The enduring contact that nurses have with all sections of society means that enormous potential exists for them to make positive and worthwhile contributions to existing and future societal health. Whether the focus of practice is on the management of chronic or acute conditions, supporting clients with complex needs and social issues, or preventive care, the core nursing values remain the same. That is, identifying and assessing need, planning and delivering evidence-based therapeutic interventions, coordinating care, referring to other agencies, reviewing and monitoring outcomes, and working in partnership with others. Through these core values all nurses promote and protect health and thereby contribute to the public health agenda in some way. This is in accordance with the National Occupational Standards for the Practice of Public Health (Skills for Health 2004: 6) which states the purpose of public health is to ‘improve the health and wellbeing of the population, prevent disease and minimize its consequences, prolong valued life, and reduce inequalities in health’. Nurses working in a variety of settings will make a contribution to achieving this maxim through their everyday practice. This chapter will focus on contexts of practice and their influence on the nurses’ involvement in public health. It will present a framework that represents nurses’ current public health engagement, outline opportunities for nurses to further enhance their contribution to the public health agenda and discuss the limitations to them pursuing such work.

Government policy advocates that nurses working in all contexts should take an active role in public health. However, not all nurses recognize such opportunities. These perceptions should be reconsidered in light of the political value attributed to nurses’ contribution in this area. Government documents such as High Quality Care for All (Department of Health 2008), Designed for Life (Welsh Assembly Government (WAG) 2005) and the Designed to Realise our Potential consultation paper (WAG 2007) outline the changing face of healthcare. The Welsh Assembly states that ‘a predominant focus on health promotion, illness prevention, managing long-term chronic conditions, supporting self-care and providing services in a community environment’ is the future nurse’s role (WAG 2007: 4). The Department of Health (DH; 2004: 12) reiterates the need for public sector workers to ‘increase their knowledge and understanding of health issues and this increased health awareness should permeate all areas of work so everyone understands how they can contribute to improving health’. Despite these political imperatives, some nurses may find it challenging to articulate how they address public health within the context of their work. This is understandable considering the diversity of settings in which nursing is delivered, which may either hinder or help opportunities for public health interventions.

The literature pertaining to public health in nursing focuses on a range of activities. There is growing evidence to illustrate the contribution of specialist community public health nurses (SCPHNs) and other community nurses to the public health agenda. With regard to health visitors, qualitative findings from Bowes and Meehan Domokos (1998), Bowns et al (2000) and McIntosh and Shute (2006) all share a common theme: the value parents place on health visitor support. The most highly valued aspects of the service were the availability of health visitors as a source of information to reassure on common childcare issues and their role in facilitating opportunities to meet other parents through networking strategies. Quantitative evidence of the effectiveness of practice also exists –Elkan et al’s (2000) systematic review and Bull et al’s (2004) review of reviews concluded that the professional practice of health visiting enhances parenting abilities and parental management of common childhood difficulties; improves cognitive functioning in children of low birthweight; reduces incidence of childhood accidental injury; improves detection and management of postnatal depression; enables supportive environments for mothers; and improves breastfeeding rates. These beneficial outcomes may be due in part to health visitors’ ability to discriminate their services positively to those clients with the greatest needs, as a means to ensure equity of service provision, while the availability of the service to all enables the profession to maintain a primary preventative approach to public health. Health visitors are recognized as the most likely group of nurses to engage in broader public health work (Whitehead 2003) and the principles they adhere to which include searching for health needs, stimulating an awareness of health needs, facilitation of health-enhancing behaviours and influencing policies affecting health place them in a unique position to undertake broad public health practice (Cowley and Frost 2006, United Kingdom Public Health Association).

Brooks et al (2007) identify how school nurses are ideally placed to deliver key public health interventions for children and adolescents. They are recognized to be effective links between education, health and social care and thereby make health services more accessible to pupils, parents, carers and staff (Department for Education and Skills, DH 2006). However, an evidence base to demonstrate the effectiveness of school nursing remains weak (Brooks et al 2007). Similarly, the Department for Work and Pensions et al (2005) recognize the potential for occupational health nursing to reduce health inequalities and improve the health of the working population but again evidence to support this is currently lacking. Both school nurses and occupational health nurses work with well populations and engage in primary preventive public health practice.

Community psychiatric nurses play a vital part in delivering behaviour modification programmes for people with problems associated with drug misuse and deliver early interventions for people with enduring mental health problems. With regard to community nursing, the Scottish Executive (2006) reported evidence of effectiveness in relation to community nurses reducing readmission rates through effective discharge planning and evidence of proactive risk assessment interventions conducted by community nurses reducing hospital admission in the over-75s. The Executive also revealed that there is some evidence that focused and prolonged community nursing interventions can improve the health of clients/patients or at least prevent them from getting worse.

The report (Scottish Executive 2006) highlighted that individuals and families value the relationships they are able to develop with nurses. This is an often overlooked yet significant aspect of public health working. For vulnerable individuals, in particular, their relationships with nurses may be the only contact available to them where they feel able to confide their concerns and seek support or assistance. In such circumstances individuals may disclose their deepest concerns; for example, women confide in health visitors their experiences of domestic violence, children disclose to school nurses their experiences of physical or sexual abuse, the learning disabled adult conveys inappropriate care to the learning disability nurse and it is the district nurse who is informed of the inadequate and abusive care experienced by the older, vulnerable adult. These are just some examples of how different nursing disciplines may act as key resources for different populations and make an important contribution to the public health agenda.

Hospital-based nurses working in a variety of roles in a secondary setting usually have less opportunity to encompass the total remit of public health within their work (Whitehead 2003), although it is recognized that there may be exceptions to this based on role and areas of practice. Early work undertaken by Watkins (1995) into factors which facilitate and inhibit health promotion in nursing practice found that implementation of health promotion initiatives were higher among nurses who worked in a community setting compared to hospital nurses. This may have been associated with the higher grade of staff, thus providing greater autonomy over practice, as well as the context of the patient’s home providing a more conducive environment to discuss issues relating to the achievement of health. This view is supported by an early study by Caraher (1994: 544) who states that ‘the institution of the hospital militates against the development of health promotion in a clinical setting as the organizational structure demands compliance and order’. The very acute nature of hospital work can be a constraint to promoting health, thus confounding the traditional role of the nurse in caring for the sick, although, as the patient moves to recuperation, opportunities to promote health may present. Political imperatives to move care into the community and care for only very acute conditions in a hospital environment may further inhibit opportunities for nurses to promote health in acute settings.

Public health in nursing practice is presented in this chapter as a ‘framework of engagement’ and divides nurses’ work into biomedical public health practice and socio-political public health practice. Biomedical is defined as an individualistic approach that uses disease prevention or disease management as its focus. Its aim is to activate a behaviour change, or compliance, and in doing so utilizes a medical/preventative/behavioural approach to practice based on objective evidence. Education is usually the way in which interventions are delivered, and in the main there is limited consideration given to the determinants of health and how these influence decision-making (Blinkhorn 2002, Whitehead 2001, 2003). Behaviour change is seen as a simple process whereby the acquisition of knowledge will result in a change in lifestyle or adherence to prescribed outcomes. Socio-political includes consideration of the social and economic influences on health and aims to address these through using a more radical and empowering approach to public health practice. This includes empowerment of individuals and communities and is based on a philosophy of partnership working and collaboration. It aims to shape and influence healthy public health policy and to raise awareness through adopting a critical consciousness approach (Whitehead 2003).

There are advantages and disadvantages to basing public health practice on biomedical or socio-political perspectives and using approaches that mirror the underpinning philosophies (refer to Chapter 7 for further discussion of this). An evidence-based, pathogenic, biomedical approach to public health practice ignores social inequalities and as a result may marginalize those who are the most vulnerable (Ilett and Munro 2000). Adopting a socio-political perspective can provide insight into the impact of social circumstances on health and broaden thinking in public health practice. It can reveal differences in social groups, and discrimination and oppression; it can identify unmet needs and promote the establishment of services for the disadvantaged, thus making a contribution to reducing health inequalities. However, public health practice based on a biomedical perspective is the most common approach adopted by nurses and it is criticized for being individualistic and ignoring socio-economic, political and environmental issues (Whitehead, 2001 and Whitehead, 2003). While the importance of understanding these influences on health achievement cannot be ignored and should be considered in any public health work, it is often beyond the control of the nurse in a secondary setting to be able to directly influence these issues. This may be one reason why the nurse’s contribution to public health is undervalued, although they play a very important part in promoting and supporting individuals through lifestyle changes and in managing chronic disease. These activities play a large part in helping to meet the public health agenda in the United Kingdom by minimizing the consequences of disease and prolonging valued life.

The framework presented in this chapter illustrates how hospital-based nurses engage in a greater proportion of biomedical public health compared to SCPHNs, who undertake more socio-political public health activity, although it is recognized that the practice of some SCPHNs retains a biomedical element. Community nurses are depicted as having slightly more socio-political public health within their practice than hospital-based nurses, but maintain a predominant focus on biomedical practice, the former being constrained by looking after clients/patients with acute and chronic health or social care needs.

To help identify public health in nursing practice, the framework takes guidance from the National Occupational Standards for the Practice of Public Health (Skills for Health 2004). This document outlines what is expected of someone whose work has a primary public health orientation (Box 23.1, Table 23.1) and this has been drawn upon to illustrate the degree of involvement in public health working of nurses who work within a hospital environment, community-based nurses and SCPHNs. The framework illustrates how nurses’ current engagement in public health is largely dependent upon their practice foci, environment and mode of care delivery.