Public Health Nursing Vol. 32 No. 2, pp. 91–93 0737-1209/© 2015 Wiley Periodicals, Inc. doi: 10.1111/phn.12193
EDITORIAL
Creating the Future of Public Health Nursing: A Call to Action Canales and Drevdahl (2014) recently questioned whether there is a future for the specialty of community/public health nursing (C/PHN). Their article in Nursing Outlook is an overview of 100 years of education and practice where they identify both internal and external factors, which they believe have contributed to the decline of the specialty. We applaud their examination of the specialty of public health, as practiced in nursing, and want to use their well-documented article to stimulate further discussion on the role of nurses in public health. Public health nursing (PHN) has a long and storied history. Despite ongoing discussions on the titling of the specialty over the years (public vs. community health nursing), nurses whose main goal is to promote and protect the health of the public in settings where people live, work, and play will continue to be an important component of the health care system. Shamansky and Graham, founding editors of PHN, understood this when they wrote an editorial in 1992 about the centennial celebration of public health nursing (1893–1993). They attributed the survival of public health nurses to a community of colleagues with the “tenacity to continually grapple with social challenges” who remained true to one basic principle: “the greatest good for the greatest number of people” (p. 217). We agree with Shamansky and Graham (1992) that the specialty will endure because of public health nurses’ “dogged determination to persist and problem-solve” the many challenges to promoting the public’s health (p. 217). While public health is significant historically in nursing, its practice is a conceptual shift for most nurses. Traditionally, nurses care for individual clients in acute care settings or in the community. Indeed, most nurses would probably say that they entered the profession to care for individuals. Whether providing primary, secondary, or tertiary prevention to individuals in the community, the value of nursing to public health includes the
nursing skills of assessing client health, communicating with clients, and addressing health holistically. The family and the community provide the context for holistic, individual-level care. Public health science also focuses on the social context for health, but almost exclusively at the community and population-level. Generalist nurses who work in public health put this perspective in practice with interventions such as immunizations, mass screenings for disease, and home visiting across all levels of prevention. Nurses practicing in community/public health, i.e., PHNs, bring nursing practice to where people live, work, and play. Canales and Drevdahl appropriately recognize generalist PHN practice as valuable to clients. Indeed, individual-level PHN practice will be increasingly important across settings as the Patient Protection and Affordable Care Act (ACA) (2010) becomes fully implemented. Under the ACA, the focus of care is patient-centered and addresses care transitions, as well as the social determinants of health (Leong & Roberts, 2013). Accountable Care Organizations (ACOs) are beginning to take responsibility for populations of patients and their overall health outcomes across settings, including helping clients better manage health and illness. As Canales and Drevdahl (2014) point out, other providers, including Community Health Workers, Health Educators, and Social Workers, might effectively do some of this work. We contend, however, that there will continue to be a role for PHNs in this care, both as part of a team available for clients who need nursing’s clinical perspective to assist them, as well as in supervising and supporting nonclinical team members. It is likely that health departments will continue to decrease their role in individuallevel care, but the PHN role will be maintained in models such as the Nurse Family Partnership and in home health care, where nursing knowledge and skills are needed in community, nonacute care settings. We also strongly agree with Canales and
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Drevdahl that further research is needed to document the effectiveness of such care and to determine the best providers for different populations (Issel, Bekemeier, & Kneipp, 2012; University of Michigan Center of Excellence in Public Health Workforce Studies, 2013; Swider, Levin, & Kulbok, 2014). However, Canales and Drevdahl go on to conflate this individual-focused PHN role with the role of nurses choosing to specialize in public health, such as Advanced Public Health Nurses (APHNs). Nurses pursuing graduate education in public health learn and practice at a population-level. APHNs gain this specialty knowledge and skills either through graduate education in a school of nursing or in a school of public health. APHNs, as with other specialty education, spend considerable time and effort developing higher level skills in public health, to enhance their nursing background. Necessary content includes biostatistics; epidemiology; environmental health; community or population assessment; planning, implementing and evaluating population-level interventions; health policy development and analysis; and often content in such areas as communicable disease control and prevention; water and air quality management; and public health law and ethics, etc. (Association of Schools and Programs of Public Health, 2014; Levin et al., 2008). In addition to such coursework, most APHN programs at the doctoral level have considerable practicum hours post-BSN to help students learn to apply these skills to populations. This requires a significant paradigm shift, as well as skill development, from individual-focused nursing practice. Indeed, one of the strengths of the new Doctor of Nursing Practice (DNP) programs in APHN is the major investment in clinical application of approximately 1,000 hours post baccalaureate. This is truly a specialization in public health by nurses. We agree with Canales and Drevdahl that all nurses should have some basic background in population health as a context for their practice; this aligns with the American Associations of College of Nursing’s (AACN) Essentials documents (2006, 2011). We contend however, it is unrealistic to think that all nurses could gain sufficient knowledge and skills in population health to be an integral part of public health teams. Such specialization, in addition to their individualfocused specialty education (most often APRN)
March/April 2015
would make DNP programs exceedingly expensive. In addition, given that the majority of those studying for APRN licensure are focusing on direct care to individuals and families, i.e., prescribing, diagnosing, and managing illness, it is highly unlikely that they would engage in sufficient practice experience either during their program or in postgraduation employment to help them develop these population-level skills. While it is valuable to have APRNs be “population health aware,” they would not have the requisite preparation to make a significant contribution alongside other public health professionals who have completed graduate education or comparable experience in public health. The nursing contribution to public health in policy development and assessment and assurance of population health would be lost, as public health professionals with more advanced training would fill these roles. In addition, APHNs are also needed in colleges or schools of nursing to provide the basic population health knowledge and skills that all providers should receive. Indeed, part of the work of the AACN CDC—Cooperative Agreement (AACN, 2012) is to come to general agreement on what population health knowledge and skills are necessary across all health professional education. Population health is an increasingly important context for practice, but will in no way replace the need for public health specialization. The number of nurses who choose to specialize in public health will likely remain small given the profession’s history of caring for individuals, and the expansion and proliferation of advanced practice nursing roles, allowing nurses to continue individual-focused practice at more skilled levels. The small number of programs for preparing APHNs is likely due to this nursing preference for individually focused care and the lack of funding to support advanced education for APHNs. Other contributing factors include the need for more providers to care for individuals than for populations, due to economies of scale; and the current need to increase the number of APRN jobs as part of health care reform. An additional factor is that nurses seek their specialty education in schools of public health, as well as in colleges or schools of nursing. Therefore, a more valid comparison would be to examine the numbers of nurses in both types of programs.
Swider et al.: Future of Public Health Nursing We see this moment in time as a crossroads for PHN practice. Generalist level PHNs will continue to practice, but the profession will need to demonstrate the value-added of the nursing perspective to individual-focused roles in community settings. As health departments shift from a dual focus on individual and population health to a sole focus on population health, enhanced population health expertise will be needed to perform the essential functions of the departments. The nursing voice in public health must not be lost. Our nursing expertise and our role as America’s most trusted profession, augmented by advanced education in public health, will be instrumental to achieve Health for All. We welcome the discussion. Susan M. Swider PhD, APHN-BC, FAAN Pamela F. Levin PhD, APHN-BC Chicago, IL Pamela A. Kulbok DNSc, RN, PHCNS-BC, FAAN Charlottesville, VA
References American Association of Colleges of Nursing (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author.
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American Association of Colleges of Nursing (2011). The essentials of master’s education in nursing. Washington, DC: Author. American Association of Colleges of Nursing. (2012). AACN & CDC partner to advance the public health nursing workforce. Retrieved from http://www.aacn.nche.edu/news/articles/ 2012/cdc-public-health Association of Schools and Programs of Public Health. (2014). MPH degree report. Retrieved from http://www.aspph.org/educate/models/mph-degree-report/ Canales, M. K., & Drevdahl, D. J. (2014). Community/public health nursing: Is there a future for the specialty? Nursing Outlook, 62, 448–458. Issel, M., Bekemeier, B., & Kneipp, S. (2012). A public health nursing research agenda. Public Health Nursing, 29, 330–342. Leong, D., & Roberts, E. (2013). Social determinants of health and the Affordable Care Act. Rhode Island Medical Journal, 96, 20–22. Levin, P. F., Cary, A. H., Kulbok, P., Leffers, J., Molle, M., & Polivka, B. J. (2008). Graduate education for advanced practice public health nursing: At the crossroads. Public Health Nursing, 25, 176–193. Patient Protection and Affordable Care Act (ACA). (2010). Public Law 111-148. 111th United States Congress. Washington, DC: United States Government Printing Office. (enacted). Retrieved from http://www.gpo.gov/fdsys/pkg/PLAW111publ148/pdf/PLAW-111publ148.pdf Shamansky, S. L., & Graham, K. Y. (1992). Powerful women: 100 years of public health nursing. Public Health Nursing, 9(4), 217. Swider, S. M., Levin, P. F., & Kulbok, P. (2014). Quad Council of Public Health Nursing Organizations invitational forum on the role and future of nurses in public health: Final report. Retrieved from http://www.quadcouncilphn.org University of Michigan Center of Excellence in Public Health Workforce Studies. (2013). Enumeration and characteristics of the public health nurse workforce: Findings of the 2012 public health workforce surveys. Ann Arbor, MI: University of Michigan. Retrieved from www.rwjf.org/content/dam/ farm/reports/reports/2013/rwjf406659
EDITORIAL
Creating the Future of Public Health Nursing: A Call to Action Canales and Drevdahl (2014) recently questioned whether there is a future for the specialty of community/public health nursing (C/PHN). Their article in Nursing Outlook is an overview of 100 years of education and practice where they identify both internal and external factors, which they believe have contributed to the decline of the specialty. We applaud their examination of the specialty of public health, as practiced in nursing, and want to use their well-documented article to stimulate further discussion on the role of nurses in public health. Public health nursing (PHN) has a long and storied history. Despite ongoing discussions on the titling of the specialty over the years (public vs. community health nursing), nurses whose main goal is to promote and protect the health of the public in settings where people live, work, and play will continue to be an important component of the health care system. Shamansky and Graham, founding editors of PHN, understood this when they wrote an editorial in 1992 about the centennial celebration of public health nursing (1893–1993). They attributed the survival of public health nurses to a community of colleagues with the “tenacity to continually grapple with social challenges” who remained true to one basic principle: “the greatest good for the greatest number of people” (p. 217). We agree with Shamansky and Graham (1992) that the specialty will endure because of public health nurses’ “dogged determination to persist and problem-solve” the many challenges to promoting the public’s health (p. 217). While public health is significant historically in nursing, its practice is a conceptual shift for most nurses. Traditionally, nurses care for individual clients in acute care settings or in the community. Indeed, most nurses would probably say that they entered the profession to care for individuals. Whether providing primary, secondary, or tertiary prevention to individuals in the community, the value of nursing to public health includes the
nursing skills of assessing client health, communicating with clients, and addressing health holistically. The family and the community provide the context for holistic, individual-level care. Public health science also focuses on the social context for health, but almost exclusively at the community and population-level. Generalist nurses who work in public health put this perspective in practice with interventions such as immunizations, mass screenings for disease, and home visiting across all levels of prevention. Nurses practicing in community/public health, i.e., PHNs, bring nursing practice to where people live, work, and play. Canales and Drevdahl appropriately recognize generalist PHN practice as valuable to clients. Indeed, individual-level PHN practice will be increasingly important across settings as the Patient Protection and Affordable Care Act (ACA) (2010) becomes fully implemented. Under the ACA, the focus of care is patient-centered and addresses care transitions, as well as the social determinants of health (Leong & Roberts, 2013). Accountable Care Organizations (ACOs) are beginning to take responsibility for populations of patients and their overall health outcomes across settings, including helping clients better manage health and illness. As Canales and Drevdahl (2014) point out, other providers, including Community Health Workers, Health Educators, and Social Workers, might effectively do some of this work. We contend, however, that there will continue to be a role for PHNs in this care, both as part of a team available for clients who need nursing’s clinical perspective to assist them, as well as in supervising and supporting nonclinical team members. It is likely that health departments will continue to decrease their role in individuallevel care, but the PHN role will be maintained in models such as the Nurse Family Partnership and in home health care, where nursing knowledge and skills are needed in community, nonacute care settings. We also strongly agree with Canales and
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Number 2
Drevdahl that further research is needed to document the effectiveness of such care and to determine the best providers for different populations (Issel, Bekemeier, & Kneipp, 2012; University of Michigan Center of Excellence in Public Health Workforce Studies, 2013; Swider, Levin, & Kulbok, 2014). However, Canales and Drevdahl go on to conflate this individual-focused PHN role with the role of nurses choosing to specialize in public health, such as Advanced Public Health Nurses (APHNs). Nurses pursuing graduate education in public health learn and practice at a population-level. APHNs gain this specialty knowledge and skills either through graduate education in a school of nursing or in a school of public health. APHNs, as with other specialty education, spend considerable time and effort developing higher level skills in public health, to enhance their nursing background. Necessary content includes biostatistics; epidemiology; environmental health; community or population assessment; planning, implementing and evaluating population-level interventions; health policy development and analysis; and often content in such areas as communicable disease control and prevention; water and air quality management; and public health law and ethics, etc. (Association of Schools and Programs of Public Health, 2014; Levin et al., 2008). In addition to such coursework, most APHN programs at the doctoral level have considerable practicum hours post-BSN to help students learn to apply these skills to populations. This requires a significant paradigm shift, as well as skill development, from individual-focused nursing practice. Indeed, one of the strengths of the new Doctor of Nursing Practice (DNP) programs in APHN is the major investment in clinical application of approximately 1,000 hours post baccalaureate. This is truly a specialization in public health by nurses. We agree with Canales and Drevdahl that all nurses should have some basic background in population health as a context for their practice; this aligns with the American Associations of College of Nursing’s (AACN) Essentials documents (2006, 2011). We contend however, it is unrealistic to think that all nurses could gain sufficient knowledge and skills in population health to be an integral part of public health teams. Such specialization, in addition to their individualfocused specialty education (most often APRN)
March/April 2015
would make DNP programs exceedingly expensive. In addition, given that the majority of those studying for APRN licensure are focusing on direct care to individuals and families, i.e., prescribing, diagnosing, and managing illness, it is highly unlikely that they would engage in sufficient practice experience either during their program or in postgraduation employment to help them develop these population-level skills. While it is valuable to have APRNs be “population health aware,” they would not have the requisite preparation to make a significant contribution alongside other public health professionals who have completed graduate education or comparable experience in public health. The nursing contribution to public health in policy development and assessment and assurance of population health would be lost, as public health professionals with more advanced training would fill these roles. In addition, APHNs are also needed in colleges or schools of nursing to provide the basic population health knowledge and skills that all providers should receive. Indeed, part of the work of the AACN CDC—Cooperative Agreement (AACN, 2012) is to come to general agreement on what population health knowledge and skills are necessary across all health professional education. Population health is an increasingly important context for practice, but will in no way replace the need for public health specialization. The number of nurses who choose to specialize in public health will likely remain small given the profession’s history of caring for individuals, and the expansion and proliferation of advanced practice nursing roles, allowing nurses to continue individual-focused practice at more skilled levels. The small number of programs for preparing APHNs is likely due to this nursing preference for individually focused care and the lack of funding to support advanced education for APHNs. Other contributing factors include the need for more providers to care for individuals than for populations, due to economies of scale; and the current need to increase the number of APRN jobs as part of health care reform. An additional factor is that nurses seek their specialty education in schools of public health, as well as in colleges or schools of nursing. Therefore, a more valid comparison would be to examine the numbers of nurses in both types of programs.
Swider et al.: Future of Public Health Nursing We see this moment in time as a crossroads for PHN practice. Generalist level PHNs will continue to practice, but the profession will need to demonstrate the value-added of the nursing perspective to individual-focused roles in community settings. As health departments shift from a dual focus on individual and population health to a sole focus on population health, enhanced population health expertise will be needed to perform the essential functions of the departments. The nursing voice in public health must not be lost. Our nursing expertise and our role as America’s most trusted profession, augmented by advanced education in public health, will be instrumental to achieve Health for All. We welcome the discussion. Susan M. Swider PhD, APHN-BC, FAAN Pamela F. Levin PhD, APHN-BC Chicago, IL Pamela A. Kulbok DNSc, RN, PHCNS-BC, FAAN Charlottesville, VA
References American Association of Colleges of Nursing (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author.
93
American Association of Colleges of Nursing (2011). The essentials of master’s education in nursing. Washington, DC: Author. American Association of Colleges of Nursing. (2012). AACN & CDC partner to advance the public health nursing workforce. Retrieved from http://www.aacn.nche.edu/news/articles/ 2012/cdc-public-health Association of Schools and Programs of Public Health. (2014). MPH degree report. Retrieved from http://www.aspph.org/educate/models/mph-degree-report/ Canales, M. K., & Drevdahl, D. J. (2014). Community/public health nursing: Is there a future for the specialty? Nursing Outlook, 62, 448–458. Issel, M., Bekemeier, B., & Kneipp, S. (2012). A public health nursing research agenda. Public Health Nursing, 29, 330–342. Leong, D., & Roberts, E. (2013). Social determinants of health and the Affordable Care Act. Rhode Island Medical Journal, 96, 20–22. Levin, P. F., Cary, A. H., Kulbok, P., Leffers, J., Molle, M., & Polivka, B. J. (2008). Graduate education for advanced practice public health nursing: At the crossroads. Public Health Nursing, 25, 176–193. Patient Protection and Affordable Care Act (ACA). (2010). Public Law 111-148. 111th United States Congress. Washington, DC: United States Government Printing Office. (enacted). Retrieved from http://www.gpo.gov/fdsys/pkg/PLAW111publ148/pdf/PLAW-111publ148.pdf Shamansky, S. L., & Graham, K. Y. (1992). Powerful women: 100 years of public health nursing. Public Health Nursing, 9(4), 217. Swider, S. M., Levin, P. F., & Kulbok, P. (2014). Quad Council of Public Health Nursing Organizations invitational forum on the role and future of nurses in public health: Final report. Retrieved from http://www.quadcouncilphn.org University of Michigan Center of Excellence in Public Health Workforce Studies. (2013). Enumeration and characteristics of the public health nurse workforce: Findings of the 2012 public health workforce surveys. Ann Arbor, MI: University of Michigan. Retrieved from www.rwjf.org/content/dam/ farm/reports/reports/2013/rwjf406659
