PHN competency tools keep up with the

dynamic practice of PHN? What do PHN practitioners report about their evolving roles?

Zahner and Quynh (2005) looked at themes of PHN practice change and

recommendations for improvement from staff level PHN’s. A cross sectional written survey was

collected from a sample (n =424) of PHN’s representing 81% of local health departments in

Wisconsin with five or more years of PHN work experience. The research aimed to explore the

degree of recent practice change in among PHN’s practicing in Wisconsin. The survey

instrument included demographic characteristics, characteristics of practice change over the

previous 5 years measured on a 5-point Likert-type scale and with open-ended questions.

Researchers used STATA 8.0 to analyze the characteristics of change data. The results relevant

to this paper and to nursing education were the majority of respondents’ perceptions of an

increase in population focus and with a reduction of focus on individual and direct service in

their practice over the last 5 years. The respondents also recommended to increase of continuing

education and peripherally mentioned the need for collaboration with SON. The need for

collaboration between academia and practice is more prevalent in the next article.

In a the study Self-Reported Competency of Public Health Nurses and Faculty in Illinois

(Issel, Baldwin, Lyons, & Kusuma, 2006) researchers sent questionnaires to all SON and public

health departments in Illinois with responses from 168 PHN’s working public health departments

and 46 PHN course faculty. The study endeavored to both assess and compare competency levels

of PHN’s and PHN faculty via self-reporting on ACHNE’s nine categories of competency. The

study’s sample size complied with Cronbach’s alpha scale of internal consistency and the

questionnaire was piloted to validate content. Participants completed 67 items rated on a 5-point

Likert scale to self-rate their PHN competencies. Results revealed PHN’s self-reported practice
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competency in only one area and PHN faculty did not feel competent to teach in any of the nine

categories. PHN’s and PHN faculty in this study reported less than minimal competency and the

authors identified a need for formal education and workforce enhancement. This study illustrated

a profound lack of self-perceived competency among the sample of PHN’s and PHN faculty in

Illinois. Most alarming was faculty did not feel competent to teach PHN content. A defect of the

study was the sole focus of ACHNE competencies without a rationale for selection of ACHNE

over other PHN competency tools. What other major current PHN competency tools are in the

current literature?

Oppewal, Lamanna, and Glenn’s (2006) research on PHN competencies in

practice and academic settings aimed to illustrate similarities and differences in the use of core

standards of practice. The survey was a non-experimental, descriptive study in which researchers

assessed participants’ knowledge and use of both the 2001 COL Core Competencies for Public

Health Professionals and the Quad Councils PHN Competencies (2003). A sample of 334

respondents received invitation via email to complete a web-based survey from three

professional PHN organizations in the United States. The survey tool had 17 open and closed

ended questions that queried participants on their level of familiarity with COL and Quad

Council competencies. The results indicated that the sample was equally familiar with both

competencies. Researchers reported two thirds of the PHN’s were informed of the competency

documents through their professional PHN organizations, and faculty integrated competency

tools far more rapidly that rate than practitioners. The study also found that participants who

once they adopted a competency tool continued use of the tool, also professional PHN

organization were described by researchers as a workable means of disseminating competency

tools. The 70% participants who were familiar with the core competencies used them in work or
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education settings. Eighty-eight percent of respondents who did not use core competencies

reported that they would be more inclined to use them if their host institution or employer

publicized and encouraged their use of core PHN competencies. Twenty percent of faculty

respondents had seen or heard of the core competencies in contrast to only 46% of practitioners

indicating a level of familiarity.

The limits of the survey were the homogeneous sample with 85% with masters or higher

degree and membership in a professional PHN organization would be more likely to aware and

informed of new developments in their discipline than a sample of respondents who did not

belong to a professional organization. The descriptive tool teased out unique key themes from

participants and their familiarity and use of core competencies in practice and academic settings.

Unique themes to knowledge and adaptation of core competency tools identified in the sample

were: lack of assess to current PHN professional information, lack of time, staff, and or budget

and barriers to curricular change or faculty adherence to another competency tool.

In 2003, the Quad Council of Public Health Nursing Organizations (Quad Council) put

together PHN competencies for utilization by educators and practitioners across the United

States (Kalb 2006). The Quad Council established a long awaited performance appraisal tool

specifically designed to provide a framework to both practitioners and educators to evaluate

PHN competencies. Contributors and consensus building in the Quad Council involved the PHN

section of the American Public Health Association (APHA), the Association of State and

Territorial Directors of Nursing (ASTDN) of Association of Community Health Educators

(ACHE) with input from the Centers from Disease Control (CDC) and Council of Linkages

(COL). The Quad Council provides a eight page PHN Grid of Performance which differentiates

levels of practice competencies of RN, PHN field nurse, nurse practitioner, Clinical Nurse
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Specialist and Nursing Supervisor. Kulbok describes the Quad competencies as the definitive

tools to assess PHN faculty competence and guide PHN course curriculum (2006).

Shortcomings of the Quad PHN competencies are a lack documented involvement of nursing

education accreditation bodies, state boards of nursing in agreeing to and actively requiring use

of the competencies in education and at the state practice levels. Critical aspects of the grid are

the categories are encompassing and pliable. The grid does not include a PHN student as a

specific level of practice, but the differentiation between the RN and field PHN roles are useful

for educators to discern what is pre-licesure CH practice from the unique competencies of the

advanced PHN role. Yet, the Quad categories of competencies may be difficult for SON to

incorporate into established curriculum strands and clinical evaluation formats.

Analysis

PHN competency themes presented were; 1) specialty competencies as a guide to course

development, 2) practice recommendations, and 3) competency self rating methods, faculty

knowledge and barriers in the use of PHN competency tools and 2003 Quad Council PHN

competency tool. This preliminary review of literature shows the fields of public health nursing

and BSN education are evolving and just beginning to look at the use competency tools and

standards of performance appraisal in the work place and frameworks for curriculum design.

Specialty competencies can appropriately steer nursing curriculum, yet the experts in the area of

PHN, both field practitioners and faculty rate their own abilities as low. In the meantime, the

field of PHN is moving to population based care and a revision of the current models of BSN

education need updating to maximize workforce readiness. Faculty report more access to

updated PHN competency materials but research on use of and recommendations on ACHNE,

COL and Quad Council competency tools are lacking.

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Conclusion

The need for graduates to be competent in population based work paramount for nursing

education’s role in preparing BSN for the public. Are BSN educators in California moving in the

right direction to prepare what the Public Health Foundation calls for in current graduates to be

Champions for Public Health as called for by the Public Health Foundation (2005)? In 2006,

Kalb, Cherry, Kauzloric, Brender, Green, Miyagawa and Shinoda-Mettler published the

Competency-Based Approach to Public Health Nursing based on the 2003 Quad Council’s work.

These and other PHN clinical competency tools lack integration into the PHN workplace and

academic courses (Oppewal, Lamanna, Glenn, 2006). Tools to measure PHN student’s clinical

performance are available yet educators and practitioners fail to use it. The underlying concept

of uncertainty about the actual level of practitioner and faculty competency seems to directly

influence with progression to establish statewide benchmarks for PHN student performance.

More examination the appropriate selection and effective use of competency tools in PHN

practice and BSN education specifically in California are needed.

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References

Bastable, S. (2003). Nurse As Educator: Principles of Teaching and Learning for Nursing
Practice, ed 2, Jones and Bartlett Publishers. Sudbury, MA

California Board of Registered Nursing. Public Health Nurse Certification Requirements,

Retrieved on May 20 2008 from http://www.rn.ca.gov/pdfs/applicants/phn-app.pdf

Foss, G., Janken, J., Langford, D., & Patton, M. (2004). Using Professional Specialty
Competencies to Guide Course Development. Journal of Nursing Education, 43(8),
368-375. Retrieved June 3, 2008 from CINAHL with Full Text database.

Issel, M., Baldwin, K., Lyons, R., & Kusuma, M., (2006). Self-Reported Competency of Public
Health Nurses and Faculty in Illinois. Public Health Nursing, 23(2), 168-177. Retrieved
June 1, 2008 from CINAHL with Full Text database.

Kalb, K., Cherry, N., Kauzloric, J., Brender, A., Green, K. Miyagawa, L., & Shinoda-Mettler, A.
(2006). A Competency-Based Approach to Public Health Nursing Performance
Appraisal. Public Health Nursing, 23(2), 115-138. Retrieved June 1, 2008 from
CINAHL with Full Text database.

Kulbok, P. (2006). PHN Competencies. Public Health Nursing, 23(2), 97-98. Retrieved May 28,
2008, from CINAHL with Full Text database.

Scharff, DP. "Bridging research and practice through competency-based public health
education." Journal of public health management and practice 14.2 (2008):131-.
Retrieved May 28, 2008, from CINAHL with Full Text database.

Public Health Foundation, December 5, 2005. Press Release. Lack of Performance Tools and
Measures Undermines Preparedness Efforts. Retrieved on May 28, 2008 from:
http://www.phf.org/performance-press-release.htm

Oppewal, S., Lamanna, B., & Glenn, L. (2006). Comparison of the Dissemination and
Implementation of Standardized Public Health Nursing Competencies in Academic and
Practice Settings. Public Health Nursing, 23(2), 99-107.

Public Health Foundation (PHF). (2005, December 6). Lack of performance tools and measure
undermines preparedness efforts. Retrieved June 2, 2008, from
http://www.phf.org/performance-press-release.htm
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Zahner, S. & Gredig, Q. (2005). Public Health Nursing Practice Change and Recommendations
for Improvement. Public Health Nursing, 22(5), 422-428. Retrieved June 1, 2008 from
CINAHL with Full Text database.