The PHNAT offers a kaleidoscopic way to view the process of assessment. The authors see this kaleidoscopic capability as essential to public health nurses’ practice as they work with a wide spectrum of clients. In the public health nurse’s practice, clients include individuals, families, communities, systems, and populations. Therefore, a tool that permits the public health nurse to focus on each of these types of clients must be flexible. The PHNAT permits the public health nurse to assess the individual as well as simultaneously assess the community, population, and system, and this flexibility permits the public health nurse to shift his or her view back and forth depending on the area of focus and the priority needs at that moment in time. The authors developed the PHNAT using the Process Model for Healthy People 2020: Improving Health of Americans (Process Model) as a guide. It is located on the inside front cover of this text, and facilitates this shifting back and forth.

The PHNAT is embedded in and guides the user throughout the Mobilize, Assess, Plan, Implement, and Track (MAPIT) process discussed in Chapter 1, including the mobilization of partners who work together toward ensuring the health of the public. These partners participate in the assessment data gathering, analysis, planning, implementation, tracking of data, evaluation, and reflection. A visualization of the MAPIT process is also presented in the Process Model. Each part of the tool includes space for responses to questions, tables where data can be organized, and definitions for each of the foundational measures. The PHNAT prompts the user to analyze and reference the data collected. As the user becomes more familiar with the PHNAT, additional information and data may be sought, new tables formed, and original ones revised, depending on the needs of the user. For example, if the user wants to compare the findings with national or global data, he or she can do so. An online version of the PHNAT further facilitates the use of this tool because it can be more easily manipulated and implemented. The comprehensiveness of the PHNAT also suggests that the completion of a public health nursing assessment would lend itself to group work in a course or in the practice setting.

The Internet provides a wealth of data that can be incorporated into the study. Information such as geography and history of a community, as well as census track boundaries and data, can also be found on the Internet and facilitates the assessment of the community. Online databases, such as those found in Box 3-2, are examples of important resources the public health nurse can use when completing the PHNAT. The data needed for many of the suggested tables on the PHNAT can be found through the Internet and the various electronic databases. The public health nurse should be sure to select reliable and valid sources on the Internet by taking the time to search sites to see what types of information they offer. When public health nurses come across other sites and resources, they can share them with their colleagues.

The various parts of the PHNAT can be completed in any sequence. This flexibility permits the group to work on this tool and collect the data simultaneously. Assessment is not a linear process and allows for the public health nurse to complete the process based on expediency, interest, time, and efficiency.

The PHNAT can be used by faculty to teach graduate and undergraduate nursing students. It is also meant to be used by public health nurses who work in all types of community settings such as home care, visiting nurse service, health departments, neighborhood health centers, schools, and industry. Because the PHNAT encourages mobilization and collaboration within a community, this tool can be shared and used by others in the community. The ethics of public health practice warrant that public health nurses who collect data be mindful and respectful of those they are assessing— for example, students assessing a community must schedule appointments with the various stakeholders rather than showing up unannounced. They also should carry identification and a letter of introduction from their school in some instances. Just as an assessment is never a static process, neither is the PHNAT a final product.

General health status is one of the four foundational health measures. It refers to data that inform the public health nurse and partners in the health initiative about the health of the population and includes information located in Box 3-1 (U.S. DHHS, 2010c). It is important to note that some of this information is not population-focused, such as self-assessed health status; however, this is an example of how public health nurses serve individuals in the community as well as the general population.

Another foundational health measure is health-related quality of life. Health-related quality of life is a complex concept and focuses on “the impact health status has on quality of life” (U.S. DHHS, 2010d). This portion of the PHNAT also focuses on the individual and again sheds light on those public health nurses who do practice on a one-to-one basis with clients in the community. The particular areas included in this portion of the tool are (1) patient-reported outcomes measurement information system (PROMIS) tools to measure health outcomes from a patient perspective, (2) well-being measures, and (3) participation measures that also reflect an individual’s perception of his or her health or ability to participate in and interact with the environment (U.S. DHHS, 2010d).

A major portion of the PHNAT includes the determinants of health. In this section the public health nurse collects information pertaining to those factors that determine the health of the individual, family, and the population living in a community. The health determinants that organize this section include biology and genetics, social factors, health services, policymaking, and individual behavior (U.S. DHHS, 2010e).

The public health nurse, along with other partnering members of a health initiative, analyzes the information gathered during the assessment process. Many times the public health nurse will examine past data to see whether trends and patterns have emerged over time. This process of analysis takes time and reflection. The key here is that the public health nurse does not do this alone but takes part in a partnership. This process identifies issues in a community and sets priorities.

Once the public health nurse and partners conduct the assessment, an analysis of the data elucidates which priority public health issues exist in the community. In determining the priority health issues, the public health nurse, using a population-based focus, collaborates with other public health practitioners, key informants in the community, and any organization or agency that may have a voice with regard to the population and public health issue. In population-based care, partnerships form the necessary bonds to make sustainable changes necessary for health in the particular targeted population. Those involved in the partnership work together to form a common understanding of the issue. All involved, including the population of interest residing in the community, agree on the priority issue identified; this is essential for a positive outcome. Once the priority is noted, the partners confer with the Healthy People 2020 topic areas and corresponding objectives for guidance in creating and implementing a plan to address the issue (U.S. DHHS, 2010h).

In this section of the PHNAT, the public health nurse, along with any members of the partnership, develops a plan of action using the intervention wheel strategies. Again, working with members of the partnering organizations as well as other stakeholders is critical, because partnering is more likely to ensure a plan that is congruent with cultural ideas, values, and beliefs. It is also important to engage in reviews to determine a plan that is based in best practice. The PHNAT involves the application of the intervention wheel, which identifies 17 nursing interventions applied to three levels of practice: individual/family, community, and system. The intervention wheel began in
the mid-1990s as part of a “grounded theory process carried out by the public health nurse consultants at the Minnesota Department of Health” (Keller, Strohschein, & Briske, 2008, p. 189). Questioning the contribution public health nurses made in population-based care, the consultants held a series of workshops that informed them of the work of public health nurses. Using a systematic, evidenced-based review of the literature, they analyzed the input of public health nurses who worked in a variety of community settings. This enabled the consultants to construct the wheel graph depicting the 17 intervention strategies applied to the three levels of practice (Stanhope & Lancaster, 2008). The intervention strategies visually depicted and color coded on the wheel are case finding, surveillance, disease and health event investigation, outreach, screening, referral and follow-up, case management, delegated functions, health teaching, counseling, consultation, collaboration, coalition building, community organizing, advocacy, social marketing, and policy development and enforcement. The intervention wheel was “conceived as a common language or catalog of general actions used by public health nurses across all practice settings” (Keller et al., 2008, p. 193).

For the purposes of this text, these intervention strategies have been separated out into five themes addressed in specific intervention chapters:

These intervention chapters focus on each of the themes noted above by using case study examples from public health nurses who use the intervention wheel strategies to address public health problems experienced by individuals, families, and populations within their communities. The reader can refer to these chapters when using the PHNAT.

Overall, when selecting the intervention strategy and developing a plan of action, the public health nurse works in concert with others in the community and considers the following:

Tracking and evaluation are critical to the entire Process Model outlined on the inside front cover of this text and noted as the last part of the MAPIT process. While the partnership is
determining what the plan will be and how the plan will be implemented, it is also important for them to determine what type of information will be collected, where it will be collected, who will collect it, where it will be stored, what kind of technology will be used, how it will be collected, and what type of resources will be needed. This is important for tracking so that the public health nurse and partners may determine if progress is being made in meeting objectives. If it is determined that there is progress, the public health nurse and partners will need to decide if the same plan and course of action will be sustained. If there are questions about the progress, changes may need to be initiated. This tracking of information and evaluation feed back to all levels of the Process Model. Over time, analysis of the data may inform the public health nurse and the members of the partnership that the vision or goals may need to change, or the partners may determine that the plan is not based in evidence or is not culturally congruent or that one or more of the Seven A’s is not met and that these are the reasons for the weak outcomes. The tracking of data and evaluation, although at the bottom of the model, are important and inform every part of the Process Model. In 2010, the Institute of Medicine (IOM) published a report, For the Public’s Health: The Role of Measurement in Action and Accountability, which speaks to some of the issues related to tracking and evaluation. Some of the interesting and complex questions raised include: How do we measure our progress as a nation in our movement toward a healthier America? What measurement approaches can we implement that will help us evaluate and critique agencies’/partnership’s health initiatives with regard to population-based health outcomes? What are the best ways to gather and analyze data with a focus on all of the foundational health measures? So much time, energy, and resources are spent in partnership development, assessment, prioritizing of issues, planning, and in the implementation of health initiatives; tracking and evaluation are critical to all of these processes in that they bring us back to the three core functions of public health: assessment, policy development, and assurance.

This final section of the PHNAT reminds the public health nurse to be reflective in his or her practice. Self-reflection aids in the decisionmaking process (Truglio-Londrigan & Lewenson, 2008) and causes the public health nurse to be vigilant during the assessment process and in the implementation of any plans. Questions that the public health nurse may ask include: What am I observing? What am I hearing? Am I seeing and hearing all that needs to be seen and heard? What am I missing? What feelings am I experiencing during this assessment process? Are these feelings facilitating this assessment or creating a barrier to the assessment? Are these feelings hindering the development of the partnership and the development of trust? Am I engaging in activities that help in mobilizing the community of interest?

The table in this reflection section asks the public health nurse to keep a record of the experience. The public health nurse can use this table to record when he or she worked on the assessment and how he or she responded to the various parts of the assessment, reflect on the group experience if the assessment was conducted in a group, or record any personal or professional reflection observed during the assessment process.