The public health nursing intervention of counseling begins with professional conversations between the nurse and the individual, family, and/or target population within the context of the community. Counseling “establishes an interpersonal relationship with a community, system, family, or individual intended
to increase or enhance their capacity for self-care and coping. Counseling engages the community, a system, family or individual at an emotional level” (Keller et al., 2008, p. 199). The counseling relationship helps the population to reflect, clarify views, identify alternatives, examine available resources, and explore options in a supportive context. The public health nurse encourages the individual/family and population to consider the consequences of potential courses of action and to formulate their own decisions.

Counseling relationships evolve as the public health nurse earns trust through continuing contact with the population. Deborah Antai-Otong (2007) notes “Trust is germane to therapeutic and authentic nurse-client relationships… . The client’s capacity to trust is governed by early interactions with patients and caregivers…. However, trust evolves through nurse-client relationships that convey acceptance, empathy, caring, and understanding” (p. 29). A study of public health nurses in Canada highlighted the role of trust in client empowerment. Aston, Meagher-Stewart, Edwards, and Young (2009) found that public health nurses fostered trust by shifting the balance of power away from the “nurse as expert” and instead engaging clients in transparent dialogue through active listening, believing in the client’s strengths, and creating an atmosphere of safety and accessibility. Truglio-Londrigan (2008) spoke about trust as a process that forms through a connection that unfolds over time, allowing for a working together that further builds the relationship.

Vulnerable populations who have previous negative experiences with “the system” may require extended time to develop even a tenuous level of trust. Cultural norms and current life stressors may also extend the time required to earn trust (deChesny & Anderson, 2012; Drury, 2008a). In addition, as the sphere of communication widens from individuals/family through community and systems, and to populations, the possibility for miscommunication multiplies. Public health nurses as well as other public health practitioners need to be conscious of this as they seek to work “with” individuals/ families and populations, always practicing actions that build trust.

Although public health nurses often deal with sensitive issues such as intimate partner violence, addiction, or homelessness, it is important to keep discussions focused on “here and now” problem solving via counseling. Psychotherapy is not within the scope of practice for public health nurses, and referrals to prescreened sources should be facilitated when needed (Browne, Doane, Reimer, MacLeod, & McLellan, 2010; Clark, 2008; Keller et al., 2008). The prescreening process takes place as the public health nurse locates organizations and agencies to serve as partners. These partners may assist the public health nurse in the provision of services such as psychotherapy. The prescreening process clarifies eligibility requirements, fees, and waiting lists, ensuring that those being served will not encounter bureaucratic barriers to treatment. This prescreening process ensures a place where the needs of the individual/family or a population can be addressed. The public health nurse in this situation promotes trust by facilitating access to care and following up on its efficacy.

The literature presents evidence of the importance of counseling as a populationbased public health nurse intervention strategy. Edinburgh and Saewyc (2008) studied a home-visiting intervention that helped young (10- to 14-year-old) sexually assaulted adolescent runaways. The authors noted that the teens in this study refused traditional counseling as an intervention, and that traditional counseling was not culturally congruent with the needs of this specific age group. The authors noted
“the solution was to offer all teens participation in a therapeutic empowerment group, which met after school weekly under the guidance of a skilled therapist” (p. 45). Other interventions in this home-visiting intervention program included mental health and screening referrals, health education, and daily living skills. Outcomes were positive in terms of reconnecting these young runaways to school and family. Hollenbeck (2008) advocated for universal newborn hearing screening and stressed the importance of providing emotional support, counseling, and education throughout the process, particularly if the screening identified that further examination was needed.

Frank and Grubbs (2008) studied the effectiveness of a faith-based screening and education program focusing on diabetes, cardiovascular disease, and stroke. The study outcomes noted the importance of conducting the programs in small groups that facilitated one-to-one counseling. Huang, Lin, and Li (2008) addressed the vulnerable population of older adults. These authors studied the service needs of residents in community-based long-term care and noted a need for psychological support and counseling pertaining to lifestyle change, role change, and environmental change. The importance of counseling as a population-based intervention is also noted among other public health practitioners. Olshtain-Mann and Auslander (2008) studied parents’ stress and perceptions of competence 2 months after their preterm infant was discharged from a neonatal intensive care unit. These authors noted the importance of emotional support and counseling during the first year after discharge. Although this work comes out of the social work literature, many public health nurses work in early childhood programs supporting families during these first few years after discharge. Counseling is an intervention strategy that public health nurses in all settings “apply” and “do” daily in their practice.

The complexity of public health practice may require a wide range of expertise. Public health nurses may therefore find themselves seeking the consultation of others in their practice. These consultation services may include health officers, sanitarians, health educators, area professionals, epidemiologists, environmentalists, and media experts. Public health nurses may consult with a media expert if they need assistance on how to reach out into the community and gain the attention of a targeted population. Or, the public health nurse may seek consultation services of many different types of professionals or organizations. In this situation the development of a coalition may be the answer, and the public health nurse may be instrumental in the organization of this coalition and the development of a partnership between and among all involved.

Part of the success of partnerships and coalitions is that every organization involved in the coalition is actively seeking consultation from the other. Working together in these types of partnerships facilitates sharing of ideas and information where everyone’s expertise is honored and used in the decision-making process. The public health nurse works within coalitions to mediate power and to ensure that decision making remains within the target population. Consultation “seeks information and generates optimal solutions to perceived problems or issues through interactive problem solving with a community, system, family or individual. The community, system, family or individual selects and acts on the option best meeting the circumstances” (Keller et al., 2008, pp. 199, 204). Just as the public health nurses draw upon multiple sources of information to assist populations to meet their needs, they
may in turn be sought for consultation purposes to provide nursing expertise within the community at large. Ideally, the coalition includes members of the targeted population.

Hopson and Steiker (2008) demonstrate consultation in adapting the evidence-based drug abuse prevention program called “Keepin’ it REAL” to a variety of schools. The authors noted that schools differ and that each and every school has its own culture and population of students. “Interventions that work well at one school may be a poor fit for others” (p. 116). To address this issue Hopson and Steiker used a participatory action research (PAR) approach to consult with students and staff to improve the program’s “fit within a particular school” (p. 118). “PAR is dialogical and proactive typically focusing on empowerment and with researchers’ and participants’ values both being central to the planning process” (Kidd & Kral, 2005, p. 187). Kidd and Kral noted that collaboration exists in every phase of a PAR project. The collaborative partnership of the students and staff of the schools is critical so that the researchers may not only collaborate but also engage in consultation and learn from these partners about interventions that are most likely to succeed at each school.

Health teaching focuses on providing information needed by the individual/family or population so they may become more aware of the promotion of health, the prevention of disease and injury, health screenings, available community services, and how to access those services. Health teaching “communicates facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices of individuals, families, systems, and/or communities” (Keller et al., 2008, p. 199). Health teaching engages participants at an intellectual level, whereas counseling engages participants emotionally. In practice, health teaching proceeds from the counseling relationship. For example, if a public health nurse is developing a mammography program for a particular population residing in a particular community, the nurse may first have to provide counseling services to address barriers to participation such as fear. The public health nurse must carefully assess the population and structure information accordingly. Once this assessment is completed, the public health nurse can develop educational programs tailored to the priorities of the individual/family or population. Information must be provided in a “user friendly” form and offered in measured amounts that can be absorbed easily. The goal for the public health nurse is to facilitate outcomes such as knowledge attainment and behavior change in the individual/family or population.

The public health nurse takes a flexible approach that helps the individual/family or population to progress gradually from nonthreatening topics to areas that may be more emotionally or culturally challenging. For example, a public health nurse who offers a support group for battered women may have minimal attendance; however, offering a “mothers’ group” instead may bring women who eventually, once trust is established, reveal abuse. These mothers may explain that if their partner caught them attending a group focused on domestic violence, their risk of battering would increase.

If we are to consider that public health is an interdisciplinary science, of which nursing is a critical participant, we may see the entire process of the development of educational programs in the following way. For example, multiple organizations in a particular community may form a coalition to promote health. The members of this coalition together have agreed to a formal partnership and have identified one of the organizations as the lead agency. Methods
of communication, formal and informal, have been developed to reduce miscommunication. The coalition decides to collectively conduct an assessment of the community to identify issues and to organize these issues in order of priority. The coalition also has members of the community involved as key participants. All the data from the community assessment are compiled, and an analysis reveals several issues. One of the issues is obesity in elementary school children. Once the key issue is decided, the members of the coalition must collectively determine who the targeted individual/family or population will be, what content will be delivered, how the content will be delivered, where and when the content will be delivered, and by whom. Table 11-1 identifies these areas with examples of some of the key questions that the members of the coalition and the public health nurse must ask in the development, implementation, and evaluation of the educational program.

Many of these areas noted in Table 11-1 correspond with the determinants of health noted in the Graphic Model for Healthy People 2020 (U.S. Department of Health and Human Services [U.S. DHHS], 2010). The determinants of health depicted in this model include: physical environment, health services, social environment, individual behavior, and biology and genetic. Policymaking, however, although not depicted in the Graphic Model for Healthy People 2020 is described as a determinant of health in the Healthy People website (U. S. DHHS, 2010). Each determinant is considered here as it applies to health teaching and from here forward is referred to as a Systematic Approach to Health Teaching, understanding that there is an overlap of each of these determinants.

Biological/genetic determinants such as age, gender, and ethnicity can influence whether an individual seeks out new information, places relevance on the information, and puts that information to use. For example, Kaye, Crittenden, and Charland (2008) noted that “reaching and properly serving older men can be a challenge for practitioners” (p. 9). Older men may fail to participate in health education programs or to actively seek help because “many older men believe that a stigma is attached to seeking help” (p. 9). Age is associated with learning styles, sensory capacity, and familiarity with technological developments (Knowles, Holton, & Swanson, 2005). For example, the act of producing a pamphlet requires the public health nurse to be conscious of normal aging changes with regard to vision, requiring the production of pamphlets that have larger print and colors that are easily identifiable.