Effective public health nursing relies on the development of responsive and collaborative relationships with families. While nurse-family relationships are endorsed by home visitation programs, training nurses to follow visit-to-visit protocols may unintentionally undermine these relationships and may also obscure nurses’ clinical understanding and situated knowledge. With these issues in mind, we designed a home visiting intervention, titled Listening with Care, to cultivate nurses’ relationships with teen mothers and nurses’ clinical judgment and reasoning. Rather than using protocols, the training for the intervention introduced nurses to narrative methods and therapeutic tools. This mixed-method pilot study included a quasi-experimental design to examine the effect of the intervention on teen mothers’ depressive symptoms, self-silencing, repeat pregnancy, and educational progress compared to teens who received usual care. Qualitative data was collected from the nurses to evaluate the feasibility and acceptability of the intervention and therapeutic tools. The nurses endorsed the therapeutic tools and expected to continue using them in their practice. Despite the lack of statistically significant differences in outcomes between groups, findings suggest that further study of the intervention is warranted. Future studies may have implications for strengthening hidden aspects of nursing that make a difference in the lives of teen mothers.

Background Limited data exist on correlates of psychological outcomes after kidney donation. Methods We used a database integrating OPTN registrations for 4,650 living kidney donors in 1987–2007 with administrative data of a U.S. private health insurer (2000–2007 claims) to identify depression diagnoses among prior living donors. The burden and demographic correlates of depression after enrollment in the insurance plan were estimated by Cox’s regression. Graft failure and death of the donor’s recipient were examined as time-varying exposures. Results After start of insurance benefits, the cumulative frequency of depression diagnosis was 4.2% at one-year and 11.5% at five years, and was less common than among age-and-gender matched general insurance beneficiaries (rate ratio 0.70, 95% CI 0.60–0.81). Demographic and clinical correlates of increased likelihood of depression diagnoses among the prior donors included female gender, white race and some perioperative complications. After adjustment for donor demographic factors, recipient death (aHR 2.23, 95% CI 1.11–4.48) and death-censored graft failure (aHR 3.30, 95% CI 1.49–7.34) were associated with two-to-three times the relative risk of subsequent depression diagnosis among non-spousal unrelated donors. There were trends towards increased depression diagnoses after recipient death and graft failure among spousal donors, but no evidence of associations of these recipient events with the likelihood of depression diagnosis among related donors. Conclusions Recipient death and graft loss predict increased depression risk among unrelated living donors in this privately-insured sample. Informed consent and post-donation care should consider the potential impact of recipient outcomes on the psychological health of the donor.

This article extends the argument in Part 1 that stand- ards, protocols, textbook knowledge, and other external guidelines, while important for beginners, must yield to the "real world" of practice. Additional narratives document how the development of practical reasoning, perceptual skills, and responsiveness to clients supplants the beginner's reliance on external guidelines and promotes a situated understanding of practice. This growth in understanding and clinical know-how, cultivated by frontline experience with individuals and families, fosters a perceptual grasp of the "big picture" and makes it possible for the nurse to learn the community through the eyes of clients. Experiences from home visiting and community-based activities provide critical lessons that inform and inspire nurses to act and think upstream. This interpretation provides additional evidence for legitimizing clinical practice as a rich source of situated knowledge and clinical reasoning.

Although therapeutic letters (TLs) have been included in graduate nursing programs, studies have not examined the impact of TLs on the clinical learning of undergraduate students. This qualitative study was part of a larger project that introduced TLs into already established undergraduate clinical courses. Instructors prepared students for writing TLs by discussing their purpose and by providing a relevant article and examples. In all, 74 students participated in 12 focus group interviews. Interviews were audiotaped, professionally transcribed, and analyzed using qualitative description. Results suggest that TLs cultivate rapport building and the development of students' relational skills. Although the assignment promoted clinical learning and reflection on helping relationships for the vast majority of students, a few students treated TLs as an instrumental activity. Implications for educating health professionals are described.

While the competencies and theory relevant to public health nursing (PHN) practice continue to be described, much less attention has been given to the knowledge derived from practice (clinical know-how) and the development of PHN expertise. A study was designed to address this gap by recruiting nurses with varied levels of experience and from various practice sites. A convenience sample of 28 public health nurses and seven administrators/supervisors were interviewed. A subsample, comprised of less-experienced public health nurses, were followed longitudinally over an 18-month period. Data included more than 130 clinical episodes and approximately 900 pages of transcripts and field notes. A series of interpretive sessions focused on identifying salient aspects of the text and comparing and contrasting what showed up as compelling, puzzling, and meaningful in public health nurses' descriptions. This interpretive analysis revealed changes in understanding of practice and captured the development of clinical know-how. In Part 1, we describe the sample, study design, and two aspects of clinical knowledge development--grappling with the unfamiliar and learning relational skills--that surfaced in nurses' descriptions of early clinical practice. In Part 2, which is to be published in the next issue of Public Health Nursing (SmithBattle, Diekemper, & Leander, 2004), we explore gradual shifts in public health nurses' understanding of practice that led to their engagement in upstream, population-focused activities. Implications of these findings for supporting the clinical learning of public health nurses and the development of expertise are described.