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As team leader of the county's Child Health Advocate program, House works mainly with children referred by agencies such as the state Department of Social & Health Services. Her clients range from young, new parents to children from dysfunctional families to children in the court system. She educates parents on how their children's brains develop so they can be more effective parents, and this can reduce child abuse and neglect.

House said she prefers teaching families in this setting over interacting with them in a hospital or clinic setting.

Schmidt agrees. "You learn so much about people and how to best work with a family when you do home visits, as opposed to in a clinic room," she said.

House's public health nurse co-workers, Marty Gordon, PHN, and Nancy Acosta, PHN, also work in the Parent Child Health Program. However, they see a wider age range of clients than House, and primarily see pregnant women and young parents.

Gordon said she enjoyed giving clients the support and confidence to achieve their goals, such as becoming educated about breast-feeding.

Besides parent and child health, public health nurses also focus on specialties such as controlling the spread of communicable and sexually transmitted diseases, nonemergent and preventive care for inmates, injury and violence prevention, bioterrorism and surveillance and emergency preparedness and disaster planning.

House, Gordon and Acosta usually make about three or four scheduled home visits each day, and carry a 50- to 60-client caseload at a time.

Self-management

Sharon Trucker, MS, RN, assistant nursing director and nurse recruiter at the Los Angeles County Department of Health Services, said that public health nursing is fairly independent in that nurses have a lot of say in planning their schedules.

This is especially true in Alaska. Doctors don't run the Fairbanks public health center; the nurses work under nursing guidelines, said Schmidt, who sometimes must drive long distances to see clients in remote villages.

The Alaska State Department of Health & Social Services covers most parts of the state because many boroughs don't have health departments. Most public health nurses in Alaska are state employees.

The Los Angeles County Department of Health Services-which, according to 2000 U.S. Census data, services more than 15 times as many people as the state of Alaska-is structured differently.

Two kinds of public health nurses work in Los Angeles County: district nurses and program nurses. While each district nurse services a specific geographic area of the county, program nurses focus on specific subpopulations.

As a district public health nurse, Norman Gray, MS, RN, PHN, focuses on a group of census tracts that encompass 50,000 residents. Most of his work, which is state-mandated, involves reporting people with tuberculosis, sexually transmitted diseases or acute communicable diseases, tracking people at risk of acquiring the diseases and arranging treatment and screening. He also focuses on community-based education, such as speaking to groups about healthy eating. On rare occasions, he tries to solve problems by bringing them to the attention of elected officials.

Program public health nurses work with subpopulations such as children in foster care. Nurses in Los Angeles County's foster care program educate the social workers about their clients' potential or existing medical problems. Like district nurses, program nurses work on connecting clients with the right resources.

Practice distinctions

Medical professionals nationwide have diverse beliefs about the difference between community health and public health nursing. For the Kitsap County department, the two are one and the same. However, for the Los Angeles County department, community health nurses are more focused on treating a client instead of a population, and on treating-rather than preventing-diseases.

Community and public health nursing involve three levels of prevention: primary, secondary and tertiary, according to Kathleen Smith, MPH, APRN, RN, clinical nurse specialist in community health for the Los Angeles County department. Primary prevention involves preventing a problem, secondary prevention involves solving a problem in its early stages and tertiary prevention involves tackling a full-blown problem.