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Conceptual Models for Population-focused

Public Health Nursing Interventions and
Outcomes: The State of the Art
ARTICLE in PUBLIC HEALTH NURSING JULY 2012
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Public Health Nursing

0737-1209/ 2012 Wiley Periodicals, Inc.
doi: 10.1111/j.1525-1446.2011.01006.x

SPECIAL FEATURES: THEORY

Conceptual Models for

Population-focused Public Health
Nursing Interventions and Outcomes:
The State of the Art
Jeri L. Bigbee, Ph.D., R.N., F.N.P.-B.C., F.A.A.N.,1 and L. Michele Issel, Ph.D., R.N.,2
1
Adjunct Professor, Betty Irene Moore School of Nursing at UC Davis, Sacramento, California; and 2University of Illinois, School of Public
Health, Chicago, Illinois

Correspondence to:
Jeri L. Bigbee, Adjunct Professor, Betty Irene Moore School of Nursing, University of California Davis Health System, 4610 X Street,
Sacramento, CA, 95817. E-mail: mailto:jeri.bigbee@ucdmc.ucdavis.edu

ABSTRACT The conceptual basis of public health nursing (PHN) has evolved particularly over the
past three decades. In October 2010, a national research agenda setting conference was held with grant
support from the Agency for Healthcare Research and Quality. From the conference, public health
nursing intervention models emerged as one of four top priorities. The need for a stronger theoretic base
that can guide population-focused nursing practice and research was strongly emphasized. The purpose
of this review, in concert with this priority, is to analyze the current status of PHN conceptual models.
Based on the review, a set of recommendations is presented related to future conceptual development
and testing, with an emphasis on PHN interventions and outcomes. A key recommendation is the refinement of the existing conceptual models with perhaps some consolidation of models, thereby establishing
strong grand, middle-range and practice theories that include explicit PHN intervention and outcome
components. Another recommendation calls for rigorous comparative analysis and testing. Professional
support from the PHN community along with funding agencies will be needed to implement the
recommendations related to PHN theory development and testing.
Key words: nursing theory, outcomes, public health nursing practice.

The importance of theory-based practice and

research is well established, and nursing has served
as a leader among health disciplines in advocating
for theory-based approaches. To date, there has
been limited theory development specific to public
health nursing interventions and outcomes and
even less research based on these conceptual
models. In October 2010, a research agenda setting
conference for public health nursing (PHN) was
held with multi-disciplinary experts (Issel, Bekemeier & Kneipp, 2012). The goal of the conference
was to identify a set of research questions and
themes related to population health outcomes
sensitive to PHN interventions. To refine these

questions and themes, a roundtable session, sponsored by the PHN section at the 2010 American
Public Health Association meeting in November
2010, allowed participants to add to and clarify the
research questions and themes generated at the
previous conference. The final step in generating
the PHN research priorities was a survey in which
participants ranked the themes. The final four high
priority research themes were: (1) PHN populationfocused intervention models, (2) quality of PHN
practice, (3) metrics of/for PHN practice and comparative effectiveness, and (4) PHN outcomes
research. In this article, we expand on the first
research priority area related to PHN intervention

Public Health Nursing

models, reviewing the current status of PHN conceptual models along with recommending priorities
for future conceptual development and testing, with
an emphasis on PHN interventions and outcomes.

Background
Conceptual models constitute an integrated set of
concepts and relational statements that provide
direction for clinical assessment, analysis, planning
and evaluation, along with the basis for the
development of theories, which are more structured
(U.S. Department of Health & Human Services,
National Institutes of Health, 2005). In addition,
conceptual models represent a framework for
selecting variables in research and for articulating
the relationships among the variables. Educationally, conceptual models can also serve as guides for
developing professional curricula. In nursing, there
has been considerable advancement in the past half
century related to theory development and the conceptual basis of practice, particularly in the development of conceptual models. Walker and Avant
(2011) outline the four levels of theory development
metatheory, grand nursing theories, middle-range
theories, and practice theories. Middle-range theories, as exemplified by Penders Health Promotion
Model (2011) and the Translational Environmental
Research in Rural Areas (TERRA) framework
(Butterfield, Postma & ERRNIE research team,
2009), are more limited in scope and variables than
grand theories, are testable, and speak to a more
defined scope of experience, such as public health
nursing. Middle-range theories are highly useful, in
that they propose the nature of the relationship
between two or more concepts to explain and predict one concept on the basis of the other (Blegen
& Tripp-Reimer, 1997). The development of middle-range theories in nursing is essential to predict
outcomes of nursing interventions. Middle-range
theories can also be used to refine grand theories to
which they may be connected, along with directing
the prescriptions of practice theories. A limitation
of current middle-range theories in nursing is that
the focus is generally on the individual or family
levels, not populations, which reduces their applicability to PHN practice (Ervin, 2002). Practice theories, as exemplified by the Theory of the Peaceful
End of Life (Ruland & Moore, 1998), provide tests
of propositions in practice, thereby supporting the

development of middle-range theory (Walker &

Avant, 2011). This type of theory includes desired
goals and prescriptions for actions to achieve the
goal, thus providing the basis for interventions.
Nursing intervention is defined as treatment based
on clinical judgment and knowledge performed by
a nurse to enhance patient/client outcomes
(McCloskey & Bulechek, 1996). PHN interventions
are population-focused and delivered by PHNs on
behalf of or (more commonly) in partnership with
the community (Ervin, 2002).
Other broad perspectives and advances in nursing theory development also inform this discussion.
Fawcett (1995) identified the now well established
four metaparadigm concepts that are central to
conceptual models in nursingperson, environment, health, and nursing. From an intervention
and outcomes perspective, Sidani, Doran and
Mitchell (2004) argue for the use of a theory-driven
approach to evaluate the quality and outcomes of
nursing care at the individual, group and community levels, including the identification of patient,
professional and setting factors that impact the process of care and outcomes at both the micro and
meso levels. For PHN practice, the macro level
must also be considered.

Context
The development of PHN conceptual models and
related research has been most active over the past
three decades. The context during that period has
been influenced by critical documents and developments impacting PHN practice. Most recently,
greater emphasis has been placed on public health
nursing as a specialty focused on population health
and population-level interventions. This is reflected
in the 2007 American Nurses Association (ANA)
Scope and Standards for Public Health Nursing
Practice which builds on the nursing process
including assessment, population diagnosis and
priorities, outcomes identification, planning, implementation (including coordination, health education and health promotion, consultation, regulatory
activities), and evaluation.
Public health agencies are increasingly exploring strategies to provide population-focused care
that are optimally cost-effective in achieving
population health compared with providing individual or family level services. A related contextual

Bigbee and Issel: Conceptual Models

factor is the increased emphasis on interprofessional practice in public health settings (Salmon, 1993).
These perspectives are reflected in the public health
core functions of assessment, policy development
and assurance, which was first published in 1988
by the Institute of Medicine (IOM). Building on
those core functions, the ten Essential Public
Health Services have been widely disseminated
beginning in 1994. Another contextual factor is the
trend in public health practice, and public health
systems research, to frame population health concerns in terms of socio-ecological determinants of
health (Bronfenbrenner, 1979) and life course models (Mayer, 2009). Both of these approaches were
adopted from the social sciences rather than from
public health nursing, despite public health nursing
historically advocating for both of these
approaches. These frameworks, although popular
and intuitively attractive, do not readily translate
into mid-range practice theories that can be tested.
In evaluating the conceptual basis of public
health nursing intervention and outcomes, the evolving research context must also be considered. The
Association of Community Health Nursing Educators (ACHNE) research priorities set forth in 2000
included Develop new and interpret existing middle
range the theories or models for application to a
community-as-client perspective as one of ten priorities. In 2010, ACHNE published updated research
priorities. In updating the research priorities, members of the Research Committee reviewed 485
research reports from 2000 to 2006, revealing that
only 3.9% of the reports addressed the theory-related
priority. The current Research Priorities for Public
Health Nursing, established by the Association of
Community Health Nursing Educators Research
Committee (2010) focus on (1) population-focused
outcomes, and (2) public health nursing workforce.
They acknowledge that:
Public health nursing has built a practice model
primarily from tradition and is only in its early
stages of basing it on practice theory research in
public health nursing must begin with the recognition of the overarching need to: (1) develop grand
theories that provide the theoretic basis of public
health nursing, and (2) develop, test, and refine
middle-range theories that provide the foundation
of evidence-based nursing practice (p. 97).

These contextual factors have heightened the

need for PHN conceptual models and research,

which can effectively guide population-focused

practice. This background information suggests that
a strong conceptual basis for population-focused
public health intervention and outcomes is essential
for promoting the quality of public health nursing
care and particularly the related research agenda.

Review of Existing Public Health

Nursing Conceptual Models
For the purposes of this review, a search of conceptual models specific to public and/or community
health nursing practice in the U.S. was conducted,
focusing on CINAHL, public health nursing texts,
and books addressing specific models. A total of 12
models, all of which resemble practice theories,
were identified (see Table 1). In addition, a search
for documentation of application and/or testing of
each of the models was conducted, and the results
are included in Table 1. There appears to be limited
application and testing of the various models, particularly by nurses not associated with model developers. Most of the reported research using the
models has been small, non-experimental cross-sectional studies. This review suggests that historically
there has been considerable conceptual development activity, which has produced a number of
PHN conceptual models. The literature also suggests
that most of these models have not been tested,
applied or refined over time to a significant degree.
On the basis of the contextual factors and our
review of the existing PHN models, we identified
three descriptive dimensions to facilitate our
comparison of the models, including Nursing as a
Discipline, Public Health Practice and Competencies, and Application to PHN Practice (see Table 2).
Within the Nursing as a Discipline dimension,
specific evaluation elements included (1) based on
previous theory, (2) inclusion of nursings metaparadigm, and (3) inclusion of the nursing process.
Within the Public Health Practice and Competencies dimension, specific evaluation elements
included (1) levels of prevention, (2) PHN Standards/practice model, (3) PH Essential Services,
and (4) PH core functions. Within the Application
to PHN Practice dimension, specific evaluation elements included (1) population-focused, (2) levels of
practice (community/family/individual), (3) interventions addressed, (4) outcomes addressed, (5) interprofessional aspects addressed, (6) inclusion of

Public Health Nursing

TABLE 1. Public Health Nursing (PHN) Conceptual Models and Application/Testing Evidence

Model
Community energy theory
(Helvie, 1981, 1998)

A public health nursing conceptual

model (White, 1982)

Community-as-partner model
(Anderson & McFarlane,
1988, 2011)

The interactive and organizational

model of community as client
(Kuehnert, 1995)
The dimensions model of
community health nursing
(formerly known as the
epidemiologic prevention process
model) (Clark, 1996, 2008)
The public health nursing model
(Kuss, Proulz-Girouard, Lovitt,
Katz & Kennelly, 1997)

The intervention wheel (previously

known as the public health
nursing interventions (PHI)
model (Keller et al., 1998)

The integrative model of holistic

community health nursing
(Laffrey & Kulbok, 1999)

ASTDN public health nursing

practice model (Association of
State & Territorial Directors of
Nursing, 2000)
Public health nursing
population-focused practice
model (Kaiser et al., 2002)

Description
This model is based on systems theory and
focuses on energy as the capacity to do work.
The human system is a changing energy field
with energy exchanges influencing the health
of the population
This model includes the determinants of health
as impacted by the nursing process and
the valuing process along with the PHN scope
of practice, at individual, family, and aggregate
levels
Based on Neumans health system model and
the nursing process, this model includes
an assessment wheel with eight subsystems
and normal and flexible lines of defense.
Interventions are based on the Intervention
Wheel

This model includes the organizational context

of PHN practice using the nursing process
with individual/family, aggregate, and
community-wide foci
This model includes the nursing process and
public health levels of prevention with an
emphasis on the determinants-of-health and
dimensions of nursing
This model uses a flowering tree depiction of
PHN with an emphasis on community
empowerment along with the Core Public
Health Functions within the context of the
public health environment
This population-based model includes 17
nursing interventions applied at the
individual, community, and systems levels

This model includes the interrelated dimensions

of the focus of care (health promotion,
illness/disease/disability prevention, and illness
care), and client system (individual,
family, aggregate and community) levels of care
This model focuses on the art and science or nursing
practice through the nursing process along with
the Core Public Health Functions and Essential
Services
This population-focused model includes multiple
levels of PHN care as related to strategies and
outcomes. Interventions are based on the
Intervention Wheel model

Documentation of application/
empirical testing
Liou, Wang, Hung &
Lin, 2009;

Bernal, Shellman & Reid,

2004;
Huttlinger, Schall-Ayers &
Lawson, 2004;
Shellman, 2000;
Eshlerman & Davidhizar,
2000;
Springer, Black, Martz, Deckys
& Soelberg, 2010;
Kuehnert, 1995;

Clark, 1995;

Keller, Strohschein,
Lia-Hoagberg & Schaffer,
2004a;
Keller, Strohschein, Schaffer &
Lia-Hoagberg, 2004b;
Katz et al., 2007;
Tembreull & Schaffer, 2005;

Kaiser et al., 2002;

Bigbee and Issel: Conceptual Models

TABLE 1. Continued

Model
Comprehensive multi-level
nursing practice model
(May, Phillips, Ferketich &
Veraan, 2003)
The public health nursing
practice model (LA County
Health Dept.) (Smith &
Bazini-Barakat, 2003)

Description
Based on the PHN practice model and
community-based action research, this model
focuses on the interventions of personal
preventive nursing, organized indigenous
caregiving, and community empowerment
This population-based model uses the nursing
process in addressing health indicators using
nursing interventions based on the Intervention
Wheel

client participation, and (7) determinants of health

addressed. In addition, we documented general
impressions and overall observations based on our
holistic review of the models in light of the current
literature and context.
Using the descriptive evaluative dimensions
and elements outlined above, several commonalities
and differences between the models were noted, as
summarized in Table 2. Within the Nursing as a
Discipline dimension, the models reflect the evolution of nursing theory development over time to
some extent. Three of the models specifically build
on larger existing theories, which support the development of middle-range theory. A strength noted
over time is that three of the models have also
incorporated elements of The Intervention Wheel
model (Keller, Strohschein, Lia-Hoagberg & Schaffer, 1998). This example of conceptual sharing
represents a positive step for the future in terms of
the refinement and coalescence of existing models.
Only one of the models specifically includes the
four elements of the nursing paradigm as identified
by Fawcett (1995), but most of the models include
elements of the nursing process with particular
emphasis on assessment.
In relation to the Public Health Practice and
Competencies dimension, our review suggests that
the existing conceptual models reflect to some
degree the important contextual factors impacting
PHN practice over the past 30 years. Three of the
12 models incorporate the historic public health
concept of levels of prevention, and three of the
models build on the current Standards and Scope
of PHN Practice or previous related documents.
Only two of the models address the Essential Public
Health Services, and three address the public health
core functions.

Documentation of application/
empirical testing
May et al., 2003;
McGinty, 2003;

Mondy, Cardenas &

Avila, 2003;
Sakamoto & Avila, 2004

Within the Application to PHN Practice dimension, most of the models address the multiple levels
of practice (individual/family/aggregate/community), which is critical to PHN as a specialty, but
only three are specifically identified as populationfocused. Focusing specifically on the aspect of
intervention, our review revealed that the majority
of the models address PHN interventions to some
degree. The Intervention Wheel (Keller et al.,
1998) (which, as noted above, has been incorporated into several other models) stands out as the
most detailed in relation to interventions. In this
model, the interventions are fairly generalized (e.
g., collaboration) and are not linked conceptually
to specific health determinants, concerns or outcomes. This limits the prescriptive power and testability of the models overall. In terms of
intervention delivery, the models are also fairly
nonspecific. The prescriptive value and testability
of the models would be strengthened, for example,
if dosage, duration, and strength/intensity were
incorporated, including who (i.e., the nurses background and qualifications) delivers the intervention, similar to the work by Brooten and
Youngblut (2006). Inclusion of this interventional
aspect in greater depth would serve to identify the
unique contribution of the PHN within the interprofessional public health team. This level of detail
is needed to direct theory-based practice and to
generate results for evidence-based practice. In
general, the prescriptive aspect of intervention,
which is characteristic of practice theories, needs
further development in the current PHN conceptual models. As shown in Fig. 1, for an intervention to have an effect, it must act upon a
determinant or cause of a health problem/concern.
To direct practice and research, conceptualizations

Descriptive dimensions

Communityenergy theory
(Helvie)
X
X

A public health nursing

conceptual model (White)
X

Community as partner
model (Anderson)
Xa
X

X
X
X

The interactive organizational

model of community as client
(Kuehnert et. al)

Note: aThe Intervention Wheel has been incorporated into these models.

Nursing as a discipline
Based on previous theory
Includes nursings meta-paradigm
Includes nursing process
Public health practice & competencies
Includes levels of prevention
Includes PHN standards/practice
model
Includes PH essential services
Includes PH Core functions
Application to PHN practice
Population-focused
Includes levels of practice
(community/family/individual)
Interventions addressed
Outcomes addressed
Inter-professional aspects addressed
Client participation included
Determinants of health addressed

The dimensions model of

community health nursing
(Clark)
X

The public health nursing

model (Kuss)

TABLE 2. Comparison of Components of Existing Public Health Nursing (PHN) Conceptual Models

The intervention wheel

(Keller-Olson)
X

X
X

The integrative model of

holistic community health
nursing (Laffrey)
X

ASTDN public health nursing

practice model
X

X
X

Public health nursing

population-focused practice
model (Lopez Kaiser)
Xa
X

Comprehensive multi-level
nursing practice model (May)
X

X
X

Xa
X
X
X

X
X

X
X

The public health nursing

practice model (LA model)

6
Public Health Nursing

Bigbee and Issel: Conceptual Models

Determinant of health problem

Health Outcome
Mediating Factor(s)

Moderating Factor(s)

Public Health Nursing Intervention

Figure 1. Generic Model of Intervention Effect (Adapted from Issel, 2009)

of PHN interventions should include a clear and

specific delineation of the causes or determinants
of specific population health concerns and issues,
which then are the targets of the PHN populationfocused interventions.
Only five of the models reviewed specifically
address outcomes, often in quite general terms,
such as healthy people in healthy communities
(Smith & Bazini-Barakat, 2003) or advocacy/services (Kuehnert, 1995). The Public Health Nursing Population-Focused Practice Model (Kaiser,
Barry & Kaiser, 2002) outlines some of the most
explicit population-based outcomes, but clear linkages between specific interventions and outcome
are not included. The identification and evaluation
of measurable outcomes that are sensitive to PHN
interventions is essential to evaluate the impact of
PHN services. Issel, Bekemeier and Baldwin
(2010) have addressed this issue using a consensus building approach. An alternative approach
would be to theoretically derive the outcomes
based on the interventions used and the determinants addressed. The emphasis on the determinants of health is specifically addressed in only
two of the models. The general lack of inclusion of
determinants of health limits the models ability to
link specific factors to the health status of the
population, which reduces the prescriptive power
of PHN interventions. Inclusion of the determinants of health is also essential in the measurement of outcomes. Three of the models speak to
the interprofessional aspect of PHN practice, and
only two of the models include client/consumer
involvement. These observations suggest that
addressing relevant contextual factors in greater
depth may be indicated in future PHN conceptual
model development.

Implications
This review of existing PHN conceptual models has
demonstrated that a considerable amount of nursing scholarship has been produced particularly over
the past three decades that addresses the conceptual basis of PHN practice. This conceptual activity,
which has produced a total of 12 models, is impressive, given the limited conceptual development
among other nursing specialties. Strengths of this
scholarship include the creativity of the models, the
variety of perspectives addressed, the recent sharing and incorporation between models particularly
related to intervention, and the general grounding
in the nursing process and the multiple levels of
public health practice. Of the 12 models identified,
all resemble practice models that may be approaching or have potential to become middle-range theories. As Ervin (2002) notes, the current PHN
conceptual models lack the specificity of prescriptive actions to achieve specific goals (p. 85), which
greatly limits their usability in practice and
research as well as their contribution to theory
development.
Our analysis supports the call for the increased
development of current models and perhaps new
and/or combined models to guide both PHN practice and research in the future. This enhanced conceptual basis will be highly useful in addressing the
four high priority research areas related to PHN
intervention models that were identified during the
consensus conference (Issel, Bekemeier & Kneipp,
under review): developing and testing populationfocused interventions, identifying essential PHN
interventions for optimal population health, delineating PHNs unique role in providing public health
core services, and communicating relevant findings

Public Health Nursing

to policy makers and the public. PHN theory

development efforts will also contribute to the conceptual development of other public health disciplines and public health science and practice in
general. Future strategies for PHN theory development may include new approaches, such as creating
data driven theory, perhaps through the use of
PHN databases generated through electronic systems such as the Omaha system or other datasets
(Monsen, Bekemeier, Newhouse & Schutchfiled,
2012), utilizing multi-disciplinary collaborations to
develop interprofessional public health theory, and
extending individually based conceptual models to
address PHN-sensitive population and systembased outcomes. Greater specificity addressing the
link between determinants of health, interventions,
and population outcomes is needed in the current
PHN practice models if we are to move toward
developing middle-range PHN theory in the future.
In addition, significantly more testing and application of the models is needed, which will be
facilitated by greater specificity of the interventionoutcome links in the models.
On the basis of this review, we propose the following recommendations for the future regarding
developing the conceptual basis of PHN practice,
particularly related to interventions and outcomes.
The existing conceptual models need to be refined
and perhaps consolidated, thereby establishing a
core of strong grand, middle-range, and practice
theories that include explicit PHN intervention and
outcome components. This refinement process
would build on the work to date and reflect current
contextual factors. Next, rigorous comparative analysis and testing is needed to evaluate the models by
a variety of investigators and practitioners using
diverse methods and populations. Funding agencies
will need to provide targeted support for these
PHN theory development and testing activities. The
PHN community must also embrace these efforts
with continued dialog and recognition of the importance of developing and strengthening our conceptual base. These recommendations need to be
implemented aggressively over the next decade to
address the current challenges and rapidly changing
health care and public policy environment.
In summary, a strong conceptual base is essential to the evaluation of the interventions and outcomes associated with population-based nursing
care. Our review suggests that the scholarship

related to the development, refinement, testing, and

application of conceptual models specifically related
to public health nursing interventions and outcomes
is relatively young, and greater public health
nursing-specific theory development is needed.
Application and testing of the existing models in a
variety of public health nursing settings is particularly indicated. Rigorous conceptually based
research examining public health nursing interventions and outcomes is essential to effectively
evaluate the quality and effects of population-based
nursing care. Nursing conceptual leaders, Walker
and Avant, provide the public health nursing
community with an apt charge for the future;
although much has been achieved in nursings
theoretic development, the challenge to develop relevant and useful theories to meet the knowledge
needs of nurses for the 21st century remains with
us (Walker & Avant, 2011, p. 6). The progression of
public health nursing practice, research, and
theory development must go hand-in-hand as this
vital and vibrant nursing specialty continues to
evolve.

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