Population-Based Care: PHN Scope of Practice

Population-Based Care: PHN Scope of Practice

Families play a crucial role in the development of infants and young children. However, many families across different states in the United States, including Minnesota, face challenges that hinder their children’s development. According to the Minnesota Department of Health (2023), factors such as poverty and adverse experiences disproportionately affect children and families in disadvantaged communities, increasing their risk of health disparities later in life. Public health nurses (PHNs), with their unique blend of clinical expertise, community knowledge, and advocacy skills, are positioned as effective agents of change in reducing health disparities among families with infants (Schoon & Porta, 2023). This paper delves into the role and scope of practice of public health nurses (PHNs) in population-based care by reflecting on my shadowing experience with a PHN during her needs assessments of families with infants.

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Summarizing the Role and Scope of Practice of the PHN

Family home visiting is a voluntary program that provides families with support and information during pregnancy and the early years of a child’s life. The program helps parents create a safe and healthy environment for their children, provides parenting skills, and connects families to community resources (Minnesota Department of Health, 2023). The PHN I shadowed demonstrated a broad scope of practice, including various aspects of public health nursing. She conducted comprehensive assessments of families with infants, gathering information about their health history, social determinants of health, and current needs. She then provided anticipatory guidance and education to families, covering infant development, nutrition, immunizations, and safety topics.

The PHN also played a crucial role in connecting families to community resources. She identified available resources that addressed the specific needs of each family, such as early childhood programs, parenting support groups, and nutrition assistance programs. She then facilitated the connection between families and these resources, ensuring they received the support they needed (Schoon & Porta, 2023). Her practice aligned seamlessly with the characteristics and health needs of the population she served, primarily low-income families with young children. The PHN advocated for the health and well-being of families. She collaborated with other healthcare providers to ensure coordinated care and addressed any health disparities families face. She also engaged in community outreach and education, promoting healthy behaviors and raising awareness about public health issues.

Specific Public Health Interventions and Level of Prevention

The PHN provided various public health interventions that addressed primary, secondary, and tertiary levels of prevention. Primary prevention focuses on preventing health problems before they occur (Minnesota Department of Health, 2019). PHNs and LSNs actively engage in anticipatory guidance and education, empowering families to make informed decisions and adopt healthy behaviors that promote infant well-being. The PHN provided anticipatory guidance and education to families, empowering them to make informed decisions and adopt healthy behaviors to prevent future health problems. This included educating parents about infant development, nutrition, immunizations, and safety practices.

Secondary prevention involves identifying and addressing health problems early to minimize their severity and impact. According to the World Health Organization (2023), surveillance is the ongoing collection, analysis, and interpretation of health data to improve health outcomes. The use of data to improve care in nursing has a long history traced back to the 19th century in Florence Nightingale’s work. The PHN I shadowed conducted screening and surveillance activities to identify potential health problems early on. She assessed infants’ growth and development, monitored for signs of illness, and provided timely referrals for further evaluation when necessary (Minnesota Department of Health, 2019). At the tertiary prevention level, the PHN provided targeted support to families facing health challenges with their infants. She provided case management and support to families with infants facing health challenges. She coordinated care with other healthcare providers, developed individualized care plans, and assisted families in accessing necessary resources.

Henry Street Consortium Population-based Public Health Nursing Competencies

The Henry Street Consortium (2022) outlines the five foundational assumptions underpinning public health nurse interventions on the wheel, which include a concentration on the entire population, a foundation grounded in the assessment of community health, a prioritization of health promotion and prevention, and the implementation of interventions at various levels. The PHN I shadowed demonstrated several Henry Street Consortium population-based public health nursing competencies in her practice. First, she conducted comprehensive needs assessments of families within the community, identifying their strengths, challenges, and resource needs (Schoon & Porta, 2023). She then tailored her interventions to address the specific needs of each family. Additionally, she demonstrated cultural sensitivity and understanding when interacting with families from diverse backgrounds. She considered their cultural values, beliefs, and practices when providing care and education. Furthermore, she upheld ethical principles throughout her practice, maintaining confidentiality, respecting families’ privacy, and advocating for their best interests.

Benefits of Public Health Nursing Services

The public health nursing services provided by the PHN I shadowed yielded numerous benefits to individuals, families, and the community. At the individual level, families with infants receive comprehensive and personalized care. The PHN conducted thorough needs assessments, considering health histories, social determinants, and current needs. By tailoring interventions to the specific needs of each family, the PHN ensured that individuals received targeted support, ranging from anticipatory guidance to connecting them with community resources (Schoon & Porta, 2023). This personalized approach addressed immediate health concerns and empowered families to make informed decisions about their health and well-being.

At the family level, the PHN’s role as a connector to community resources played a pivotal role. The PHN strengthened the family’s support system by identifying and facilitating access to resources such as early childhood programs, support groups, and nutrition assistance programs (Minnesota Department of Health, 2023). This contributed to the overall well-being of the family unit and fostered a sense of community and social support. Families were recipients of healthcare services and active participants in a network that aimed to improve their health outcomes.

On a community level, the PHN’s role in advocacy and community outreach had a broader impact. The PHN actively collaborated with other healthcare providers to address health disparities, engaged in community outreach to promote healthy behaviors and raised awareness about public health issues. By doing so, the PHN contributed to the community’s overall health, emphasizing prevention, early intervention, and support for families facing health challenges (Schoon & Porta, 2023). The community benefited from a more informed and health-conscious population, ultimately improving community health outcomes.


The scope of practice of public health nurses (PHNs), exemplified through my shadowing experience, reveals a comprehensive and impactful approach to addressing the health needs of families with infants. Through family home visiting programs, PHNs are crucial in providing personalized care, conducting needs assessments, and connecting families with community resources. The PHN’s interventions span primary, secondary, and tertiary prevention levels, demonstrating a commitment to preventing health problems, identifying issues early, and providing targeted support when challenges arise. Aligned with the Henry Street Consortium’s population-based public health nursing competencies, the PHN exhibited cultural sensitivity, ethical practice, and a focus on health promotion. The benefits of PHN services extend from individualized care for families to strengthened support systems and improved community health outcomes.


Henry Street Consortium. (2022). Henry Street Consortium. Henry Street Consortium. http://www.henrystreetconsortium.org/

Minnesota Department of Health. (2019). Public health interventions: Applications for public health nursing practice. https://www.health.state.mn.us/communities/practice/research/phncouncil/docs/PHInterventions.pdf

Minnesota Department of Health. (2023, January 3). Family home visiting program. Www.health.state.mn.us. https://www.health.state.mn.us/communities/fhv/index.html

Schoon, P., & Porta, C. (2023). Population-Based public health clinical manual, fourth edition: The Henry Street model for nurses. In Amazon (4th edition). Sigma Theta Tau International. https://www.amazon.com/Population-Based-Public-Health-Clinical-Manual/dp/1646480384

World Health Organization. (2023). Surveillance in emergencies. Www.who.int. https://www.who.int/emergencies/surveillance#:~:text=Public%20health%20surveillance%20is%20the


1. Summarize the role and scope of practice of PHN of LSN you shadowed. How did the practice of the PHN or LSN fit the characteristics and health needs of the population they served?

The public health nurse (PHN) I shadowed played a crucial role in providing healthcare services to low-income Latino families with children under two-years-old. Her scope of practice involved conducting home visits to assess the health and well-being of both the infants/toddlers and their parents. She offered guidance on infant care, immunizations, breastfeeding support, nutrition, and overall family health (MDH, 2019). Additionally, she connected families to community resources, such as WIC (Women, Infants, and Children) and early childhood education programs (MDH, 2019). The PHN’s practice aligned well with the characteristics and health needs of the population she served. She employed culturally sensitive and bilingual approaches, addressing the specific needs and concerns of Latino families she visited in the Spanish language. Her focus on preventive care, education, and community resources directly addressed the socio-economic and cultural factors affecting the well-being of this vulnerable population, making her practice a vital asset in promoting the health and development of children in these low-income Latino families (Schoon & Porta, 2024).

2. Describe specific public health interventions (MDH, 2019) and the level of prevention for these interventions that the PHN or LSN provided to individuals or families to protect and promote their health.

The PHN I shadowed offered a range of specific public health interventions to the families she visited—addressing various levels of prevention. At the primary prevention level, she conducted family visits to educate parents on child development, nutrition, and early childhood care practices, promoting healthy behaviors and preventing potential health issues (MDH, 2019). By using screening tools like ASQ-3, ASQ-SE2, and the Maternal Mental Health screening tool, she engaged in secondary prevention, identifying developmental delays, socio-emotional concerns in children, and potential maternal mental health issues (MDH, 2019). This early detection allowed for timely interventions and referrals, effectively preventing the progression of health and developmental challenges (Schoon & Porta, 2024). Finally, by measuring children’s weight, height, and head circumference, the nurse implemented tertiary prevention, monitoring and managing existing health conditions to mitigate their impact and improve the children’s overall health (MDH, 2019). These comprehensive interventions aligned with the needs of the population and incorporated various levels of prevention to protect and promote the health of infants/toddlers and their families.

3. Explain how the PHN or LSN demonstrated one or more Henry Street Consortium Population-based Public Health Nursing Competencies in their practice.

The PHN I shadowed effectively demonstrated several of the Henry Street Consortium Population-based Public Health Nursing Competencies in her practice. Her ability to communicate in Spanish during home visits showcased her cultural competence, ensuring effective communication with the Latino families she served. By utilizing screening tools like ASQ-3, ASQ-SE2, and the Maternal Mental Health screening tool, she demonstrated strong assessment skills, enabling her to identify and address developmental and mental health concerns in children and mothers (Schoon & Porta, 2024). Furthermore, her provision of resources, including diapers, safety equipment, and books, highlighted her skill in community partnership and resource mobilization, promoting improved daily living conditions for the families (Schoon & Porta, 2024). The PHN also offered referrals to meet family needs, which exemplified her ability to navigate and connect families with the necessary support services, emphasizing her proficiency in care coordination (MDH, 2019). In conclusion, the PHN’s effectively encompassed several key competencies in her practice, including cultural sensitivity, comprehensive assessment, community partnership, and care coordination, which are all integral to population-based public health nursing.

4. Based on your shadowing experience, what do you believe were the benefits to individuals, families, and the community of the public health nursing services provided by the PHN or LSN you shadowed.

Based on my shadowing experience, the public health nursing services provided by the PHN I shadowed offered significant benefits to individuals, families, and the community. At the individual and family level, these services ensured early detection and intervention for developmental and mental health issues in children and mothers, improving overall health outcomes (MDH, 2019). The provision of essential resources like diapers, safety equipment, and books not only enhanced the families’ daily living conditions, but also supported the developmental needs of the children (Schoon & Porta, 2024). Additionally, the PHN’s referrals connected families with vital community resources, addressing their broader needs and promoting a higher quality of life (MDH, 2019). At the community level, the PHN’s work contributed to the overall well-being of the Latino community by promoting preventive care, reducing health disparities, and enhancing the community’s access to public health services (MDH, 2019). Overall, the public health nursing services provided had a positive and far-reaching impact, benefiting individuals, families, and the community by addressing their unique needs and contributing to better health and well-being.




Minnesota Department of Health (MDH). (2019). Public health interventions: Applications for nursing practice, 2nd ed. (“The wheel manual”). Public health interventions: Applications for nursing practice, 2nd ed. ( The Wheel Manual ) – MN Dept. of Health. https://www.health.state.mn.us/communities/practice/research/phncouncil/wheel.html

Schoon, P. M., & Porta, C. M. (2024). Population-based public health clinical manual: The Henry Street model for nurses (4th ed.). Sigma Theta Tau International



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