Public Health Nursing Vol. 28 No. 3, pp. 249–260
0737-1209/r 2011 Wiley Periodicals, Inc.
doi: 10.1111/j.1525-1446.2010.00923.x
SPECIAL FEATURES: CLINICAL CONCEPTS
Cornerstones of Public Health Nursing
Linda Olson Keller, Susan Strohschein, and Marjorie A. Scha¡er
ABSTRACT The ‘‘Cornerstones of Public Health Nursing’’ describe the values and beliefs that underlie
the practice of Public Health Nursing, which is a synthesis of public health and nursing. The impetus for
the development of the Cornerstone framework originated from the need to advocate for public health
nursing programs, positions, and funding. Grounded in practice, their development engaged stakeholders
from the public health nursing community at every phase. The Cornerstone framework has been used over
the past decade by educators to teach public health nursing and by administrators in state and local health
departments for orientation and continuing education. The Cornerstones have been nationally and inter-
nationally disseminated. This paper describes the development and dissemination of the Cornerstones
framework by public health nurses in Minnesota and features exemplars from practice.
Key words: beliefs, decision making, public health nursing practice.
Despite widespread agreement that public health cause public health nurses (PHNs) were unable to
nursing practice is a synthesis of the disciplines of articulate their unique contributions to the then
public health and nursing, that synthesis has not been newly defined public health core functions (Insti-
clearly articulated. A synthesis requires the identifica- tute of Medicine, 1988).
tion of the values and beliefs contributed by each of In response to this challenge, the PHN consultants
the underlying disciplines. The ‘‘Cornerstones of pub- at the Minnesota Department of Health led an initia-
lic health nursing’’ propose a coherent synthesis of tive to identify the interventions that PHNs perform,
these values and beliefs and an underlying structure regardless of the work setting or the level of practice.
for the practice of public health nursing. This effort (Keller, Strohschein, Lia-Hoagberg, &
The need for a clear articulation of that synthe- Schaffer, 2004) produced the Public Health Interven-
sis strongly emerged in the health care reform ini- tion Wheel, a model that defines what PHNs do. While
tiatives of the 1990s. Cost containment strategies the Intervention Wheel has proven to be broadly useful
compelled the public health nursing discipline to for public health nursing education, research,
clearly define its role or risk severe cuts in funding. and practice (Caley, Shipkey, Winkelman, Dunlap, &
Nursing positions in Minnesota’s local health de- Rivera, 2006; Fahrenwald, 2003; Lee, Bakken, & Saba,
partments were being reduced or eliminated be- 2004; Smith & Bazini-Barakat, 2003; Tembreull &
Schaffer, 2005), it did not define why PHNs practice
as they do, that is, it did not define the core values and
Linda Olson Keller, D.N.P., R.N., F.A.A.N., is Clinical beliefs of public health nursing that remained constant
Associate Professor, University of Minnesota, Minneap- over time. The PHN consultants were committed to ar-
olis, Minnesota. Susan Strohschein, M.S., R.N., is Project ticulating the shared values and beliefs of PHNs that
Coordinator, University of Minnesota, Minneapolis, were previously unspoken assumptions. Specifically,
Minnesota. Marjorie A. Scha¡er, Ph.D., R.N., is Profes- what were the values and beliefs that informed PHNs’
sor, Bethel University, St. Paul, Minnesota. decision making and action?
Correspondence to: The purpose of this paper is to document the
Linda Olson Keller, School of Nursing, University of chronological process of articulating the values and
Minnesota, 5-160 Weaver-Densford Hall, 308 Harvard beliefs that serve as the foundation for public health
St, S.E. Minneapolis, MN 55455-0342. E-mail: olson173@ nursing and to disseminate the resulting framework
umn.edu and its constituent concepts.
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, 250 Public Health Nursing Volume 28 Number 3 May/June 2011
Development of the Cornerstone the public health principles as defined in state
Framework administrative rules for community health services
at the time (Minnesota Administrative Rules 1978,
The Cornerstones framework evolved in three distinct chap. 4700);
phases over a 9-year period (Table 1)—a much longer the core functions as outlined in The Future of
process than anticipated. This process began with 10 Public Health Institute of Medicine report (Insti-
PHN consultants in a state health department. The tute of Medicine, 1988);
consultants’ job descriptions were to provide policy State Community Health Services Advisory Com-
and programmatic liaison between the state and mul- mittee position paper delineating the core functions
tiple local health departments in a region on topics for local health departments (Minnesota Depart-
such as disease prevention and control, health pro- ment of Health, 1995);
motion, maternal and child health, and services for the legal authority for public health nursing prac-
the ill and disabled. Eight of the PHN consultants tice as outlined by the state’s nurse practice act
possessed master’s degrees in public health nursing; (Minnesota Statutes, Nurse Practice Act 1999, Sec-
the group represented 242 years of public health nurs- tion 148.171);
ing experience, ranging from 15 to 30 years. Later, state statutory requirements for PHN registration
practicing PHNs and PHN directors in local health (Minnesota Administrative Rules 2008, chap.
departments were included in the development pro- 6316).
cess, as described below.
Analysis. The thematic content of the docu-
Phase 1: Identification of common themes ments was organized into a grid for analysis. For
in seminal documents example, the theme of ‘‘focus on populations’’ was
Sources. Our search for the common themes represented by the APHA definition and role docu-
relevant to public health nursing began with the iden- ment, the public health principles, and the state stat-
tification of documents, standards, policies, and laws utory requirements for PHN registration included a
that guided public health nursing practice in our state. focus on populations. Once themes from each docu-
While this was not an exhaustive search, it included ment were identified, we compared and contrasted
the major influential public health, nursing, and pub- the content and commonalities of themes across doc-
lic health nursing documents currently in use at the uments. For example, the Institute of Medicine report
time, including: identified the core function of assurance, ‘‘to assure
the Definition and Role of Public Health Nursing: their constituents that services necessary to achieve
A Statement of the American Public Health Associ- agreed upon goals are provided, either by encouraging
ation (American Public Health Association, 1996); actions by other entities (private or public sector), by
requiring such action through regulation, or by pro-
TABLE 1. Cornerstones’ Development Timeline viding services directly’’ (Institute of Medicine 1988,
p. 8). One of the principles of public health as stated in
Phase 1
the Rule was that ‘‘public health does what others
1996 Search for Cornerstones commenced
1997 Development of common themes cannot or will not do’’ (Minnesota Administrative
1998 Development and distribution of Cornerstone Rules 1978, chap. 4700). Both of these documents
brochure describe the assurance role, although the terminology
Phase 2 differs. The PHN consultants reviewed and critiqued
1999 Search of historical records and modern literature multiple drafts of the themes and ultimately affirmed
1999 Development of Cornerstone background papers
1999 Public health and nursing Cornerstone magnet
a comprehensive list of common themes, listed in
2000 Regional trainings for Division of Nursing grant Table 2.
2000 CDC/HRSA satellite conference
Phase 3 Dissemination. The final analysis of the themes
2003 Presented at annual public health conference
that represented public nursing’s contribution to the
2004 Public health nursing Cornerstones magnet
public health core functions was developed into a bro-
Note. CDC 5 Centers for Disease Control; HRSA 5 Health chure. The brochure illustrated the relationships
Resource Services Administration. between the identified themes; public health nursing
