1 Chapter 1: Introduction to Population Health Nursing

1.1 What is Community Health?

Community health refers to a community’s physical, mental, and social well-being and involves health promotion, risk reduction, and disease prevention efforts to support health. Nurses in community health care for an entire community. They identify, assess, and respond to the health needs of populations (Kulig, 2000). A community is a group of people with at least one characteristic in common. The characteristic may be a place, a personal attribute, or a common goal. Every community has individuals with health problems and health risks. For example, members of communities that lack access to clean drinking water share health risks related to the harmful chemicals in their water, dehydration, and concern about a water crisis. A community situated near a busy highway may notice increased rates of hearing loss. Yet another community may see high rates of gun violence, leading to fewer children engaging in outdoor play. All communities, regardless of location or their members’ personal characteristics, have health risks and health needs and can benefit from the involvement of nurses with expertise in providing population health care. Remember, population health is an approach to supporting the health of people through research, data analysis, and health programming that considers the impact of public policy, environmental, social, behavioral, and other factors that might facilitate or hinder health for all.

1.2 The Nurse’s Role in Community Health

Public/community health nurses act as change agents in their communities, working to support health outcomes for clients and the broader population. They play a pivotal role in advancing the health of clients, communities, and families and in achieving population health objectives. The actions of public/community health nurses align with the principles and functions of public health: assessment, assurance, and policy development.

Nurses provide services to clients, families, groups of people, and the larger community in a specific place. The place may be a school or school district, health center, prison, or memory care facility, as only a few examples. Public/community health nurses may set goals related to each of the essential services and core functions, implement interventions, and lead aspects of care in the community to meet the public’s health needs and broad population health goals. They provide direct care, education, and assessments and fill other duties to promote health, prevent disease, reduce risk, and support the health of the determined community.

Public/community health nurses may work in specialty roles as school nurses, street nurses, occupational health nurses, home care nurses, correctional nurses, or clinic nurses. Public/community health nurses apply a community-focused lens to their professional practice. This lens provides a broader view of health and captures more of the community members in their professional efforts. Their work will involve promoting public health practices and preventing disease among large groups, such as those in schools, prisons, or community care centers.

While the community is the client, individuals and families can be recipients of care. Public/community health nurses also provide direct care to individuals and families outside of acute-care centers, such as in personal homes and clinics. Individuals and families may need direct nursing care and support to address their conditions and personalized health concerns. Public/community health nurses help individuals and families learn to manage conditions and can administer ordered care and treatments.

When a public/community health nurse cares for a client, family, or group, the benefits of such care extend to the community at large. The individual or family benefit from direct nursing care; and the community at large may experience reductions in communicable diseases, amelioration of health care disparities, lowered health care costs, and other benefits. To address health needs in the community, public/community health nurses may mobilize existing resources or develop new programs that will benefit clients and families across the community. They work with community members to determine their health priorities and align programs and initiatives with the community’s needs. This requires analysis of community member input and community-level health data.

1.3 Scope of Practice and Practice Standards

The American Nurses Association (ANA) provides a scope of practice and practice standards that guide the current, evidence-based, ethical work of public/community health nurses. Across nursing specialties, such documents or guides are called “scope and standards.” Scope of practice refers to the professional activities involved in a particular role. Defining a scope of practice helps nurses work within and to their level of qualification, expertise, and competence. Standards of practice are the principles and guidelines to which professionals must adhere. Standards of practice support nurses’ decision-making and delivery of care. Standards can change with the dynamics of the nursing profession and depend on specific contextual factors like clinical situations and circumstances. Nurses across specialties and care settings are expected to be familiar with and adhere to the scope and standards relevant to their professional role.

The ANA identified the following nine core concepts of practice based on the dynamic and complex work of public health nursing:

1. Social determinants of health
2. Community collaboration
3. Population health
4. Ecological model of health: Micro- to macro-levels
5. Culturally congruent practice: Respectful, equitable, and inclusionary
6. Levels of prevention
7. Ethics
8. Social justice
9. Health equity (American Nurse Association [ANA], 2022)

These principles provide a framework to guide public/community health nurses in practice and support their work in addressing the population’s needs and collaborating with varied parties.

Additionally, the American Nurse Association (2022) developed 18 standards of practice and professional performance for public health nursing. The standards for public/community health nursing follow standards set for nurses of any discipline or specialty by the ANA, which describe the who, what, where, when, why, and how of professional nursing practice (ANA [American Nurse Association], 2023). The standards of professional public health nursing practice are:

• Assessment: Collects comprehensive data pertinent to the health status of populations.
• Diagnosis: Analyzes the assessment data to determine actual or potential diagnoses, problems, and issues related to health and well-being.
• Outcomes identification: Identifies expected outcomes for a plan specific to the health status of the population or situation.
• Planning: Develops a plan that prescribes strategies to attain optimal health and well-being.
• Implementation: Implements identified plans.
• Coordination of care: Coordinates care delivery.
  • Health teaching and health promotion: Employs multiple strategies to promote health and safety.
  • Consultation: Provides consultation to enhance the abilities of diverse people to create and effect change.
  • Policy and regulatory activities: Participates in policy and regulatory activities related to health.
• Evaluation: Evaluates progress toward the attainment of goals and outcomes.
• Ethics: Practices ethically.
• Respectful and equitable practice: Practices with cultural sensitivity, humility, and safety in a manner that is congruent with principles of cultural diversity, inclusion, and equity.
• Communication: Communicates effectively in a variety of formats in all areas of practice.
• Collaboration: Collaborates with the population and others in the conduct of nursing practice.
• Leadership: Leads within the professional practice setting and the profession.
• Education: Seeks knowledge and competence that reflect current nursing practice and promote futuristic thinking.
• Evidence-based practice and research: Integrates evidence and research findings into practice.
• Quality of practice: Contributes to quality nursing practice.
• Professional practice appraisal: Evaluates personal nursing practice in relation to professional practice standards, guidelines, and relevant law.
• Resource utilization: Uses appropriate resources to plan and provide nursing and public health services that are safe, effective, and financially responsible.
• Environmental health, planetary health, and environmental justice: Practices in an environmentally safe, fair, and just manner (ANA, 2022).

Using this scope and these standards, public health nurses can help create healthier environments, foster partnerships that promote and protect health, and advocate for justice and health equity in practice.

1.4 American Nurse Association (ANA) Code of Ethics

Cultural and social identity are related but distinct concepts that refer to different aspects of a person’s sense of self and belonging. An individual’s cultural and social identities combine to form their cultural background. The American Nurse Association (2025) emphasizes the need for nurses to be aware of their cultural background to avoid letting personal biases affect the therapeutic relationship.

1.5 Core Competencies

Public/community health nurses must possess certain knowledge, skills, and attitudes to effectively fulfill their professional role and successfully meet the community’s health needs. In general, nurses need knowledge of epidemiology, environmental health, social determinants of health, statistics, evidence-based practice, health promotion, and factors that impact health. Public/community health nurses need strong communication and relationship-building skills to effectively engage with the community. Attitudes in alignment with social justice, health equity, and advancing health, as well as cultural humility and respect for all community members, are needed to fulfill the roles and responsibilities.

Public/community health nurses have a vital role in meeting the health needs of a community. Their expertise in epidemiology, environmental health, social determinants, statistics, evidence-based practices, and health promotion impacts the communities they serve and the greater population. These nurses build relationships with community members and local agencies to make appropriate connections and referrals in support of health. Nurses in this area must guide their professional practices with a social justice lens, recognizing that health disparities and inequities in communities exist and influence health.

1.6 Key to Achieving Positive Health Outcomes

1.7 Levels of Prevention

Much of public health focuses on prevention—preventing injuries, preventing acute illnesses, preventing chronic conditions, even preventing unexpected death. The five levels of prevention in public health are primordial, primary, secondary, tertiary, and quaternary (Figure 1.1). Not all public health professionals or nurses may consider primordial and quaternary prevention in their work; the concepts of primordial and quaternary prevention entered the health care lexicon in 1978 and 1986, respectively, while the other three levels of prevention are familiar to generations of clinicians (Kisling & Das, 2023; Martins et al., 2018).

• Primordial prevention focuses on risk factor reduction for an entire population and is usually carried out through large social changes and national policy (Falkner & Lurbe, 2020).
  • The American Heart Association has emphasized following the DASH diet (dietary approaches to stop hypertension), participating in physical activity, keeping a healthy body mass index, avoiding smoking, and consuming low or no alcohol as primordial prevention strategies to avoid risk factors for poor cardiac health (Lloyd-Jones et al., 2021).
• Primary prevention involves interventions to prevent an adverse health outcome from occurring. Primary prevention interventions may target the population, groups, and communities at high risk of a particular condition. Immunizations and education on healthy lifestyle factors are two examples of primary prevention strategies.
  • Medication overuse headache occurs when those who experience headaches take medications to address their pain but then have rebound headaches from using medications too often. A group of researchers designed and implemented an education campaign and guidance for primary care providers and clients on stopping overused medications to prevent this type of headache (Diener et al., 2019).
• Secondary prevention focuses on early disease detection to diagnose conditions early and promptly treat them to stop or slow progression and minimize impact. Screening is the primary activity in secondary prevention, but other activities may be conducted.
  • During an ischemic stroke, blood flow to part of the client’s brain is blocked. Following identification of an ischemic stroke, a secondary prevention strategy includes surgical placement of a stent to help restore blood flow (Diener & Hankey, 2020).
• Tertiary prevention strategies aim to lessen the negative impact of a health condition and prevent complications. Treatment through medications, surgical procedures, complementary modalities, therapies, and rehabilitation approaches are tertiary prevention activities.
  • Researchers studied an intervention to help individuals who are unhoused during the transition to becoming housed. Over six months, youth who were unhoused received outreach-based case-management services, individual and group mental health support, and peer support. Following program participation, the youth displayed gains in employment, education, and connection to mental health services (Kidd et al., 2019).
• Quaternary prevention aims to protect clients from health interventions that might cause more harm than good (Martins et al., 2018). To carry out quaternary prevention, clinicians attempt to avoid conducting tests and exams that are not essential to the client’s plan of care or well-being. For social problems, public health professionals address the risks and harm associated with excessive intervention.
  • For example, if a client presented to the urgent care clinic with a runny nose, cough, and no fever for three days with clear lung sounds, the clinician may reason that the client has a viral upper respiratory infection instead of a bacterial upper respiratory infection. Antibiotics would not be needed given the likely viral cause. Additionally, a viral panel to determine the causative agent would yield interesting results but would not change the client’s plan of care. Regardless of the virus, the client would be asked to avoid other people and public spaces, possibly wear a surgical mask when around others, hydrate, get rest, and use over-the-counter medications as needed.

Table 1.1 provides some examples of the levels of prevention applied to different health conditions. Of note, quaternary prevention is not included in the table, as the quaternary activities are generally focused on what clinicians should not do.

Condition	Primordial	Primary	Secondary	Tertiary
Cervical cancer	Mandating health plan coverage of cervical cancer screening tests	HPV vaccine administration	Cervical cancer screening tests	Electrosurgical excision to remove diseased tissue from the cervix
Preeclampsia	Mandating health plan coverage of prenatal visits	Blood pressure monitoring and urine testing during pregnancy	Medications to control blood pressure	Immediate delivery of the baby on conversion to eclampsia
Migraine	Promoting migraine-friendly schools and offices	Educating individuals about migraine triggers	Medications for symptom relief and prevention	Specialized infusions for chronic pain management
Influenza	Use of masks, handwashing, and cough courtesy	Annual vaccine administration	Rapid influenza testing	Antiviral treatments
Food insecurity	Funding of social safety nets to reduce poverty and food inaccessibility	Food assistance programs and community gardens	Referrals to food banks and government assistance programs	Employment assistance, financial literacy, and budget training
Gun violence	Comprehensive gun control policies	Safe firearm storage education	Early identification of perpetrators and deployment of crisis response	Emergency care and support for victims
Youth social media and mental health	Positive digital citizenship and online behavior guidelines for students	Cyberbullying, privacy, safety, and screen time education	Twice-yearly mental health screenings in schools	Therapy programs to address mental health and promote coping strategies

Table 1.1 Levels of Prevention Examples

References

American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. Accessible online at https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf

American Nurses Association (2025). Code of ethics for nurses. https://codeofethics.ana.org/home

American Nurses Association. (2022). Public health nursing: Scope and standards of practice (3rd ed.). American Nurses Association.

American Nurses Association. (2023). Nurses serving in Congress. Practice & Advocacy. https://www.nursingworld.org/practice-policy/advocacy/federal/nurses-serving-in-congress/

Diener, H.C., Dodick, D., Evers, S., Holle, D., Jensen, R. H., Lipton, R. B., Porreca, F., Silberstein, S., & Schwedt, T. (2019). Pathophysiology, prevention, and treatment of medication overuse headache. The Lancet Neurology, 18(9), 891–902. https://doi.org/10.1016/S1474-4422(19)30146-2

Diener, H.C., & Hankey, G. J. (2020). Primary and secondary prevention of ischemic stroke and cerebral hemorrhage. Journal of the American College of Cardiology, 75(15), 1804–1818. https://doi.org/10.1016/j.jacc.2019.12.072

Falkner, B., & Lurbe, E. (2020). Primordial prevention of high blood pressure in childhood: An opportunity not to be missed. Hypertension, 75(5), 1142–1150. https://doi.org/10.1161/HYPERTENSIONAHA.119.14059

Kidd, S. A., Vitopoulos, N., Frederick, T., Leon, S., Karabanow, J., & McKenzie, K. (2019). More than four walls and a roof needed: A complex tertiary prevention approach for recently homeless youth. American Journal of Orthopsychiatry, 89(2), 248–257. https://doi.org/10.1037/ort0000335

Kisling, L. A., & Das, J. (2023). Prevention strategies. StatPearls. http://www.ncbi.nlm.nih.gov/books/NBK537222/

Kulig, J. C. (2000). Community resiliency: The potential for community health nursing theory development. Public Health Nursing, 17(5), 374–385. https://doi.org/10.1046/j.1525-1446.2000.00374.x

Lloyd-Jones, D. M., Albert, M. A., & Elkind, M. (2021). The American Heart Association’s focus on primordial prevention. Circulation, 144(15). https://doi.org/10.1161/CIRCULATIONAHA.121.057125

Martins, C., Godycki-Cwirko, M., Heleno, B., & Brodersen, J. (2018). Quaternary prevention: reviewing the concept: Quaternary prevention aims to protect patients from medical harm. European Journal of General Practice, 24(1), 106–111. https://doi.org/10.1080/13814788.2017.1422177

Quad Council Coalition Competency Review Task Force. (2018). Community/public health nursing competencies. https://www.cphno.org/wp-content/uploads/2020/08/QCC-C-PHN-COMPETENCIES-Approved_2018.05.04_Final-002.pdf