In the Institute of Medicine's words (The Future of Public Health, 1988), public health is "what we, as a society, do collectively to assure the conditions in which people can be healthy" — preventing disease, prolonging life, and promoting health through organized community effort. Its focus is the population, not only the individual.

Public health nursing (PHN) is defined by the American Public Health Association as "the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences." Its hallmarks:

• Population focus — the "client" is a population or community, even when care is given to individuals and families
• Prevention and health promotion as the main strategy, at all levels of prevention
• Assessment of the whole population, including people who do not seek care
• Social justice and health equity — attention to the conditions that shape health
• Partnership with communities and other sectors
• Greatest good for the greatest number, using resources efficiently

Community health nursing / community-based nursing. "Community health nursing" is often used broadly for nursing in community settings. Community-based nursing focuses on care of individuals and families where they live, work, and learn (e.g., home health, clinic nursing) — care is in the community but not necessarily population-focused. Community/public health nursing (C/PHN) is population-focused.

Levels of prevention (Leavell and Clark)

Some texts add primordial prevention (preventing risk factors from developing, such as policies that create walkable neighborhoods).

Historical milestones

Three core functions and the 10 Essential Public Health Services (framework revised in 2020 with equity at its center)

Professional standards and competencies

• ANA Public Health Nursing: Scope and Standards of Practice (3rd ed., 2022) — applies the nursing process to populations: assessment, population diagnosis and priorities, outcomes identification, planning, implementation (including coordination, health teaching and promotion, consultation, and regulatory activities), and evaluation, plus standards of professional performance (ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, environmental health)
• Community/Public Health Nursing Competencies of the Council of Public Health Nursing Organizations (CPHNO, formerly the Quad Council Coalition), aligned with the Council on Linkages core competencies. Eight domains: analytic and assessment skills; policy development and program planning; communication; cultural competency; community dimensions of practice; public health sciences; financial planning, evaluation, and management; leadership and systems thinking. Three tiers: Tier 1 generalist/entry level, Tier 2 program management or supervisory, Tier 3 senior management or executive
• CPHNO members include the Association of Community Health Nursing Educators (ACHNE), the Association of Public Health Nurses, the APHA Public Health Nursing Section, the Alliance of Nurses for Healthy Environments, the National Association of School Nurses, and the Rural Nurse Organization. ACHNE publishes guidance on essential content for baccalaureate C/PHN education

Roles of the community/public health nurse

Settings: state and local health departments, schools, workplaces, home health and hospice, community and migrant health centers (including Federally Qualified Health Centers), correctional facilities, faith communities, shelters, and disaster response.

Where US public health authority lies. Public health powers belong mainly to the states; states delegate many functions to local (county or city) health departments. Federal agencies (for example, the CDC and HRSA within the Department of Health and Human Services) provide funding, guidance, and national data. Health departments may be voluntarily accredited by the Public Health Accreditation Board (PHAB).

• Assess the health of the population and identify at-risk groups, including those not using services
• Plan, implement, and evaluate programs using the nursing process at the population level
• Use evidence and surveillance data to set priorities
• Build partnerships and empower communities to act on their own health
• Protect health through communicable disease investigation, immunization, and environmental health work
• Advocate for policies that improve conditions for health and reduce inequities
• Maintain competencies appropriate to the tier of practice

• Legal basis: state public health laws and the state Nurse Practice Act define what PHNs may do (e.g., standing orders for immunizations, TB testing, communicable disease reporting and investigation)
• Mandatory reporting: notifiable diseases to the health department (lists are set by each state), child and elder abuse
• Balancing individual rights and community protection: isolation, quarantine, and directly observed therapy restrict liberty and must be the least restrictive means, legally authorized, and applied fairly
• Confidentiality: HIPAA allows disclosures to public health authorities for disease reporting and surveillance; PHNs protect sensitive information such as HIV or TB status
• Ethics: public health ethics emphasizes social justice, beneficence to the population, and respect for community values; the ANA Code of Ethics calls nurses to address social determinants and health disparities

Case 1 — Level of prevention. A PHN organizes free blood pressure checks at a community center and refers people with high readings. This is secondary prevention because it detects existing disease early. Why: screening finds disease; education to prevent hypertension would be primary.

Case 2 — Population focus. A school nurse notices many absences for asthma. Besides caring for each student, she maps cases, finds they cluster near a bus depot, and works with the district on idling limits and asthma action plans. Why: PHN looks for patterns and upstream causes affecting the whole group.

Case 3 — Core function. A county health department nurse helps draft a local ordinance for smoke-free multiunit housing. This is policy development. Why: creating and supporting policies is a core function distinct from assessment (data) and assurance (services).

• Equating any care outside the hospital with public health nursing — community-based care of individuals is not necessarily population-focused
• Classifying screening as primary prevention (it is secondary)
• Attributing the Henry Street Settlement to Nightingale — it was Lillian Wald (with Mary Brewster); Rathbone and Nightingale developed district nursing in England
• Assuming the federal government runs local public health — authority rests mainly with states
• Forgetting that the 2020 revision of the essential services places equity at the center

• PHN = population-focused, prevention-oriented, equity-driven practice
• Lillian Wald: Henry Street Settlement (1893), coined "public health nurse," first NOPHN president (1912)
• Rathbone (1859, Liverpool) = district nursing; Lina Rogers (1902, NYC) = first school nurse; Mary Breckinridge (1925) = Frontier Nursing Service
• Three core functions: assessment, policy development, assurance; 10 Essential Public Health Services (2020, equity at the center)
• Prevention: primary (before disease), secondary (screening, early treatment), tertiary (rehabilitation, limit disability)
• ANA PHN standards apply the nursing process to populations, including population diagnosis
• CPHNO (formerly Quad Council) competencies: 8 domains, 3 tiers
• Public health authority rests mainly with the states; PHAB accredits health departments
• PHN roles: clinician, educator, advocate, case finder, case manager, collaborator, leader, researcher, policy advocate