A unique and distinct aspect of PHN practice is the autonomy required when working in a setting"without walls." Clinical judgment and clinical decisions are a central part of nursing practice that demands a high level of knowledge and clinical versatility. PHNs do not generally work in the protected and controlled environment of an institution, but rather in the client's setting, where the clients determine who will enter their homes, and whether they follow （or even listen to）the health teaching and counseling given. If the setting is a clinic, there is no force that can make a client come to or return to a clinic, or, for that matter, follow any regimen given.

  在一个“没有围墙”的工作环境中，PHN实践所具有的一个独特、突出的特点是护士必须具有自主性。临床判断和临床决策是护理实践的中心工作，要求护士必须掌握高水平的知识并能够在临床工作中担当多面手。在通常情况下，公共卫生护士并不是工作在一个封闭的医疗环境，而是在患者的处所，在家里，患者有权决定谁可进来，是否听从甚至是否聆听护士所给的健康宣教和建议。如果工作地点是诊所，人们就无法强制患者来就诊或来复诊，也不可能让他们服从该诊所内所做的治疗方案。