Chapter 12 Population-Based Public Health Nursing Practice The Intervention Wheel Part 3

Scenario 1: Individual/Family Level of Practice

• Learning Objective: Apply the nursing process at the individual/family level of practice.
• Key principle: PHNs use the nursing process at all levels of practice and customize components (assessment, priority problem, planning, implementation, evaluation) for the three levels of practice (community, systems, individual/family). See Table 12.1 for outlines.
• Context: Home visiting as a strategy to address family-level risk factors; recognizing that parental mental health problems are a major stressor on children and that support from others and a caring environment can temper this vulnerability.

Public Health Nursing Process: Assessment (Case data sources)

• Data sources during community assessment:
  • Staff PHNs who work with families in clinics, schools, and homes
  • Community partners (health care providers, mental health workers, social workers, school personnel)
  • Preschool screening program data (past 5 years) on developmental delays/problems
  • County social services data (past 5 years) on substantiated child maltreatment/neglect
• PHNs participate in community meetings to prioritize issues.
• Identified top priority: Decreasing numbers of children at risk for delayed development, injury, and disease due to inadequate parenting by parents experiencing mental health problems.
• Community health plan goal: Decrease children with delayed development, injury, and disease attributable to inadequate parenting by providing a home visiting strategy.
• Rationale for home visiting: Enhances child environment and increases parental capacity to behave appropriately; parental mental health problems are a major stressor that can be tempered through support and caring environments.
• Home visiting as a family-focused intervention: Interventions delivered to families at the individual level with the goal of changing parental knowledge, attitudes, practices, and behaviors.

Case Study: Public Health Nursing Process — Assessment of a Family (Tyler, age 3)

• Profile: Ashley, 19-year-old single mother with severe depression; Tyler is her only child; lives in an old rental; limited public assistance; unstable partner situation; Ashley’s depression complicates engagement.
• PHN approach: Assess resilience, assets, protective factors, problems, deficits, and health risks; elicit Ashley’s perception of her situation (perception screening) to align professional assessment with client reality.
• Relationship-based practice: All PHN practice is relationship-based; establishing trust with Ashley is crucial, despite Ashley often being seldom out of bed; persistence leads to relationship development.

Public Health Nursing Process: Priority Problem

• Priority problem: Increased risk for delayed development, injury, and disease due to inadequate parenting by a primary parent experiencing depression.
• Population at risk: Young children whose primary caregiver has mental health problems.
• Prevention level: Secondary prevention (families have an identified risk).

Public Health Nursing Process: Planning (including selection of interventions)

• Based on assessment, the PHN negotiated meaningful, measurable intermediate goals:
  • Ashley will get out of bed at least 3 days in a week.
  • Tyler will be dressed when the PHN arrives.
  • Tyler will get to the bus on time 3 days in a row.
  • Clutter will be cleaned off the steps.
  • Ashley will call to make a doctor’s appointment for Tyler’s well-child check.
  • Ashley will use time-outs instead of spanking.
  • Ashley will read a story to Tyler twice a week.
  • These are intermediate indicators at the individual level aimed at changing knowledge, attitudes, motivation, beliefs, values, skills, practices, and behaviors that influence health status.
• Health status indicators to measure population impact:
  • No signs or reports of child maltreatment
  • Child regularly attends preschool
  • Immunizations up to date; well-child examinations per schedule
  • Family seeks medical care for acute illness as needed and does not seek inappropriate care
  • Child’s developmental tests within normal limits
• Interventions selected: collaboration, case management, health teaching, delegated functions, referral and follow-up.
• Considerations when selecting interventions: evidence of effectiveness, political support, acceptability to the family, cost-effectiveness, legality, ethics, greatest potential for successful outcome, and level of prevention.

Public Health Nursing Process: Implementation

• Sequence and frequency of home visits based on assessment; frequency ranged from weekly to twice monthly; initial weekly visits with spacing later.
• Interventions used:
  • Collaboration: Involve multiple caregivers (Tyler’s biologic father, Ashley’s aunt/uncle, grandparents, Ashley’s boyfriend).
  • Case management: Arrange childcare services and coordinate transportation for Tyler.
  • Health teaching: Provide information on child growth/development, nutrition, immunizations, safety, medical and dental care, and discipline to Ashley and caregivers.
  • Delegated functions (PHN to CHW): Place a community health worker in the home to model for Ashley; PHN supervises the CHW.
  • Referral and follow-up: Refer Ashley to early childhood services, legal aid, food stamps, mental health counselors, transportation.

Public Health Nursing Process: Evaluation

• Ongoing reassessment and plan modification at each visit; regular feedback to Ashley and caregivers; results documented and compared to indicators.
• Six-month outcomes:
  • Ashley: got out of bed most days, but rarely dressed; improved in getting Tyler to bus/preschool; CHW helped clean clutter; Ashley scheduled a doctor’s appointment for Tyler’s well-child visit but did not attend.
  • Ashley learned to substitute time-outs for spanking with CHW help.
  • Tyler: no signs of maltreatment; attended preschool regularly; immunizations still lagging due to missed appointment.
  • All developmental tests: within normal limits.
• PhN professional development: Reported results to supervisor; engaged with other PHNs to share issues and best practices and applied learnings.

Scenario 2: Community Level of Practice

• Learning Objective: Apply the nursing process at the community level of practice.
• Note: At the community level, the community assessment, program planning, and evaluation process is the public health nursing process.

Public Health Nursing Process: Assessment (Community Health Context: Childhood Obesity)

• Obesity is a serious pediatric problem with long-term health risks.
• Obesity prevalence (ages 2–19, CDC 2017–2018):
  • 2–5 years: $13.4\%$
  • 6–11 years: $20.3\%$
  • 12–19 years: $21.2\%$
• Obesity prevalence by race/ethnicity:
  • Hispanic: $25.6\%$
  • Non-Hispanic Black: $24.2\%$
  • Non-Hispanic White: $16.1\%$
  • Non-Hispanic Asian: $8.7\%$
• No significant difference in obesity prevalence by sex within age groups (CDC, 2021a).
• Public health link: Childhood overweight/obesity is associated with continued overweight/obesity into adulthood and higher risk of chronic diseases (CDC, 2022).
• Response: Health department leadership convened a childhood obesity prevention summit (80 participants) to discuss problems and solutions across healthcare, schools, childcare, and community organizations.

Public Health Nursing Process: Problem (Community Priority Problem)

• Priority: The percent of children aged 2–11 who are overweight or obese is unacceptable and threatens community health.
• Population of interest: Children aged 2–11.
• Level of prevention: Primary prevention.

Public Health Nursing Process: Planning (Including Selection of Interventions)

• Summit conclusion: Each organization commits to promoting healthy eating and physical activity for all residents, with emphasis on parents of young children.
• Recognition: A substantial portion of a child’s caloric intake occurs in childcare settings.
• Action: Initiate a 24-week evidence-based program to promote fruit/vegetable consumption among young children via licensed home childcare providers.
• Program: LANA the Iguana (Learning About Nutrition Through Activities)
  • Targeted produce: eight items – broccoli, sweet red pepper, cherry tomatoes, apricots, sugar snap peas, kiwi, sweet potatoes, strawberries (Fig. 12.8).
  • Activities: integrated into menus, classroom activities, and family involvement.

Public Health Nursing Process: Implementation (Community Program Details)

• Interventions selected: consultation, health teaching, social marketing, collaboration, surveillance.
• Key considerations in selection: evidence of effectiveness, community acceptability, cost-effectiveness, legality, ethics, and potential for success.

Community Implementation Plan (Social Marketing and Education)

• Social marketing approach: LANA as a marketing program using iguana puppets and storybooks, recipe cards, activities; retention incentives for providers (two grocery store gift cards) and children (plastic fruit/vegetable toys).
• Library integration: LANA kits (iguana puppets, activities, storybooks) placed in local libraries for parent check-out; PHNs wore the LANA costume to deliver curriculum and train providers/parents.
• Health teaching: Training home childcare providers to ensure fidelity to the curriculum.
• Consultation: Ongoing regular consultation with home childcare providers.
• Collaboration: Coordinated with health educators to develop/distribute LANA materials (curriculum guide, recipe books, storybooks, parent newsletters, puppets) and with public health nursing students to collect program evaluation data.
• Surveillance: Data collection on fruit/vegetable consumption in home childcare settings.

Public Health Nursing Process: Evaluation (Community Level)

• Follow-up surveys with county’s 75 licensed home childcare providers (serving ~500 children):
  • 67% of children more likely to eat fruits; 78% more likely to eat vegetables.
  • 92% of children more likely to try new foods.
  • 76% of providers offered fruits/vegetables more often at snack time.
• Interpretation: Establishing healthy eating habits among young children is linked to reduced obesity; program continues to be demonstrated in licensed home childcare providers and daycare centers (Dakota County, 2010; 2019).

Scenario 3: Systems Level of Practice

• Learning Objective: Apply the nursing process at the systems level of practice.
• Note: Some community problems emerge from practice rather than formal assessment; this scenario illustrates that reality.

Public Health Nursing Process: Assessment (Systems Level Context)

• Context: Longstanding concern about poor living conditions in an apartment complex where many clients lived.
• Issues observed: Moldy walls, dirty/deteriorated carpet, broken closet doors causing injuries; apartment manager required cash payments for repairs; increased rent after births; many tenants were undocumented Latinos with limited English proficiency; signed leases without noticing damage or problems; manager blamed tenants for mold and humidity; negative references from manager harmed relocation prospects; efforts to involve city officials failed due to lack of legal recourse.
• Complications: Manager’s hostility toward PHNs (towing cars); legal complexities; a nonfunctional smoke detector found during a home safety check; a family faced false negative references hindering move; multiple legal issues emerged.
• Insight: Systemic legal issues intersect with housing, immigration status, language barriers, and tenant rights; PHNs recognized need for legal/advocacy support.

Public Health Nursing Process: Priority Problem

• Problem: Families at risk of illness and injury due to hazardous housing and abuse of legal rights.
• Population at risk: Families living in hazardous housing in the apartment complex.
• Prevention level: Secondary (risk for injury/illness due to housing conditions and legal rights issues).

Public Health Nursing Process: Planning (Including Selection of Interventions)

• System-level goal: Change policies, laws, and structures; enforce tenants’ legal rights; improve housing conditions.
• Plan elements: Seek advice from a housing advocate service; connect clients with legal counsel; obtain supervisor and health department director clearance before proceeding.

Public Health Nursing Process: Implementation

• Interventions implemented:
  • Consultation with housing attorneys
  • Referral and follow-up through housing advocate service; tenants’ input needed before proceeding
  • Advocacy: Public health interpreter accompanied advocates to door-to-door outreach; interpreter attended meetings to interpret concerns; encourage tenant attendance
  • Policy development: Collaborated with housing attorneys to develop meeting agenda
  • Surveillance: Ongoing monitoring of housing conditions

Public Health Nursing Process: Evaluation

• Meeting outcomes: Many tenants attended; attorney moved to place rent in escrow until legal determination; manager dismissed due to fraud; a new manager hired who began improving conditions.

Linking Content to Practice: Practice Application (Intervention Wheel Wedges)

• Instruction: Select one intervention from each of the five Intervention Wheel wedges to apply to your public health practice; consider all three practice levels (individual/family, community, systems).
• Outreach example (definition): Outreach locates populations at risk and provides information about concerns, services, and access; success measured by proportion at risk who receive information and act.
• Example scenario: Breast cancer outreach in National Breast Cancer Month
  • A health system offered free mammograms via a mobile van at a mall; service reached 180 women, mostly in their 30s with health insurance coverage for preventive services.
  • A. Population most at risk of breast cancer?
  • B. Did the mammograms reach this population?
  • C. What outreach types would PHNs use to reach the population at risk?
• Note: Answers are available on the Evolve site.

KEY POINTS

• Public health system is under constant change and must stay focused on population health.
• The Intervention Wheel: a conceptual framework defining population-based practice; illustrates how interventions occur at the community, individual/family, and systems levels to improve population health.
• The Wheel is widely used as a practice model in state and local health departments; it is backed by 10 assumptions and includes 17 interventions.
• The Wheel is a companion to the Cornerstones of Public Health Nursing and originated from Minnesota Department of Health (mid-1990s) via grounded theory with extensive literature review.
• The Wheel serves as a common language across practice settings and supports documenting interventions performed by public health nurses.
• Core components of the Wheel: population basis, three levels of practice, 17 interventions.
• The Wheel has inspired innovation and adoption across nursing programs and service units (example: adapting by Navajo communities).
• The Wheel is used to teach and guide practice, aligning with the 10 essential public health services.

Clinical Decision-Making Activities
1) Describe the three components of the Intervention Wheel. How do they relate to each other? How can you apply them to your clinical practice?
2) Revisit Chapter 1 definitions of the core functions of public health practice and the 10 essential services. How does the Wheel address the core functions? How does it relate to the 10 essential services?

Additional Notes and Context

• Public health nurses collaborate with various sectors (schools, clinics, social services, mental health, legal aid) to implement comprehensive strategies.
• When applying the nursing process at any level, nurses must consider ethics, legality, social justice, cultural competency, and resource constraints.
• The content emphasizes evidence-based practice, community engagement, and the importance of evaluation data to guide program modifications and demonstrate impact.
• The content also highlights the importance of trust-based relationships, particularly when working with vulnerable populations (e.g., families dealing with depression, language barriers, or housing insecurity).
• Health equity considerations, including access to services, affordability, and systemic barriers, are implicit throughout the scenarios.

References to supporting documents

• Healthy People 2030 (2020): Public Health Reference
• CDC growth charts and obesity prevalence data (2017–2018) and related health policy implications
• Evolve site for lesson answers and additional resources
• LANA the Iguana program materials and Dakota County program evaluation (2010, 2019)
• Minnesota Department of Health interventions and Cornerstones of Public Health Nursing (context for Wheel adoption)