“Over broken asphalt, over dirty mattresses and heaps of refuse we went... There were two rooms and a family of seven not only lived here but shared their quarters with boarders... [I felt] ashamed of being a part of society that permitted such conditions to exist... What I had seen had shown me where my path lay.”

Lillian Wald, 18939

Many people have had such an experience or event occur in their life like Wald’s that resulted in a relentless dedication to improving and protecting the precious gift of human life. Others may be aware of similar tragedies and lives led by their fellow man, through their own rise from within such conditions. Throughout history, many have witnessed the plight of the less fortunate, and have had a similar desire stirred to make a difference in another’s life. The health of each person that lives in the world is enhanced or undermined by their environment, among other factors. This is the motivating force for those that work in the field of public health.

To set the role of public health nursing in context, a classic definition of public health by C.E. Winslow[1] will assist in setting the stage;

“Public Health is the science and the art of preventing disease, prolonging life, promoting health and efficiency through organized community effort for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventative treatment of disease, and the development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity”.

As evidenced by this definition, there are many players in the field of public health. Three core public health functions are utilized to guide the health promotion and disease prevention activities of all public health professionals:

· “Assessment and monitoring of the health of communities and populations at risk to identify health problems and priorities;

· Formulating public policies, in collaboration with community and government leaders, designed to solve identified local and national health problems and priorities;

· Assuring that all populations have access to appropriate and cost-effective care, including health promotion and disease prevention services, and evaluation of the effectiveness of that care”.[2]

The mission of public health summarizes the above core functions in one simple sentence, which states, “to fulfill society’s interest in assuring conditions in which people can be healthy.[3]

Public health nursing (PHN) strives to work collaboratively with other public health agencies to accomplish the overriding functions and missions of public health. The Public Health Nursing Section of the American Public Health Association provides the following definition of public health nursing, which illustrates a synthesis from many areas of expertise. It is defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences”.[4]

While many disciplines are involved in the practice and provision of public health service, nursing and public health has been an inseparable pair at many levels for over a century. To speak of one and not acknowledge the influence of the other might demonstrate the need to read this chapter. There are many individuals who are still mystified by the multiple levels at which nurses are educated, and how that education is used to impact the health of the public that it serves. In addition, the public may be unclear as to the relationship between nursing and public health. It is imperative that clarification be made, in hopes that an understanding of these areas will bring more support and interested individuals to the field.

In summary, there are four core reasons to read this chapter: 1) to revisit the history of nursing, and especially its early presence and influence in the field of public health, 2) to differentiate between the different levels of nursing education, and how these levels impact public health at different levels, 3) understand the future of nursing as it relates to public health, and 4) to stimulate a heightened awareness and interest in the area of public health nursing.

Public Health Nursing: The Past

“Pre-Nursing” Origins

When the topic of early nursing practice arises, Florence Nightingale frequently comes to mind. But curing the sick and injured has been practiced for hundreds of years prior to Ms. Nightingale’s time. In addressing the present and future of public health nursing, it is important to reflect on these earlier times, which can provide a rich foundation in which to continue to build future practice.

There is a heightened interest in nursing’s origins by many organizations and individuals in this day and age, as they relate to the issues that plague this century. Keeling stated that nursing’s origins are found in the woman’s role of caring for the sick.[5] Women have traditionally filled the roles of caregiver of the sick throughout history. The Bible describes accounts throughout time, dating back as far as 1450-1410 BC that would be considered a function of nursing/public health. Midwives are mentioned in Exodus, Proverbs 31 describes a woman who helps the poor and the needy, and the book of Acts tells the story of Tabitha, known for her reputation of being compassionate, resourceful, and a helper of the poor.

During the Roman era (31BC-476 AD), Roman armies developed “mobile” war nursing units [6]. This portable hospital provided the care to troops when was carried them to far from home where they could have been cared for by their wives and families. These mobile units consisted of a series of tents that gave way to permanent buildings along battle sites. These would eventually develop into primitive types of hospitals. Though most nurses in those days were slaves, servants, or family members, nursing’s position was strengthened, and it began to emerge as a distinctly different specialty.

The Middle Ages (476-1453 AD) served as a transition between ancient and modern civilizations. Nursing during this era was most influenced by Christianity, with the beginning of “deaconesses”, or female servants, caring for the sick6. These individuals would only care for the needs of the women in the early church, while deacons cared only for the men. Later on in 1633, St. Vincent de Paul founded the Sisters of Charity in France, an order of nuns that visited the sick in their homes6. These early nuns became the first organized visiting nurse service, which are widespread throughout the United States today.

The last half of the time frame between the year 1500 and 1860 has been regarded as the “dark period of nursing”, due to the fact that nursing conditions had arrived at their worst.6 With the sweeping reformation changes that closed many monastic-affiliated institutions, including schools and hospitals, a void was created, leaving no one to pass on the knowledge of caring for the sick. Municipal authorities took over the job of staffing and managing these institutions, and filled the vacant positions with women who were illiterate, inconsiderate, and immoral, and often alcoholic.6 Nursing during these years had no organization and no standing in society.

Back in the United States, the first hospital was built in Manhattan in 1658 to care for sick soldiers and slaves. During the 17^th and 18^th centuries, these “pesthouses”, as they were called, were often used to house clients with contagious diseases. Hospitals in the 19^th century continued to be contaminated by infections, poorly ventilated, and dirty, and actually increased one’s risk of dying. Lay people, usually prisoners with no other options, worked with the sick of their time, and nursing became known as an inferior occupation.

The “Lady with the Lamp”

It would take the impact of one woman to begin to turn what seemed like a hopeless situation around. Florence Nightingale is credited with doing just that. Born May 12, 1820, in Italy, she was the second-born daughter of affluent English parents. Though she led of life of privilege, she could not shake the memories of those that were in conditions of poverty, downtrodden and ill. At an early age, she believed that God had called her to be a nurse, and became obsessed with the plight of those that suffered. During her routine education, she spent five years collecting data about public health and hospitals. In 1849, she toured Egypt, and spent much of her time with the sisters of charity of St. Vincent de Paul, which fanned the flames of her passion even further. 6Finally, in 1851 at the age of 31, her parents permitted her to go to Germany to study to become a nurse. Still fighting the stereotype that nursing had acquired, her family insisted that she tell no one what she was doing, and was forbidden to write, for fear that she would be discovered and disgrace the family name.6

Her life will be forever known for the assignment that she took in 1854. Soon after the outbreak of the Crimean War, stories of inadequate care and lack of medical resources spread throughout England. She was offered, and accepted the position of female nursing establishment of the England General Hospitals in Turkey, which showcased her ability to lead and manage. Shortly after this, Sir Sidney Herbert, the Secretary of War, sent a plea for her services for the soldiers in the Crimea. She accepted, and took 38 self-proclaimed nurses with her on a one-month trip to arrive at their assignment. What lay before them was overwhelming; 3,000 to 4,000 wounded in a hospital that was to accommodate 1,700, no laundry or kitchen facilities, little light, and open sewage filled with rats and other pests.6 Nightingale and her team proceeded to clean the barracks, providing clean dressings, beddings, fresh air and well-cooked food to the wounded and ill.

Within six months, Nightingale decreased the mortality rate from 42%-73%, down to 2%.6 Nightingale’s influence on public health after her return to London was the focus of the rest of her career. Her interest and development of statistical procedures led to her election as a fellow by the Royal Statistical Society in 1858, and an honorary member of the American Statistical Association.25 Her use of statistical analysis to replace individual case method led to marked implications for public health, and nursing.25 The results she obtained from her meticulous record keeping reflect the outcome-based quantitative research that is practiced in healthcare today. Through social activism and reform, health policy and the restoration of nursing, Nightingale’s impact forever changed how the nursing profession was viewed, and made great contributions to the field of public health.

Other accounts can be read about courageous women who had served their country in caring for the sick in the United States, less than a decade after the end of the Crimean War. During the years from 1861 through 1865, The Civil War raged on American soil. Approximately 5,000 women volunteered to serve as Army nurses during that period[7]. Disease killed more soldiers than bullets did on both sides combined. Dysentery was very common, and often fatal among the soldiers. Clara Barton, the founder of the Red Cross, was one of the individuals that volunteered to serve, distributing supplies to wounded soldiers. These individuals, their services and sacrifices to family and country, should not be forgotten in the discussion of nursing history.

Lillian Wald: The Advent of Public Health Nursing

Two years after the end of the Civil War, a baby girl was born in Cincinnati, Ohio, on March 10, 1867. She enjoyed a happy and privileged childhood, but like Nightingale, would be drawn to the profession of nursing. She graduated as a nurse at the age of 24. After working a short time, she decided to enter the Women’s Medical College. She was paired up with another nurse named Mary Brewster, and was sent to the Lower East Side of New York to teach immigrant mothers how to care for the sick. The poverty they witnessed shocked them; never had they observed such conditions. Lillian left medical school after that, moved with Mary Brewster to a local apartment, and began offering nursing care to the poor.[8] Within a short period of time, calls were coming in by the hundreds. Not only was nursing care provided, but community referrals became an integral part of the nurse’s role to assist in meeting the social needs or those that they served.

Within two years, the need for more space, nurses and social workers led to the move to what became known as the Henry Street Settlement, which is thought to be the first established American community health agency. It was staffed with 37 nurses, all who were oriented to the special cultural needs of the immigrants that they served, and understood the importance of the family and environment within the context of providing good nursing care. The mission of the Henry Street Settlement was to provide the education and tools to families to enable them to care for themselves. The nurses taught about good hygiene and how to prevent the transmission of diseases, as well as provided preventative, acute and long-term nursing care.

These early experiences lead Lillian Wald to her life’s work in public health. Her work was a testament to the impact one individual can have in shaping the face of public health, resulting in better health and longer life for all served. Among many of her accomplishments, she is credited with the title of “public health nurse”, and was the first president of the National Organization of Public Health Nurses.[9]

100 Years of Change: 1900-2000

Public Health Nursing Embraced by Government

As nursing’s presence broadened in society, its development in the state and national government took root, as well. As nurses were individually called to assist in the provision of health services to the public, more public money was invested to promulgate the continuation of such needed and necessary services. Nursing leadership positions were awarded within the government to ensure that such valuable services continued.

At the state level, the early part of the 1900’s witnessed the establishment of offices of public health nurses within state health departments. The role of the nurses moved from directing the work of public health nurses, to the transition of influencing public policy and functioning as consultants to local health authorities and the nurses that worked with them. Regulation of nursing practice also became a focus for such nurses in the public domain, as State boards of nursing formed across the country as well in the early part of the century. These state boards served an important public function, as they assisted in the regulation of safe practice standards and standardized education for nurses.[10]

Towards Standardization of Practice

Another important force that influenced the establishment and maintenance of standards in nursing education was the National League of Nursing Education (NLNE).[11] This first association of nurses in the U.S. was initially established in 1893, and was originally called the American Society of Superintendents of Training Schools for Nurses, but was renamed the NLNE in 1912. Over the next 40 years, the NLNE worked diligently towards the standardization of nursing curriculums. In 1952, at the NLNE business meeting, the members voted to become the National League for Nurse (NLN), and merged with the National Organization of Public Health Nurses (NOPHN) and the ACSN.8 Under this new structure, two major divisions would be established: the division of nursing service, whose responsibilities included public health, industrial, and hospital nursing; and the Division of Nursing Education, which was compiled of Departments for all degree programs, including Diploma and Associate Degree, Baccalaureate and Higher Degree programs, and some provisions for practical nurses.8 Many challenges would lie ahead for this organization, as it evolved in its role and responsibilities.

Training for nurses in the delivery of infants and care of new mothers was absent during these early years. Prior to the establishment of any formal midwifery program in the U.S, maternal morbidity was high, under the care of unskilled, untrained “granny midwives”. Though instruction was provided in the Nightingale schools, nurses in the US were denied this training, primarily being opposed by physicians who saw midwives as a threat, and crossing the boundary of medical practice.6 Mary Breckenridge changed all that when she organized the first midwifery service in the US in 1925.6 After graduating from nursing in New York in 1910, she obtained her midwifery certificate in London in 1925. Breckenridge used English midwives for years, until she began training her own when she started the Frontier Graduate School of Nurse Midwifery in 1939, which is still training midwives to this day.[12] Many of the nurse midwives traveled to their families on horseback, as the people in Appalachia that they served were often isolated in hollows and mountains, and roads were limited to most families. It was during this same year that WWII began.

Cadet Nurse Corps- 1943

Francis Payne Bolton, Ohio’s first congresswoman, as well as namesake and strong supporter of the Francis Payne Bolton School of Nursing in Cleveland, Ohio,[13] devoted her life to healthcare reform and the compassionate care of the sick. During WWII, she sponsored the Bolton Act, the first federal program to subsidize nursing education.[14] The legislation was passed, and was a forerunner to future federal aid programs for nurses.

The federal government understood the value and necessity of having an adequate supply of nurses to meet the needs of the United States in times of war. Due to the shortage of hospital nurses stateside, the US Public Health Service created a scholarship program to train student nurses, and in 1943, the Cadet Nurse Corps was established through the Bolton Act legislation. Schools, in turn, were assisted in upgrading to qualify for these students by providing highly-trained faculty, housing, and library course offerings. By the time the program ended in 1948, it had graduated over 124,000 nurses, many whom were among the 72,000 military nurses who served in WWII. [15] The Cadet Nurse Corps influence not only drew a large number of new nurses into the field, but also moved nursing education away from the apprentice-type of teaching model that had been practiced for decades, and closer to an academic approach. In addition, nurse instructors became lecturers on disease topics, which had previously been the function of the physician.[16]

The 1940’s also witnessed the formation of several organizations that held the mission of the public’s health as one of the central themes of their agency. In 1946, Congress established the Center for Disease Control and Prevention (CDC), and the World Health Organization (WHO) followed in 1948.6 They would be forerunners of many other organizations that would rally professionals of many disciplines to focus on improving and protecting the health of the public.

Issues and Trends Beckon the PHN

After the war, an array of issues and trends drew the attention of the nursing profession, and from them, many advancements were made in the area of public health. During the 1950’s, the nursing home industry began to grow, demanding the development of standards and licensure requirements to ensure safe care for the elderly. PHN was involved in the training of nursing assistants, administration of flu and TB skin tests, and technical assistance for care provided by nursing.6

With the advent of health insurance, improvements in technology, and better control of communicable diseases, a shift to acute care providers impacted the populations served by PHN,26 starting in the 1950’s and continuing for the next two to three decades. In the 1960’s, a national trend occurred to release psychiatric clients from institutional care, as a result of inadequate staffing, as well as improved medicinal and treatment modalities. Though an increased need for PHN was created in caring for these patients, as well as maternal/child patients, the utilization of the PHN was diminishing in some areas that it had previously held within the healthcare continuum.26

PHN assumed roles as case managers, medication monitoring, and ongoing family assessments, which continue to be an important part of services provided in the present day.6 Child health became an important focus in the early 1960’s, which led to growth and development screenings, immunizations, assessing and instructing on good oral hygiene, and evaluating for nutritional deficiencies. Many of these areas generated the need for further evaluation and intervention. School health programs also began to take off during this decade. From family planning and maternal/child health, to home health visits and social programs that addressed teenage pregnancy and sexually-transmitted diseases, PHN were impacting the health of individuals in some new areas , while easing out in others.

As the 20^th century came to a close, difficult economic times began to take a toll on the federal funding available for public health services. Federal monies were increased in some areas, such as HIV, and tuberculosis control, but cut in many others. As the US headed into the 21^st century, PHN looked towards the future with guarded optimism, as a new century laid waiting.

Public Health Nursing: The Present

“When a child has lost its health, how often the mother says

“O, if I had only known, but there was no one to tell me!”

Florence Nightingale[17]

The nursing profession has evolved over the last century to become the most trusted profession by the public that it serves[18]. And understandably so. What other profession is present to assist in the ushering in of new life at birth, the accompanying of the human spirit as it takes its last breath, and all other events related to health and living in between those two moments? Nurses impact the lives of all people, regardless of race, socioeconomic status, gender, or religion.

Many people have the false impression that only nurses with the title of “public health nurse” impact the health of the public. Quite the contrary; this is one of the unique features about the practice of nursing and public health. Public health faculty has followed the population-based, epidemiological-driven paradigm for years, in which the focus is on enhancing and managing the health status of a population as a whole.10 PHN is qualified to address health at this level, also, but can adapt its focus to the client and/or family, as warranted by each individual situation. No matter what the practice setting, all nurses have the capacity to impact the public’s health; from the discharge planner that arranges for a visiting nurse to evaluate the healing of a new diabetic’s leg ulcer, to the evaluation of a school-based intervention aimed at reducing the number of teens that smoke.

An overview of the current education, certification, and standards that govern the PHN are essential in defining the role of the PHN, the beliefs that guide the profession, and the guidelines that govern practice.

Defining PHN Practice

Education

The first step for any individual wanting to practice public health nursing is to graduate from an approved nursing program and pass the National Council Licensure Examination (NCLEX), administered by each state’s Board of Nursing. This exam is used to ensure that the nurse is safe to practice nursing at an entry level. There are three educational paths to take to be permitted to take the NCLEX; an associate degree in nursing (ADN), a diploma program, or a bachelor of science in nursing (BSN). An ADN program takes approximately two to three years to complete, and is offered by community and junior colleges. It prepares individuals for a defined range of settings and roles. Diploma programs last about three years, and are offered by hospitals. Though these programs are declining in number, a few still remain. BSN programs are offered by colleges and universities, and take about four years to complete. These programs are strongly recommended as the base for nursing practice, and prepare students for the widest variety of settings, while equipping them with the most compete range of nursing knowledge and responsibilities at this skill level.[19] Community Health content is a fundamental part of the BSN curriculum, and without it, the program will not be accredited as such.26

Nursing schools offer multiple ways to assist current nurses in furthering their education. There are many programs available to assist nurses who have an ADN or Diploma to complete “bridge” coursework, and obtain their BSN, or qualify them to enter graduate school to obtain their Master’s of Science in Nursing (MSN). Schools also provide avenues for others who may be looking at nursing as a second career, allowing them to utilize any previous education as a springboard into the profession. Individuals with a non-nursing degree may enter one of many accelerated programs that are offered around the country, allowing them to obtain their BSN in @ 16-18 months. Opportunities to pursue nursing at the doctoral level are available as well. The PhD in Nursing prepares students to enter the field of scientific research, which has made significant contributions through nursing theory and evidence-based research. The Doctorate of Nursing, or ND, is a fairly new doctorate degree when compared to the PhD, and prepares the nurse to perform research at the clinical level, as well as equip them to teach within the university setting. Though a wave of such programs are sweeping the United States at this time, the ND degree has been offered at the Francis Payne Bolton School of Nursing at Case Western Reserve University since 1979, and continues to equip doctoral-prepared clinicians and educators to meet the need for evidence-based research within the clinical arena, which will translate to more effective and efficient care for the future.

The next question that would seem logical to ask would be which level of education is necessary to work as a public health nurse. Besides state licensure, and occasionally some previous nursing experience, the major qualification for a nurse to work as a PHN is a BSN.8 Because of past and present nursing shortages, positions have and are being filled by nurses who have graduated from diploma and associate degree programs. In a March 2000 report from a national sample of RN’s in the US, the community public health nursing population reported that 37.3% were ADN’s, 18.1% were diploma graduates, 32.6% were BSN’s, 11.3% were MSN’s, and 0.3% were doctoral-prepared.[20] Though BSN education prepares the nurse with the best skills to meet the requirements of the job, this survey demonstrates less than 1/3 were prepared at that level in 2000.

In this same year, the Association of Community Health Nurse Educators (ACHNE), endorsed The Essentials of Baccalaureate Nursing Education for Entry Level Community/Public Health Nursing Practice, which provided recommendations for educational content in baccalaureate programs that is considered essential for entry into the practice of PHN/CHN.6 ACHNE is the only voice representing community health nurse educators in the US and abroad. The organization offered the recommendations with the understanding that the PHN/CHN of the future will be providing care to individuals, families and whole populations that are intermingled with a much more complex health care system.

The most recent work being done to better define the levels of clinical practice within the specialty of PHN is through the efforts of the Quad Council of Public Health Nursing Organizations (Quad Council). Current membership includes four nursing organizations, all active in addressing public health nursing issues. Current members are the Section of Public Health Nursing of the American Public Health Association (APHA), the Association of State and Territorial Directors of Nursing (ASTDN), the American Nurses Association Council on Nursing Practice and Economics (ANA), and the Association of Community Health Nurse Educators (ACHNE).21 The Quad Council began working on a set of national public health nursing competencies, utilizing the “Core Competencies for Public Health Professionals” created by the Council on Linkages between Academia and Public Health Practice (COL) as a guiding framework.

As the competencies took shape, the members of the quad council concurred that there would be two levels of PHN competencies; those at the generalist and specialist level.[21] The Council also agreed that the generalist would reflect preparation at the BSN level, and the specialist would reflect preparation at the master’s level in CHN/PHN and/or public health.21 It is believed that by structuring the competencies in this way will facilitate clarification of the PHN specialty for nursing and others in the profession of public health. The competencies are outlined under the categories of “Generalist/Staff PHN” and “Manager/CNS/Consultant/Program Specialist/Executive”. Each category is divided into two columns; “Individuals & Families”, and “Populations and Systems”. Competencies are then defined and determined for each level if it should be demonstrated as “Awareness”, “Knowledge” or “Proficiency”.21 There are eight domains outlined in the competencies. They include Analytic Assessment Skills, Policy Development/Program Planning Skills, Communication Skills, Cultural Competency Skills, Community Dimensions of Practice Skills, Basic Public Health Sciences Skills, Financial Planning and Management Skills, and Leadership and Systems Thinking Skills.21

Based on the Quad Council’s PHN Competencies, it is understood that there are many nurses practicing in the field of public health that are not prepared at the level proposed. The Council believes that these nurses will require extensive education and orientation to be able to achieve the competencies as written, or may possibly need a job description that reflects a different level of practice than that of their BSN & MSN-prepared colleages.21

Certification

As the US works towards the incorporation of the above PHN competencies, nurses can continue to seek certification in the area of community health nursing. The American Nurses Association (ANA), established in 1897, has guided nursing standards, registration and licensure, and advocating for the interests of nurses throughout the US since its inception.8 It established the American Nurses Credentialing Center in 1973, a certification program that recognized achievement of professional milestones in practice.8 When an individual becomes certified in their area of interest, it indicates a competence in advanced practice. Certification brings with it prestige, and often increased salaries and job promotions within the field.

Three levels of certification are available.8 The generalist can be certified in specialized areas of practice and requites a bachelor’s degree. Some examples of specialized practice that would seek these types of certifications would be the School Nurse, Medical-Surgical Nurse, and Cardiac Nurse. The specialist requires a minimum of a Master’s degree, and can be certified in advanced practice specialties such as the Family Nurse Practitioner, Gerontological Nurse Practitioner, and the Community Health Nurse. In 2000, the ANA approved some additional areas of certification for nurses with an associate degree or diploma. Once certification is obtained at any of the above levels, it is good for five years, and renewable, as long as practice requirements and continuing education guidelines are fulfilled. Otherwise, the examination would need to be retaken. Nurses can be certified at the BSN level in community health nursing as a specialty practice area or at the master’s degree or higher as a Clinical Nurse Specialist. Though certification is not found among any of the competencies described earlier, nurses often seek it for reasons stated previously.

Current Issues in PHN

Community Health or Public Health Nursing?

Ask different individuals as to the focus of community or public health nursing, some will say it is the population, while others will believe that it focuses on the individual and the family. It is understandable why there are different ideas as to what is nursing’s focus in this field, as nurses are seen in many areas that deal with the “public’s health”. In actuality, PHN/CHN synthesizes from both nursing

and the public health sciences to promote and preserve the health of those comprising communities, families, and down to the individual8.

To gain a better appreciation of the unique role of PHN/CHN, a clear definition of the two disciplines in which it is formed needs to be reiterated. The broad mission of public health is to “fulfill society’s interest in assuring conditions in which people can be healthy”.4 No matter what definition is used, or what title is given, nursing’s focus has, and always will be, nursing practice.

The terms public health nursing and community health nursing are two titles that have been used interchangeably to designate the specialty of nursing that focuses on the community or public at the center of its practice. The nursing profession is currently in transition in the use of this terminology, shifting to the use of public health nursing as the name of this specialty. The term community health nursing may come to mean nursing practiced in the community, instead of care of the community, as the transition to public health nursing becomes more widely utilized.[22]

Several organizations are trying to assist in the sorting out of this complicated and sometimes entangled subject. The Association of Community Health Nursing Educators explores to issue of “community-based” verses “community-focused” nursing.[23] The consensus of the public, and potentially even other nurses, is that the CHN is simply a nurse providing care in places other than a hospital, and many do not understand the unique body of skills and knowledge that is required to practice as a CHN.

Foundations of Practice

Every professional organization outlines the fundamental building blocks on which all practice is governed within that discipline. Although these foundations are shared with all fields of nursing, its focus of equality and social justice issues related to health care delivery makes it unique as it addresses nursing care for the entire population.[24] The foundations of PHN practice include the Scope and Standards of Practice, as well as the Tenets of PHN Practice, which are outlined below.

Scope of PHN Practice

All professionals function within certain boundaries that define their practice. These describe “what” the PHN is, what the PHN “does”, “who” the “client” is, and “with whom” the PHN collaborates;

Public health nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences.
Public health nursing is population-focused and community-oriented.
The goal is the prevention of disease and disability for all people.
Public health nurses most often partner with nations, states, communities, organizations, and groups, as well as individuals, in completing health assessments, policy development, and assurance activities.
Public health nurses assess the needs and strengths of the population, design interventions to mobilize resources for action, and promote equal opportunity for health.6

Standards of PHN Practice

In 1998, the ANA revised the Standards of Clinical Practice, which guide all registered nurses in all areas of practice. Specialty areas within nursing adopt these general standards to their area of expertise, while holding to this core framework.8 Authored by the Quad Council of Public Health Nursing in 1999, these standards govern the practice of the PHN. They include:

Standard I: Assessment: The Public Health Nurse assesses the health status of populations using data, community resources identification, input from the population, and professional judgment.

Standard II: Diagnosis: The public health nurse analyzes collected assessment data and partners with the people to attach meaning to those data and determine opportunities and needs.

Standard III: Outcome Identification: The public health nurse participates with other community partners to identify expected outcomes in the populations and their health status.

Standard IV: Planning: The public health nurse promotes and supports the development of programs, policies, and services that provide interventions that improve the health status of populations.

Standard V: Assurance: Action component of the nursing process for public health nursing: The public health nurse assures access and availability of programs, policies, resources, and services to the population.

Standard VI: Evaluation: The public health nurse evaluates the health status of the population.6

There still remains some work to be done to address the interesting dilemma that is lingering within the profession. In 1985, Community Health Nursing Standards of Practice were available, but eventually became somewhat obsolete, due to the specialization that occurred within the field during those years. In 1999, as mentioned earlier, the Quad Council published the Public Health Nursing Standards of Practice, and sometime after that, the CHN Standards were no longer available from the ANA. Though the certification and the standards are both “arms” of the ANA, the certification exam continues to certify nurses as “CHN”, who are following PHN standards.26 Though this might be a trivial point for some, it is one that necessitates clarification, so that the profession can move forward with one solid identity and not a dual identity, so to speak.

Tenets of PHN Practice

The beliefs of a profession will influence policy, guide care, and create a framework on which to build standards and scopes of practice. There are eight tenets of practice for the PHN. Several of these reflect the belief in “social justice” or the concern for the “greater good” of all people, as well as the place of priority for primary prevention and health promotion, population-based interventions, and the importance of collaboration with other organizations and affiliations.6 Combined with the Scope of Practice and Standards for Care, they form the basis structure for the provision of care to the individual, family, and communities in which they can be found.

Public Health Nursing in Today’s Healthcare System

Advances in medicine and technology have provides the “curative” aspect of healthcare in many areas. What is still perplexing the citizens of this nation, and the dilemma of public health professionals all over the country is this; how to turn individuals clear of lifestyles and habits that lead to sickness, disease, and death. This conceptualization of prevention is depicted in the analogy that a physician used in conveying frustration within his medical practice.[25] He represents illness as a swiftly moving river, and sees physicians so enveloped with trying to rescue individuals using a multitude of “downstream endeavors”; when they would really like to focus their efforts on “upstream” or macroscopic interventions to save individuals from the rushing waters. 25

This analogy could illustrate the frustration of every professional that considers themselves a part of the public health profession. Prevent individuals from falling in, efforts to change those things that are know precursors to poor health, including economical, environmental, and political factors, must be addressed.25

The atmosphere of practice within the field of PHN/CHN practice settings are changing rapidly, and requires that the nurse on all levels of care and expertise meet these new challenges. With the advent of managed care, patients who were once treated in hospitals are now being seen as outpatients, or in urgent care settings, and only the sickest of the sick are being admitted to hospitals. Once these patients are discharged home, they are often in need of nursing care, at least in the initial days following discharge. Instructions are provided to the patient, as well as any caregivers within the home.

Specialty areas within PHN

Through the evolution of public health nursing, there has been a redefining of the relationships between patient populations and their unique body of knowledge, and its relationship to the work and practice of public health nursing. In the 1980’s, community health nursing witnessed development in many patient populations. Community health nursing wore many hats, and could be found wherever health could be promoted, or care provided. A few of these areas include the school nurse, home health nurse, maternal/child health nurse, parish nurse, and occupational health nurse. Slowly, nurses dedicated to each of these unique populations convened to form professional organizations, each with their own standards and scopes of practice. Though these moves to restructure provided autonomy and a clear vision for each of the specialty areas, provision of public health nursing care was embedded within each task performed and every program presented.

Today, public health nursing could be conceived as “a way of thinking, transcending all communities”.[26] Public health nursing, and its mission to promote and protect the health of populations, encompasses all of the areas in which PHN/CHN is practiced today. From the perspective of the practicing public health nurse, the population that he/she serves is often reflective in the title that is carried. Albeit, public health nursing is the crux of service provided, and the population benefits with a longer, healthier life.

Public Health Nursing: The Future

The impact of September 11, 2001, known as “911”, and the revelation it brought this nation about the state of the public health infrastructure has set in motion a impetus for change at many levels of government. The world in which PHN/CHN function is the “public health system”, which is a broad term that includes all government and non-government agencies that contribute to the maintenance, or improvement of the health of a population. Public health services are provided primarily through public health departments at the state and local levels, and a large portion of funding is provided in the United States through the Department of Health and Human Services.27 It was these services, and the structure within which they are executed that has come under scrutiny in the years following 2001. Insight on the risks and challenges to public health following 911 are drawn from lessons learned by those who served and those who now reflect on the events of that tragic event in our nation’s history. Concerns include the provision of consistent public health leadership that can respond to the public regarding threats to public health; appropriate, strategic utilization of new funding to strengthen the public health infrastructure, all the while maintaining day-to-day operations that sustain our core public health mission of health protection and promotion, and disease prevention.27

In fact, our ability to successfully respond to challenges in the future will be determined by how we address areas of weakness today, resulting in a stronger infrastructure for tomorrow. How true is the old cliché, “a chain is only as strong as its weakest link.” Those weak links have been identified, and if we are to have a strong public health infrastructure, the “weak links” must be strengthened. Information technology, workforce capacity, with special attention to the issue of the shortage of nurses, stable funding sources, and leadership at all levels of government are necessary areas of focus for a stronger public health system for the future.[27]

Supporting the PHN Role to Strengthen the Public Health Infrastructure

A discussion of the public health infrastructure can not be complete without addressing the largest, single professional healthcare force within public health agencies: nursing. In 2003, the actions were adopted by the ANA House of Delegates that addresses the acknowledgement of the critical role of the PHN to society, the needed investment of technology to strengthen the public health infrastructure, funding to health departments for the recruitment and retention of PHN’s, and better inventory of the number of public health nurses, as well as further development of quality indicators that reflect PHN functions.[28]

These recommendations come in the midst of a severe shortage of registered nurses in this country, and the impact it is making in all areas where nursing work. According to the latest projections by the U.S. Bureau of Labor Statistics (Feb., 2004), more than one million new and replacement nurses will be needed by the year 2012.28 There are multiple strategies that have been implemented to address the shortage, from the Nurse Reinvestment Act, to national media campaigns, to united nursing organizations working together to seek solutions.28

Job Outlook

Registered nurses rank number one in job growth until the year 2012 in this country, according the US Bureau of Labor Statistics.[29] This should come as no surprise, as history demonstrate the ebb and flow of an inadequate supply of nurses over the years, as well as the multiple factors that are driving the need for nurses overall in the profession today.[30] Various settings employ PHN, including positions within local, state, national and international organizations, non-profit organizations, managed care settings, and academic institutions. Positions include Directors of Patient Services, Program Directors or Coordinators, Consultants, Researchers, Public Health Educators, and Grant Funding Coordinators.[31]

Conclusion

There have been many great achievements in public health over the last century that have impacted the quality and length of life for many individuals. Even so, many of these achievements were in the areas of scientific and medical care provided to individuals that were already within the acute care setting in the healthcare continuum. The biomedical model that is the foundation for this type of approach to care has dominated the attention of public (usually federal) dollars.[32] This kind of focus is vital to provide the best treatment for those experiencing sickness or disease.

It is clear to many, though, that there needs to be intervention before individuals reach this level within healthcare settings. The ecological model is being used more extensively to guide researchers in developing frameworks for education and training, in hopes that these “upstream” interventions25 will save many from falling into the river that leads to morbidity and mortality.

The public health professional of the 21^st century must have an understanding of computer science technology (informatics), and how to translate this information for use by other disciplines to guide population-based interventions and care. Equally important is an understanding of new advances in science and medical technology, which is becoming more a part of the home care environment with each passing day. Communication skills are essential in all areas of practice; from understanding the needs of an ever-increasing culturally diverse community, to the ability to articulate clearly the needs of the people through the work of public policy and advocacy.32 Academic institutions must incorporate public health education in their curriculum that will enlighten students regarding the challenges that lie ahead. Individual professions must actively seek to bridge the knowledge “gap” among their own members, and raise awareness among the workforce.

Our challenge lies ahead of us. As a nation, we cannot plead ignorance any longer. We have experienced throughout the history of this country, the impact of a strong public health nurse workforce. PHN’s possess the skills and expertise to impact communities, families and individuals in ways that no other profession can. With the ability to work at all levels within the healthcare continuum, coupled with the wisdom gained through research integrating nursing, social, and public health science, the future appears promising. Nursing is ready and willing, and with lessons learned from the past, we forge ahead. Strengthened by the support of this great country, the health of the nation, and each citi