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Science Quarterly

Nursing Science and Public Health: Contributions to the Discipline of Nursing

Pamela A. Kulbok and Naomi E. Ervin
Nurs Sci Q 2012 25: 37
DOI: 10.1177/0894318411429034

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ok, Ervin / Scholarly DialogueNursing Science Quarterly
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Scholarly Dialogue
Nursing Science Quarterly
25(1) 37­–43

Nursing Science and Public Health: © The Author(s) 2012

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Contributions to the Discipline of Nursing DOI: 10.1177/0894318411429034
http://nsq.sagepub.com

Pamela A. Kulbok, RN; DNSc; FAAN1 and

Naomi E. Ervin, RN; PhD; FAAN2

Abstract
This column highlights the unique relationship of nursing science and public health in the broader context of the discipline of
nursing and healthcare. An integrated framework is used to illustrate that nursing knowledge is the product of interaction and
interdependence of four domains –the discipline and science of nursing, the philosophy of nursing, the nursing profession, and
nursing practice. In the context of the integrated framework, knowledge specific to public health nursing is shown to inform the
discipline of nursing and other health disciplines. Ongoing challenges related to clarifying and describing unique contributions
to nursing and public health are explored. In addition, under utilization of theoretical and conceptual nursing knowledge from
public health nursing for the advancement nursing science in education, practice, and research is addressed.

Keywords
nursing education, nursing science, public health

The discipline of nursing is a distinct branch of knowledge
developed by a community of scholars with a shared view of
the world, who use this perspective to identify phenomena
specific to nursing and to guide inquiry into nursing phe-
nomena (Kulbok, Gates, Vicenzi, & Schultz, 1999). Within
the discipline of nursing, the public health nursing (PHN)
specialty is made up of scholar educators, practitioners, and
researchers, who share common concerns about the health
conditions of communities and populations, and who acknowl-
edge common approaches to resolving them (Ervin, 2007;
Josten, Clarke, Ostwald, Stoskopf, & Shannon, 1995). Public
health nursing educators, practitioners, and researchers with
diverse educational backgrounds and professional experi-
ences, inform the scholarly efforts of other nursing special-
ties and health disciplines and acquire scholarly information
through multiple ways of knowing. This interchange allows
the public health nursing specialists to articulate the breadth
and depth of their fundamental beliefs, unique perspectives,
phenomena of interest, and evolving methods of inquiry
related to nursing science and public health.
The purpose of this column is to highlight the unique
relationship of nursing science and public health science within
public health nursing practice and the importance of this rela-
tionship in the broader context of the discipline of nursing and
healthcare. The integrated knowledge development frame-
work (IKDF) is used to illustrate that nursing knowledge is the
product of interaction and interdependence of four domains—
nursing as a discipline and science, the philosophy of nursing,
nursing as profession, and nursing as practice (Kulbok et al.,
1999). In the IKDF, knowledge specific to PHN was shown to
inform the discipline of nursing and other health disciplines.
Current challenges for PHN practice include the long-standing
need to clarify, describe, and emphasize the specialty’s unique
contributions to nursing and public health. These challenges
result in part from underutilization of theoretical and con-
ceptual nursing knowledge in education, practice, and research
and theoretical and operational inconsistency in the widespread
use of concepts central to PHN (health promotion, disease
prevention, community or population focus, interprofessional
practice, and social justice).
PHN Integrated Knowledge
Development Framework
In Figure 1 the IKDF, which was originally applied to com-
munity health nursing (CHN) (Kulbok et al., 1999), is modi-
fied to reflect broad acceptance of the shift to the specialty
title of public health nursing (American Nurses Association
1
Professor of Nursing and Public Health Sciences, University of Virginia
2
Professor, Eastern Michigan University
Contributing Editor:
Pamela N. Clarke, RN, PhD, FAAN, Professor and Director, Center for
Community Health, University of Wyoming, School of Nursing, Dept.
3065, 1000 E. University Ave., Laramie, Wyoming 82079
E-mail: pclarke@uwyo.edu
38 Nursing Science Quarterly 25(1)
PHN as Philosophy
Health Promotion, Prevention, Complex
Interrelationships, Understanding
Patterns, Community as Machine,
Organism, Event or Melody
PHN as Science and Discipline
Synthesis of Nursing, Public Health,
and Social Sciences,
Transformation,
Multiple Ways of Knowing
PHN as Profession PHN as Practice
Interprofessional Collaboration, Ecological Model, Individuals,
Partnerships, Empowerment, Family, Community, Translators
Continuity of Care and Interpreters, Vulnerable
Populations, Social Justice
Figure 1. Integrated Public Health Nursing (PHN) Knowledge
[ANA], 2007). While the terms community health nursing
and public health nursing were used as synonyms for
decades (Josten et al., 1995) and some authors continue to
use them interchangeably (Ervin, 2007; Swearingen, 2009),
the term public health nursing more clearly represents the
intent to synthesize the sciences of nursing and public health
(ANA, 2007). Some terms in the IKDF were modified and
updated; for example, interprofessional rather than interdis-
ciplinary collaboration in PHN as profession, and ecologi-
cal model rather than multiple systems in PHN as practice.
In addition, social justice was added as a concept under
PHN as practice. However, the emphasis of the PHN inte-
grated knowledge development framework is unchanged.
The framework focuses on understanding the complex philo-
sophical underpinnings of PHN practice to promote popula-
tion health, through health promotion and disease prevention,
as well as through interprofessional collaboration and
partnerships, directed at multiple level client systems with
emphasis on communities and populations. The IKDF applies
Reed’s (1995) philosophical approach, which used three
worldviews or perspectives in nursing (mechanistic, organ-
ismic, and developmental-contextual) to examine PHN the-
ory and to deepen our understanding of concepts such as
community and population.
In support of an integrated approach to PHN knowledge
development, Swearingen (2009) argued for using nursing
philosophy and nursing knowledge to guide scientific inquiry
around the meaning and purpose of PHN practice; the con-
text of the discussion was the need for public health nursing
workforce development. Swearingen identified two comple-
mentary integrative knowledge development models (Chinn &
Kramer, 2004; Kulbok et al., 1999), as a basis for recognition
of the reciprocal influence between nursing science and
public health in the development of knowledge for PHN prac-
tice. Notably, when describing PHN praxis, or the interface
between nursing knowledge and practice, Swearingen pointed
out the importance of differentiating community and population-
level public health nursing practice from community-based
practice, that is, individual and family-level practice that occurs
in the community. This differentiation of PHN practice with
communities or populations, from other individual or family
nursing specialties that may practice in the community, is
another recurrent theme in the PHN literature (ANA, 2007;
Ervin, 2007; Levin et al., 2008).
Public Health Nursing
Knowledge: Challenges
Within and Beyond the Specialty
Ervin (2007, 2008) raised several questions about the future
of public health nursing and nursing education, practice, and
research. One question was about the meaning of PHN by
virtue of its fit with advanced practice specialty roles such as
the clinical nurse specialist or with those specialties consid-
ered to provide indirect care, that is, administration, informat-
ics, and education (Ervin, 2007). Another related question was
whether education leads or follows practice and the resulting
influence on PHN and nursing science (Ervin, 2008). Ervin
posed these questions during a time of national dialogue
about advanced nursing practice and the establishment of The
Essentials of Doctoral Education for Nursing Practice by
the American Association of Colleges of Nursing (AACN) in
2006. These questions are even more important today in light
of endorsement of the Consensus Model of Advanced Public
Health Nursing Regulation (Advanced Practice Registered
Nurse [APRN] Consensus Workgroup & National Council of
State Boards of Nursing [NCSBN], 2008) by 48 national nurs-
ing organizations in 2010 and the nationwide growth in Doctor
of Nursing Practice (DNP) degree programs.
Advanced Nursing Practice
Roles and Specialties
By way of background, related to the fit of PHN with advanced
practice specialties that provide direct care or with indirect
care roles, the Consensus Model of APRN Regulation (APRN
Consensus Workgroup & NCSBN, 2008) was a national
force that influenced the nature and direction of advanced
nursing practice and PHN practice, education, and research.
The APRN model excluded several master’s prepared nurs-
ing roles and specialties from the ranks of advanced practice
registered nurses (APRNs) including administration, educa-
tion, informatics, and public health. These roles and specialties
were excluded because, according to the consensus work-
group, they do not provide direct care to individuals and,
therefore, do not require regulation beyond licensure as a
Registered Nurse. Nursing roles defined as APRN roles, which
require regulatory recognition, include certified registered
nurse anesthetists, certified nurse-midwives, certified clini-
cal nurse specialists, and certified nurse practitioners. These
Kulbok and Ervin 39
APRN roles focus primarily on direct care to individuals and
include medical model practices of diagnosis, prescription,
and medical management.
The most recent dialogue around advanced nursing prac-
tice began when the ANA and AACN convened an invita-
tional meeting of 50 nursing organizations in June of 2004.
Although the initial list of invitees did not include PHN orga-
nizations, PHN leaders were invited to subsequent meetings
where they voiced collective concerns about the lack of rec-
ognition of important master’s prepared specialty practice,
which provides direct and indirect care to communities, pop-
ulations, and systems, as advanced practice nursing. These
dissenting concerns and opinions were not recorded in formal
documents because they were not supported by one-third of
the voting organizations. It is notable that Robertson (2004),
in an article on the future of advanced practice public health
nursing, acknowledged the professional and legal influences
that were driving the definition of advanced practice nursing
and the potential impact on future needs of the United States
healthcare system. Robertson reported on the growing soci-
etal needs for population health management by advanced
practice public health nurses and on the concomitant con-
cerns for the public’s health should public health nursing be
excluded from the roles and specialties of advanced practice
nursing.
If we examine this sequence of events and the dialogue
surrounding advanced practice nursing in the context of the
IKDF, it is apparent that during this dialogue little emphasis
was placed on the importance of nursing as discipline or sci-
ence, nursing phenomena, or nursing knowledge develop-
ment for advanced practice. Rather, the foundation for the
discussion and decisions related to advanced practice nursing
was regulatory and appeared to be modeled after professional
practices used by medicine. The following conclusion from
the Consensus Model for APRN Regulation is illustrative:
The recommendations offered in this paper present an
APRN regulatory model as a collaborative effort among
APRN educators, accreditors, certifiers, and licensure
bodies. The essential elements of APRN regulation are
identified as licensure, accreditation, certification, and
education. The recommendations reflect a need and
desire to collaborate among regulatory bodies to achieve
a sound model and continued communication with the
goal of increasing the clarity and uniformity of APRN
regulation. (APRN Consensus Workgroup & NCSBN,
2008, p. 20)
The Relationship of Nursing
Education and Practice
Another central question posed by Ervin (2007) about the
future of public health nursing and nursing education, prac-
tice, and research was whether education leads or follows
practice. In light of the previous discussion about evolving
APRN roles and specialties, it appears that in the current
milieu the answer is neither. That is, education is neither lead-
ing nor following practice. Rather, a convergence of external
forces is leading nursing education and practice. In the case of
APRN roles, it is clear that regulatory considerations were
driving the definition of advanced practice nursing roles and
specialties (Robertson, 2004). Another external driver of nurs-
ing education and practice, which was cited in the Consensus
Model of APRN Regulation (APRN Consensus Workgroup &
NCSBN, 2008), is the Institute of Medicine (IOM) (2003)
report on Health Professions Education: A Bridge to Quality.
A recent article by Donohue-Porter, Forbes, and White (2011),
which examined nursing theory in curricula across all levels
of nursing education, pointed to the influence of this and
other IOM reports. The emphasis of IOM reports on quality
and safety, interdisciplinary collaboration, and evidence-based
practice that resonates in current nursing education from bac-
calaureate to doctoral levels does not reflect nursing’s unique
disciplinary perspective (Donohue-Porter et al., 2011).
To some extent public health has become more medically-
oriented, being driven by categorical funding for disease-
specific programs such as STIs and tuberculosis (May, Phillips,
Ferketich, & Verran, 2003), rather than being driven by pri-
mary prevention and health promotion. This direction was
seen in the core functions of assessment, assurance, and policy
development (IOM, 1988). The widespread use of this frame-
work to structure the work of local and state health depart-
ments and the philosophy that public health should operate as
a business (May et al., 2003) has changed public health nurs-
ing practice over the past two decades. Consequently, PHN
efforts to provide holistic nursing care that focuses on health
promotion, and disease prevention, case finding, resource
identification, and community empowerment have been
hindered (May et al., 2003). The practice of PHN has moved
away from direct services to individuals, families, and com-
munities in homes or community-based settings. From the
perspective of the IKDF, it is uncertain what theoretical
frameworks public health nurses use to practice within the
assessment, assurance, and policy development tripartite
approach to public health. The evidence base that informs
education and practice within this structure is also unclear.
Swearingen (2009) pointed out that for more than two
decades, efforts have focused on elaboration of public health
workforce standards, core functions, and competencies; yet
little research has focused on PHN competencies (Swearingen,
2009) or outcomes of PHN practice (Issel, Bekemeier, &
Baldwin, 2011).
This example of shaping public health and public health
nursing from interprofessional perspectives is consistent
with what has occurred with advanced practice nursing. The
advanced practice roles of nurse anesthetists, nurse-midwives,
clinical nurse specialists, and nurse practitioners have been
influenced by the medical perspective. An examination of
references cited in The Essentials of Doctoral Education
for Advanced Nursing Practice (AACN, 2006) and The
40 Nursing Science Quarterly 25(1)
Essentials of Master’s Education in Nursing (AACN, 2011)
reveals the substantial effect of non-nursing disciplinary
views, and less influence of nursing’s unique disciplinary
perspective. To what extent is nursing knowledge central to
the advanced practice nursing roles? How far from nursing
practice can advanced practice nursing stray and still be
called nursing?
Bekemeier and Butterfield (2005) addressed related con-
cerns in their analysis of the concept of social justice, which
is central to historic accounts of the nursing profession. They
argued:
Emphasizing nurses’ primary responsibility to the
patient and to maintaining an effective immediate work
environment within existing systems that are broken
and failing, supports and perpetuates an institutional-
ized perceived reality in nursing in the United States.
This perceived reality . . .is maintained and exacer-
bated by market forces, the medicalization of health,
and privilege. Instead of creating healthy conditions in
which people can thrive, we are major participants, as
nurses, in bolstering an “American illness non-care
system” that gains from illness, rewards acuity rather
than prevention, and supports conditions that reduce
the health of many while improving the health of a few.
(Bekemeier & Butterfield, 2005, p. 159)
Another avenue for exploring the relationship between
nursing education and practice in the context of the IKDF
focuses on knowledge development and nursing science. For
example, what are advanced practice nurses and advanced
public health nurses in education, practice, and research doing
to develop nursing knowledge and science for their special-
ties? What efforts are being made to enhance the meaning of
nursing practice through integration of nursing’s unique phi-
losophy, professional, and practice perspectives in nursing
education across all levels? Are the efforts of faculty organized
around explicit nursing theoretical foundations, as espoused
by Donohue-Porter and colleagues (2011), or are their efforts
individual examples or case studies without theoretical foun-
dations upon which others can build? What education, prac-
tice, and research directions will guide the future of practice
for nursing students and graduates at all levels?
Without concerted efforts in the theoretical and scientific
scholarship of education, practice, and research, the disci-
pline of nursing and specialties such as public health nursing
risk being guided by other disciplines or fields. To a great
extent, the economics and politics of healthcare funding have
influenced the type of services that are available to the public
(Bekemeier & Butterfield, 2005; Robertson, 2004). There is
no doubt that insurance benefits, or the lack thereof, drive
the market for the delivery of healthcare services. Funding
sources also influence the type and extent of programs and
services that local health departments provide. Nurses may
have a voice in details of the service delivery, but they are
not in charge of the type of healthcare services that are avail-
able to the public.
When nursing adopts a medical or other external perspec-
tive to a greater extent than a nursing perspective, the profes-
sion suffers (Bekemeier & Butterfield, 2005). The lack of
research by advanced practice nurses into nursing phenom-
ena has hindered the development of core nursing knowledge
for nurse anesthetists, nurse-midwives, clinical nurse special-
ists, and nurse practitioners. For example, many programs for
nurse anesthetists are located in medical centers and medical
schools (America Association of Nurse Anesthetists, 2011)
reflecting the influence of a medical perspective in the prac-
tice of nurse anesthetists. Interventions by advanced practice
nurses are not well-documented because reimbursement is
not provided for them. Advanced practice nurses often do not
document nursing diagnoses because they do not get paid for
them nor do the employers. Nursing practice takes time, which
is a commodity dispensed in small doses when nurses are pro-
viding primary care. The numbers of patients seen each day
may be controlled by the office practice, the ambulatory facil-
ity, or the inpatient setting.
Public Health Science: Contributions
to Nursing Science
The absorption of medical knowledge into nursing is evident
when reviewing curricula and observing practice, especially
at the advanced level of education and practice. As previ-
ously mentioned, the influence of disciplines beyond nurs-
ing is apparent in the DNP (AACN, 2006) and Master of
Science in Nursing essentials (AACN, 2011) documents.
The presence of public health knowledge is evident when
conducting the same review of public health nursing curri-
cula and practice. However, to a great extent public health
sciences are more akin, or similar, to the nursing discipline
than is medical science. In an article about the development
of the science of epidemiology and its relationship to public
health nursing, MacDonald (2004) chronicled the evolution
of four eras of epidemiology. These include the eras of sani-
tation, communicable diseases, chronic diseases, and finally,
social ecology. MacDonald argued that there is a distinct
congruence in knowledge development between the current
era of social epidemiology and the discipline and science of
nursing.
Nurse practitioners, clinical nurse specialists, and nurse-
midwives provide care to individuals but need to incorporate
the focus of aggregate care into their practices in order to be
more effective and efficient. By adopting the medical model
of caring for one, usually ill, person at a time, advanced prac-
tice nursing has become a mirror image of medicine without
the additional years of training. It is impossible to stop the
epidemic of disease and injury without health promotion,
disease prevention, an aggregate or community focus, and an
emphasis on socially just care. Nursing is a discipline that
has and should continue to focus on the many rather than the
Kulbok and Ervin 41
few who can access individual sickness care (Bekemeier &
Butterfield, 2005; Robertson, 2004).
As a profession, discipline, and science, nursing owes
much to the specialty of public health nursing. Public health
nursing was the first recognized specialty in nursing; the first
to offer specialized training; and the first university program
of study in nursing. Public health nursing was established at
Columbia University in 1910 (Farnham, 1964; Kulbok &
Glick, 2010). In her thesis on the National Organization for
Public Health Nursing, Fitzpatrick (1975) pointed out that
when preparing nurses to address challenging social condi-
tions and promote public health and hygiene in the early 1900s
“PHN had come to be regarded as a specialized branch of
nursing” (Fitzpatrick, 1975, p. 13). There was a need for pub-
lic health nurses with “an awareness of how . . .economics,
politics, and culture affected the lives and health of their
patients . . .[with] grounding in sanitary practices, social
problems and psychology” (Fitzpatrick, 1975, p. 14).
Following in this historic tradition of leadership by public
health nurses, in 2007 the Association of Community Health
Nursing Educators (ACHNE) published a document on grad-
uate education for advanced public health nursing (APHN)
and identified critical content areas including: advanced
nursing practice, social and behavioral sciences, population-
centered nursing theory and practice, interdisciplinary prac-
tice, leadership, systems thinking, biostatistics, epidemiology,
environmental health sciences, health policy and manage-
ment, public health informatics, genomics, health communi-
cation, cultural competence, community-based participatory
research, global health, policy and law, and public health ethics
with social justice (Levin et al., 2008). Public health nursing
leaders have long recognized the importance of integration
of nursing science and public health to create a vision and
provide direction for future nursing education, practice
and research to promote the health of the public. The ACHNE
document (as cited in Levin et al., 2008) provides a guide to the
requisite education for master’s specialty practice in PHN and
for advanced practice public health nursing at the doctoral
level, that is, the clinical doctorate or the research doctorate
(Levin et al., 2008).
Graduate programs in nursing should build on the contri-
butions and perspectives of public health nursing. Advanced
practice nurses and other advanced roles and specialties require
basic knowledge of biostatistics, epidemiology, community
assessment, program planning, and evaluation, as a minimum
foundation for providing care that is oriented to health pro-
motion and disease prevention. There are far too few nurses
working in public health to provide the care and services
needed by the total population.
Nursing Models with
a Public Health Nursing Focus
Over the past few decades investigators in a number of studies
have reported remarkable results when public health nursing
models, although not titled that, were tested for quality patient
outcomes. The most established model is the nurse-family
partnership model, which was developed and tested by Olds
and colleagues over the last 30 years (Eckenrode et al., 2010;
Olds, Henderson, Chamberlin, & Tatelbaum, 1986). The model
now implemented in many locations around the nation dem-
onstrates the power of home-visiting as an intervention to
prevent long-term negative outcomes for vulnerable women
and children. A second model of importance to nursing is the
one developed by Naylor and colleagues (1999) aimed at
improving outcomes for hospital discharged older patients.
Yet a third model was developed by Brooten and colleagues
(2002) to demonstrate that nurses could make a difference
in outcomes for women with high risk pregnancies. Another
well-researched model for practice was developed by Cox in
the 1980s. The Interaction Model of Client Health Behavior
(IMCHB) (Cox, 1982; Cox et al., 2009; Carter & Kulbok, 1995)
is an established nursing model for advanced practice that could
be embraced by all advanced practice nurses and incorporates
some concepts central to public health nursing.
As discussed previously with respect to advanced practice
nursing and advanced public health nursing, a major diffi-
culty with widespread implementation of these and several
other models is that sources of payment and reimbursement
for services are not readily available. Readmissions to hospi-
tals are currently reimbursed, but the prevention of readmis-
sions and early discharge of patients who are better cared
for at home are on nursing’s “wish list” for reimbursement or
bundled payment sources. Without the concerted efforts of
nurse researchers and scholars, this and other nursing models
will not inform practice to the extent needed to continue the
development of nursing science.
Conclusion and Recommendation
The need for the nursing profession to come together for
the continued development of the profession is evident in the
literature about advanced practice. Public health sciences and
advanced public health nursing offer a route for building the
foundation for all nurses to incorporate prevention, health
promotion, a focus on an aggregate or group of individuals
rather than just one person at a time, and socially just care.
The DNP is especially relevant for incorporation of this
content because it builds on advanced practice core knowledge
that has embraced medical content as important for practice.
Public health knowledge adds the missing elements needed
for effective nursing practice and improved patient outcomes,
as illustrated in the literature on nursing models.
Nursing science cannot transcend the medical model with-
out continued explicit research about nursing. While the DNP-
prepared nurse is not educated to conduct research nor be an
educator, the highest level of clinical practice must be informed
by theoretical and conceptual nursing perspectives. The evi-
dence base for advanced nursing practice and other advanced
roles and specialties will be enhanced if more consideration is
42 Nursing Science Quarterly 25(1)
given to the integration and understanding of nursing science
and public health. Nursing science will advance when research
is conducted by nurse scholars prepared in baccalaureate and
graduate programs that emphasize the importance of nursing
knowledge development as described in the IKDF (Kulbok
et al, 1999). Nursing knowledge development is the product
of interaction and interdependence of four domains: nursing
as discipline and science, philosophy of nursing, nursing
as profession, and nursing as practice. Incorporation of the
public health nursing perspectives articulated in this column
(the integration of nursing science and public health sciences)
will strengthen current and future baccalaureate, master’s and
doctoral programs for all nurses.
The challenge of nursing knowledge development to bet-
ter inform nursing science and the evidence base for advanced
nursing practice looms large. In order to begin to answer some
of the questions raised in this column and to achieve the
underlying goals of utilization of theoretical and conceptual
nursing knowledge and the advancement nursing science, the
authors recommend the establishment of an expert panel of
the American Academy of Nursing on Nursing Science and
Public Health. The establishment of such an Expert Panel is
extremely timely given the national prevention initiative in
healthcare reform legislation, the Affordable Care Act of 2010.
While the challenge is undoubtedly complex, the work of an
Expert Panel on Nursing Science and Public Health would
offer a renewed vision and direction for the preparation of a
nursing and public health nursing workforce to promote and
protect the health of the public.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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