Public Health Nursing Vol. 9 No. 3, pp. 149-154 0737- I209/921$6.00 0 1992 Blackwell Scientific Publications, Inc.
Toward Redefining Public Health Nursing in Canada: Challenges for Education Lucia C. K. Yiu Matuk, R.N., M.Sc.N., and Martha E. Chadwell Horsburgh, R.N., M.Ed., M.Sc.N.
Abstract Faced with a recent shift from a hospital-based to a community-based health care system, Canadian public health nurses are being challenged to redefine their roles. To empower these nurses to respond effectively, it is imperative that the profession be reclarified as a specialty with a distinct philosophy and mission. Nursing education is key t o facilitate this process, and public health nursing educators must lead the way. Certain barriers hinder the response of public health nursing education, and four areas are suggested in which efforts to advance public health nursing may be best directed.
and barriers can be analyzed and incorporated into planning for the community. Fiscal responsibility is increasingly central to all public health nurses’ activities. However, nurses strive to remain politically vigilant to economic and other pressures that may threaten future accessibility to and comprehensiveness of their services. Education is the key to empower nurses to meet these challenges effectively. THE CONTEXT OF CHANGE
The Canadian health care system is widely regarded as one of the best in the world in meeting the health needs of its citizens (Evans, 1987). It delivers services to the public using five guiding principles: comprehensiveness, universality, accessibility, portability, and public administration. Although the health care system in the United States also provides comprehensive health services, it is largely privately funded, and its services are neither accessible nor affordable to all people (ClemenStone, Eigsti, & McGuire, 1991). Both systems advocate “health for all by the year 2000” (World Health Organization, 1978), and recognize the need to expand health-promotion and disease-prevention programs. These two health care systems also have the highest overall health care expenditures per capita in the world. In 1989 the United States spent $2354 per capita on health care. Canada was second at $1683 (Nightmare . . . , 1992; Ontario Ministry of Health, 1989a; Luciu C . K . Yiu Mutuk, R . N . , M . S c . N . , andMurthu E . Chudwell Rachlis & Kushner, 1989). Horshurgh, R . N . , M . E d . , M . S c . N . are Assistunt Professors, still,in response to an increasing elderly popu~ation, School of Nursing, University of Windsor. advancing technology, and pressure to control escalatAddress correspondence t o Luciu Mutuk, R . N . , M . S c . N . , School of Nursing. University of Windsor, Windsor, Onturio, Can- ing costs, the two countries are striving to improve the health of their populations within the current climate of udu N 9 B 3P4
The exciting new directions in the contemporary Canadian health care delivery system challenge today’s public health nurses to redefine their roles. The recent trend toward community-based practice has resulted in a diversity of services and consumer choices in approaches to health care. Clients discharged from the hospital to the community are sicker than before, and demand greater multidisciplinary collaboration to meet their needs. The well population continues to demand its right to health care. Furthermore, the “health for all” concept challenges public health nurses to have a better understanding of how wealth is defined in their community. They are called on to identify public health issues readily and accurately so that health determinants
149
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Volume 9 Number 3 September 1992
economic restraint. The trend of change in the Canadian system is similar to that in the United States. Both systems are working to adopt measures to transform their primarily hospital-based systems to ones that are community based. Ambulatory care and early hospital discharge have been implemented in both countries, and community-based care and rationalization of services are being explored. Examples can be seen in the United States’ ambulatory centers as well as alternate delivery systems (ADSs), which include health maintenance organizations (HMOs) and preferred providers organizations (PPOs); Canada has health services organizations (HSOs), comprehensive health organizations (CHOs), and community health centers (CHCs). Multihospital systems are also being used in both countries to rationalize services (Ontario Ministry of Health, 1989a; Stanhope & Lancaster, 1992). In the province of Ontario, government-sponsored shifts in health care funding are beginning to favor community-oriented initiatives that include improved wages and benefits for community health care practitioners (Farr, 1990). The Ontario Ministry of Health revised its guidelines (1989b) to increase the emphasis on population-based services for targeted risk groups in order to accomplish specified health goals. This landmark document reflects public health priorities for disease prevention and health promotion. It also reinforces the recommendations of three other authors that continue to shape the Ontario health care system (Evans, 1987; Spasoff, 1987; Podborski, 1987). Their reports endorse effective and innovative strategies related to ambulatory care and community-based care to meet the health needs of Ontarians. Ironically, many Ontario public health nurse leaders view this momentum toward community and public health with more skepticism and uncertainty than excitement. Their wariness reflects a prevailing societal disinterest in public health nursing that has persisted in Canada since World War 11. After the Second World War, public health was eclipsed by new developments in medicine and the relative control of communicable diseases. The stature of public health nursing declined because of lack of role clarity, lack of recognition of preventive services, and an inadequate supply of well-prepared public health nurse administrators. Furthermore, many of public health nurses’ traditional activities were increasingly replaced by competitive multidisciplinary health care professionals. These problems are described elsewhere (Matuk & Horsburgh, 1989). Despite the continuing struggle to rebuild the status of their profession, nurses’ skills have not been overtly recognized as essential to carry out today’s mandatory public health programs and services.
RECLARIFICATION OF PUBLIC HEALTH NURSING’S FOCUS
The integration of community and public health nursing education appears to have hindered the preparation of public health nurses. Analysis of the historical development of community and public health nursing education in Ontario reveals two trends. The first is one of relative deemphasis on the latter compared with the former, and the second is a tendency to disregard the distinctiveness of the two specialties and to view them as one and the same. Public health nursing education was originally offered as a specialty in 1920. It was later subsumed under community health nursing programs, and integrated as part of the basic and postdiploma registered nurse baccalaureate programs in the 1960s and 1970s (Kerr, 1988). This integration was further reinforced by the Canadian Public Health Association (1977) when it established standards for community health nursing practice directed at both public health and community health nurses without differentiating the two as distinct specialties. In the early 1980s the Canadian Nurses’ Association, the Canadian Association of University Schools of Nursing, and the Canadian Public Health Association endorsed a baccalaureate degree in nursing as the minimum preparation for community health nursing practice (Stewart, 1985). In an effort to adopt broad concepts within baccalaureate programs, the specific and more in-depth focus of public health nursing became indistinct. Concomitantly, as many students struggled to adapt a wide array of skills to broadbased community health nursing practice, their understanding of the more circumscribed concerns and roles of public health and public health nursing became vague (Salmon, 1989). Today, public health nursing remains a subspecialty within community health nursing and is typified by its more circumscribed and in-depth emphasis on health promotion and prevention. Community health nursing has subsumed aspects of both public health and hospital-based nursing to encompass primary, secondary, and tertiary care in community settings. Both are specialties within nursing in general, and each embraces a distinct philosophy and mission. Although both focus on improving the health of the community through a multidisciplinary approach, a person who is prepared as a community health nurse may not perform the roles of a public health nurse credibly, especially in such areas as community development and population-based practice. The minimum educational preparation for public health nurses is either a baccalaureate degree in nursing or a diploma in public health nursing; community health
Matuk and Horsburgh: Re-Definition of Public Health
nurses require only their registered nurse certification to practice in the community. For years, public health nurses have debated whether their profession should be defined as a specialist or as a generalist area within nursing (Salmon, 1989; Tansey & Lentz, 1988; Williams, 1977). Unfortunately, the term “public health nursing” has often been interchanged with “community health nursing” in the literature (Clemen-Stone et al., 1991; Jarvis, 1985; Login & Dawkins, 1986; Stanhope & Lancaster, 1992; Williams, 1977). Some have contended that “community health nursing” is a modern term for “public health nursing” because it signifies the focus of care on the populace. Others have felt that the use of “community health nurse” avoids the association with caring only for the poor that “public health nurse” implies. Salmon’s (1987) suggestion that “community health nursing” might be more appropriately renamed “community and public health nursing” appears to have merit. This option would foster the development of specific nursing theory and course content reflecting the missions and goals of both specialties.
I5 1
and they must give careful attention to community needs, consumer participation, and public policy. They must empower the community with the responsibility for the health of its members. To fulfill their new and evolving roles, nurses are being called on to integrate the philosophy and concepts of public health and nursing with those of epidemiology, biostatistics, sociology, anthropology, and psychology to assess the health and needs of the community as these needs are affected by the health, social, political, and economic systems (Josten, 1989). The resulting broad perspective will increasingly place them in a position to exert leadership roles within multidisciplinary teams. ENSURANCE OF A CADRE OF WELL-QUALIFIED PUBLIC HEALTH NURSE EDUCATORS
It is crucial that graduates be prepared adequately to model and market a positive and comprehensive image of public health nursing. Thus, it behooves every school of nursing to have educators who possess dexterity in both public health and community health nursing REDEFINITION OF PUBLIC HEALTH knowledge and skills. NURSING ROLES Failure to distinguish public health nursing practice At the 1990 Canadian Annual Federal/Provincial/Terri- from that of community health nursing has contributed torial Nursing Consultants’ meeting, many senior com- to the development of multiple standards and conflicting munity and public health nurses identified the need to demands on public health nurse educators teaching address the apparent discrepancies between the edu- community health nursing courses at the baccalaureate cational preparation of community and public health level. Educators are expected to possess both the depth nurses and emerging practice requirements. The nurses of knowledge and skills demanded for public health were frustrated by their lack of skills in community de- nursing, and the range of concepts and skills required velopment and population-based approaches, including for community health nursing. Lack of community disease-prevention and health-promotion strategies, and health nurse educators qualified in public health can interdisciplinary collaboration (Working Group, 1991). deny students the opportunity to receive comprehenThe Working Group (1991) identified two major edu- sive public health nursing education. cational requirements as foundational to the success of Thus it is vital that public health nurse educators poscommunity development models for community-based sess the following: a strong knowledge base of family planning and contemporary health-promotion strate- and community nursing; ability to cluster public health gies. First, a major emphasis on direct personal health issues and identify determinants and barriers that affect services through traditional one-to-one teaching and the health of the community; ability to target intervencounseling was deemed too costly and inefficient for to- tions for at-risk aggregates to promote health; and abilday’s public health nursing practice. They suggested ity to employ sound teaching strategies to facilitate that future public health nursing students learn to imple- positive attitudes toward health promotion in nursing ment effective group processes, identify group health students. Furthermore, they must take an active leadproblems among various aggregates, and collaborate on ership role to instill the value of public health nursing multidisciplinary teams to promote healthy populations. practice in students and in the larger community. This Second, they noted that consumers are more sophis- demands that educators have a strong commitment to ticated and knowledgeable. The public will not al- the profession; a clear vision of the scope and trend of ways come to public health nurses with problems and the health values of the public, politicians, and the meseek out their services. Therefore, future public health dia; a sound understanding of the funding of health care nurses must be prepared to use effective health-promo- and the development of government health policy; and tion and social marketing strategies to describe their role modeling to demonstrate effectively how nursing services. They have to exercise their role as health-pro- may affect both health values and health policy. Commotion consultants in working with well populations munity and political activities of public health nurse ed-
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Volume 9 Number 3 . September 1992
ucators must be viewed as essential and credited for professional and scholarly merits (Salmon, 1989). ENHANCEMENT OF THE RESPONSIVENESS OF THE NURSING CURRICULUM In planning for a curriculum that is responsive to the needs of evolving practice, public health nursing must go beyond the traditional personal health services rendered to individuals and families and expand its focus to encompass population health. Nonetheless, individual and family care skills should remain integral to the identification of population profiles and community needs, and should be retained in the curriculum. As a basic unit of a society, the family is made up of individual members and is the smallest group for epidemiology investigation. It is also the most effective medium by which to deliver personal health and population health services. The United States’ experience warns that with the program-based structures in local and state health departments, nurses must follow program guidelines to offer a limited set of services to well-defined populations. Fewer nurses are available to provide family-centered services (Smith, 1989). Another area of consideration is the incorporation of nursing theory into course content. Although many nursing frameworks have defined their client system as individual, family, and/or community, the focus for assessment and intervention remains primarily individuals. This approach continues despite integration of public health nursing concepts into basic nursing programs (Salmon, 1989; Williams, 1977). Furthermore, because of the lack of expert nurse clinicians, attempts to extend or modify existing frameworks to incorporate family nursing theory and community health concepts are often unsatisfactory. Discrepancies exist between contemporary nursing theories and public health theories. Thus, nurse educators are challenged to assist students to apply only the relevant content of models and theories to public health nursing practice (Hanchett & Clarke, 1988; Rogers, 1984; Selby et al., 1990). Many nursing leaders (Donaldson & Crowley, 1978; Suppe & Jacox, 1985; Wooldridge et al., 1983) have stressed the need for the development of more practiceoriented nursing theories. The development of such theories would benefit contemporary public health nursing by articulating its goals and areas of interest, and serving as a guide for research and practice. Effective implementation of public health nursing practice lies in realistic curriculum planning that embodies a proactive vision of the profession’s potential. Educators are challenged to equip graduates with a diversity of skills to provide health-promotion and illnessprevention services to individuals, families, and communities. Some of these competencies include pro-
fessional marketing, computer literacy, and business administration skills. Graduates must be able to understand their diverse communities and to create accurate population profiles to support appropriate health-promotion behaviors. Educators must ensure appropriate opportunities for students to apply theory and test their new skills in reallife situations. They must use clinical settings consistently to facilitate students’ application of practiceoriented theories to public health and community health nursing. Since a desirable curriculum presumes a knowledge base that is acceptable to the profession at large, educators must first consider what constitutes the theoretical base for public health nursing practice, and encourage students to master both theoretical concepts and clinical competence (Blank & McElmurry, 1986). The success of this goal must be monitored through evaluative research studies (Clark, Underwood, & Chambers, 1991). Some argue that in generalist-focused baccalaureate degree programs it may not be crucial to introduce both public health and community health concepts beyond a cursory overview. Rogers (1984) contended that caring for the community and aggregates provides a challenge better met by postbasic baccalaureate education, and that the focus at the baccalaureate level should be caring for individuals, families, and, to some degree, aggregates. Others also agree that expanded public health and community health programs should be offered at a graduate level (Anderson, 1989; Salmon, 1989; Williams, I 977). We agree, too. However, to meet today’s demand for public health nurses within the financial constraints currently imposed on Ontario’s educational and health systems requires that competent, entry-level public health and community health nurses be prepared at the undergraduate level. In 1990, of the 80,946 registered nurses in Ontario, 13,625 (16.8%) worked in community settings. A review of their educational preparation suggests that larger-scale graduate level education is not feasible at present (College of Nurses of Ontario, personal communication, 1990). As depicted in Figure 1, although nurses are striving to meet the demands of public and community health nursing, few are obtaining graduate degrees. Educators, administrators, and practitioners must recognize that a four-year baccalaureate program cannot reasonably produce proficient nurses beyond entry level (Dieman, Jones, & Davis, 1988). After entering practice, in-service, continuing-education, and graduate education programs are critical avenues to foster continued professional and self-development. Through joint appointments and other collaborative mechanisms, educators and administrators might de-
Matuk and Horsburgh: Re-Definition of Public Health
Graduate 1
Graduale 2 2%
ax
BDCClll",
18 ,p,oma 5.1 %
79.1%
Public Health Nurses
(excluding Public Health Nurses)
n = 1862
n=1962
in Ontario are bound only by its commitment and creativity. The call for all public health nurses to carve out their roles within the evolving health care system is urgent. Education is a key to facilitate these changes, and public health nurse educators must serve as the catalysts.
REFERENCES
61 1 %
Community Health Nurses
I53
Figure 1. Educational preparation of community health and public health nurses in Ontario in 1990 (College of Nurses of Ontario, 1990).
velop programs to assist students and practicing public health nurses to acquire new knowledge and skills and effectively implement new roles and functions (Black et al., 1989; Kerner, 1985; Zink, 1989). Collaborative team work between education and practice will provide the cornerstone on which mechanisms for continued professional development may be built (Selby et al., 1990). The merging of these two forces will strengthen both education and practice, and sensitize public health nursing students and practitioners to the needs of the profession. Resources for clinical learning, practice, and research may be shared and maximized to the benefit of all. Such collaboration could provide mutual benefits to both public health nursing students and practitioners, and foster collegial relationships between education and service.
CONCLUSION The challenges confronting contemporary public health nursing practice in Ontario are multifaceted. How they will be met will influence the nurses, their practice, and the health of Ontarians. The issue of whether public health nursing should be a distinct specialty will bear no significance if the nurses are unclear about their collective roles and functions in the rapidly evolving health care system. Public health nurse educators' commitments to the profession will nurture graduates to seek the knowledge and skills required for practice. Well-prepared graduates will provide competent population-focused care and use community-based processes to work effectively with various aggregates while still engaging in individual and family assessment and intervention. Most important, they will confidently articulate their expanded roles to the community and proactively shape future health care policy. The prospects for the future of public health nursing
Anderson, E. T. (1989). Public health content in nursing curricula. Nursing Outlook, 37, 233-235. Black, M., Edwards, N., McKnight, J., Valaitis, R . , & Van Dover, L. (1989). Experiences of nursing joint appointments in a teaching health unit. Public Health Nursing, 6 , 135- 140. Blank, J., & McElmurry (1986). An evaluation of consistency in baccalaureate public health nursing education. Public Health Nursing, 3 , 171-182. Canadian Public Health Association. (1977). The nurse and community health functions and qualificationsfor practice in Canada. Ottawa: Author. Clark, K., Underwood, J., & Chambers, L. (1991). A survey of the work perceptions and learning needs of practising public health nurses. Report and ProjectslPresentations on Research Topics, 4(4), 6-8. Clemen-Stone, A., Eigsti, D. G., & McGuire, S. L. (1991). Comprehensive family and community health nursing (3rd ed.). St. Louis: Mosby-Year Book. Dieman, P., Jones, D., & Davis, J. (1988). BSN education and PHN practice: Good fit or mismatch? Nursing Education, 36, 231-233. Donaldson, S., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26, 113-120. Evans, J. (1987). Toward a shared direction for health in Ontario: A report of the Ontario health review panel. Toronto: Ontario Ministry of Health. Farr, M . (1990). Community outlook. Registered Nurse, 2(3), 27-30. Hanchett, E. C., & Clarke, P. N. (1988). Nursing theory and public health science: Is synthesis possible? Public Health Nursing, 5 , 2-6. Jarvis, L. (Ed.). (1985). Community health nursing: Keeping the public healthy (2nd ed.). Philadelphia: Davis. Josten, L. E. (1989). Wanted-Leaders for public health. Nursing Outlook, 37, 230-232. Kerner, H. (1985). The merging of education and practice. In M. Stewart, J. Innes, S. Searl, & C. Smillie (Eds.), Community health nursing in Canada (pp. 592-602). Toronto: Gage. Kerr, J. R. (1988). Developing specialty certificate programs with credit towards the baccalaureate degree in nursing. In J. Kerr & J. MacPhail (Eds.), Canadian nursing: Issues and perspectives (pp. 3 19-328). Toronto: McGraw-Hill. Login, B. B., & Dawkins, C. D. E. (1986). Family-centered nursing in the community. Menlo Park, CA: AddisonWesley. Matuk, L., & Horsburgh, M. (1989). Rebuilding public health nursing practice: A Canadian perspective. Public Health Nursing, 6 , 169-173.
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Nightmare of the $500,000 ulcer. (1992, February 1). London Free Press, p. B 1. Ontario Ministry of Health. (1989a). Deciding the future of our health care, April 1989. Toronto: Author. Ontario Ministry of Health. (1989b). Mandatory health programs und services guidelines (2nd ed.). Toronto: Author. Podborski, S. (1987). Health-promotion matters in Ontario: A report of the Ministry’s advisory group on health promotion. Toronto: Ontario Ministry of Health. Rachlis, M., & Kushner, C. (1989). Second opinion: What is wrong with Canada’s health care system and how tofix it. Toronto: Collins. Rogers, S. (1984). Community as client: A multivariate model for analysis of community and aggregate health risk. Public Health Nursing, I , 210-222. Salmon, M . E. (1989). Public health nursing: The neglected specialty. Nursing Outlook, 37, 226-229. Selby, M. L., Riportella-Muller, R., Quade, D. Legault, C., & Salmon, M. E. (1990). Core curriculum master’s-level community health nursing education: A comparison of the views of leaders in service and education. Public Health Nursing, 7 , 150-160. Smith, G. R. (1989). Using the public agenda to shape public health nursing practice. Nursing Outlook, 37, 72-75. Spasoff, R. A. (1987). Health for all Ontario: Report of the panel on health g o d s for Ontario. Toronto: Ontario Ministry of Health.
Stanhope, M., & Lancaster, J. (Eds.). (1992). Community health nursing: Process and practice for promoting health (3rd ed.). St. Louis: Mosby-Year Book. Stewart, M. (1985). A comparison of community health content in curricula of Canadian university schools of nursing. In M. Stewart, J. Innes, S. Searl, & C. Smillie (Eds.), Community health nursing in Canada (pp. 579-591). Toronto: Gage. Suppe, F., & Jacox, A. K. (1985). Philosophy of science and the development of nursing theory. Annual Review of Nursing Research, 3 , 241-267. Tansy, E. M., & Lentz, J. R. (1988). Generalists in a specialized profession. Nursing Outlook, 36, 174-178. Williams, C. A . (1977). Community health nursing-What is it‘? Nursing Outlook, 25, 250-254. Wooldridge, P., Schmitt, M., Skipper, J., & Leonard, R. (1983). Behavioral science and nursing theory. St. Louis: Mosby. Working Group of the Federal/Provincial/TerritorialNursing Consultants. (1991). Discussion paper: Educational requirements for community health nurses. Toronto: Author. World Health Organization. (1978). Primary health care report of the international conference on primary health care. Geneva: Author. Zink, M. R. (1989). Curriculum analysis of home health content in associate degree and baccalaureate degree nursing education. Public Health Nursing, 6 , 8-15.
Toward Redefining Public Health Nursing in Canada: Challenges for Education Lucia C. K. Yiu Matuk, R.N., M.Sc.N., and Martha E. Chadwell Horsburgh, R.N., M.Ed., M.Sc.N.
Abstract Faced with a recent shift from a hospital-based to a community-based health care system, Canadian public health nurses are being challenged to redefine their roles. To empower these nurses to respond effectively, it is imperative that the profession be reclarified as a specialty with a distinct philosophy and mission. Nursing education is key t o facilitate this process, and public health nursing educators must lead the way. Certain barriers hinder the response of public health nursing education, and four areas are suggested in which efforts to advance public health nursing may be best directed.
and barriers can be analyzed and incorporated into planning for the community. Fiscal responsibility is increasingly central to all public health nurses’ activities. However, nurses strive to remain politically vigilant to economic and other pressures that may threaten future accessibility to and comprehensiveness of their services. Education is the key to empower nurses to meet these challenges effectively. THE CONTEXT OF CHANGE
The Canadian health care system is widely regarded as one of the best in the world in meeting the health needs of its citizens (Evans, 1987). It delivers services to the public using five guiding principles: comprehensiveness, universality, accessibility, portability, and public administration. Although the health care system in the United States also provides comprehensive health services, it is largely privately funded, and its services are neither accessible nor affordable to all people (ClemenStone, Eigsti, & McGuire, 1991). Both systems advocate “health for all by the year 2000” (World Health Organization, 1978), and recognize the need to expand health-promotion and disease-prevention programs. These two health care systems also have the highest overall health care expenditures per capita in the world. In 1989 the United States spent $2354 per capita on health care. Canada was second at $1683 (Nightmare . . . , 1992; Ontario Ministry of Health, 1989a; Luciu C . K . Yiu Mutuk, R . N . , M . S c . N . , andMurthu E . Chudwell Rachlis & Kushner, 1989). Horshurgh, R . N . , M . E d . , M . S c . N . are Assistunt Professors, still,in response to an increasing elderly popu~ation, School of Nursing, University of Windsor. advancing technology, and pressure to control escalatAddress correspondence t o Luciu Mutuk, R . N . , M . S c . N . , School of Nursing. University of Windsor, Windsor, Onturio, Can- ing costs, the two countries are striving to improve the health of their populations within the current climate of udu N 9 B 3P4
The exciting new directions in the contemporary Canadian health care delivery system challenge today’s public health nurses to redefine their roles. The recent trend toward community-based practice has resulted in a diversity of services and consumer choices in approaches to health care. Clients discharged from the hospital to the community are sicker than before, and demand greater multidisciplinary collaboration to meet their needs. The well population continues to demand its right to health care. Furthermore, the “health for all” concept challenges public health nurses to have a better understanding of how wealth is defined in their community. They are called on to identify public health issues readily and accurately so that health determinants
149
150 Public Health Nursing
Volume 9 Number 3 September 1992
economic restraint. The trend of change in the Canadian system is similar to that in the United States. Both systems are working to adopt measures to transform their primarily hospital-based systems to ones that are community based. Ambulatory care and early hospital discharge have been implemented in both countries, and community-based care and rationalization of services are being explored. Examples can be seen in the United States’ ambulatory centers as well as alternate delivery systems (ADSs), which include health maintenance organizations (HMOs) and preferred providers organizations (PPOs); Canada has health services organizations (HSOs), comprehensive health organizations (CHOs), and community health centers (CHCs). Multihospital systems are also being used in both countries to rationalize services (Ontario Ministry of Health, 1989a; Stanhope & Lancaster, 1992). In the province of Ontario, government-sponsored shifts in health care funding are beginning to favor community-oriented initiatives that include improved wages and benefits for community health care practitioners (Farr, 1990). The Ontario Ministry of Health revised its guidelines (1989b) to increase the emphasis on population-based services for targeted risk groups in order to accomplish specified health goals. This landmark document reflects public health priorities for disease prevention and health promotion. It also reinforces the recommendations of three other authors that continue to shape the Ontario health care system (Evans, 1987; Spasoff, 1987; Podborski, 1987). Their reports endorse effective and innovative strategies related to ambulatory care and community-based care to meet the health needs of Ontarians. Ironically, many Ontario public health nurse leaders view this momentum toward community and public health with more skepticism and uncertainty than excitement. Their wariness reflects a prevailing societal disinterest in public health nursing that has persisted in Canada since World War 11. After the Second World War, public health was eclipsed by new developments in medicine and the relative control of communicable diseases. The stature of public health nursing declined because of lack of role clarity, lack of recognition of preventive services, and an inadequate supply of well-prepared public health nurse administrators. Furthermore, many of public health nurses’ traditional activities were increasingly replaced by competitive multidisciplinary health care professionals. These problems are described elsewhere (Matuk & Horsburgh, 1989). Despite the continuing struggle to rebuild the status of their profession, nurses’ skills have not been overtly recognized as essential to carry out today’s mandatory public health programs and services.
RECLARIFICATION OF PUBLIC HEALTH NURSING’S FOCUS
The integration of community and public health nursing education appears to have hindered the preparation of public health nurses. Analysis of the historical development of community and public health nursing education in Ontario reveals two trends. The first is one of relative deemphasis on the latter compared with the former, and the second is a tendency to disregard the distinctiveness of the two specialties and to view them as one and the same. Public health nursing education was originally offered as a specialty in 1920. It was later subsumed under community health nursing programs, and integrated as part of the basic and postdiploma registered nurse baccalaureate programs in the 1960s and 1970s (Kerr, 1988). This integration was further reinforced by the Canadian Public Health Association (1977) when it established standards for community health nursing practice directed at both public health and community health nurses without differentiating the two as distinct specialties. In the early 1980s the Canadian Nurses’ Association, the Canadian Association of University Schools of Nursing, and the Canadian Public Health Association endorsed a baccalaureate degree in nursing as the minimum preparation for community health nursing practice (Stewart, 1985). In an effort to adopt broad concepts within baccalaureate programs, the specific and more in-depth focus of public health nursing became indistinct. Concomitantly, as many students struggled to adapt a wide array of skills to broadbased community health nursing practice, their understanding of the more circumscribed concerns and roles of public health and public health nursing became vague (Salmon, 1989). Today, public health nursing remains a subspecialty within community health nursing and is typified by its more circumscribed and in-depth emphasis on health promotion and prevention. Community health nursing has subsumed aspects of both public health and hospital-based nursing to encompass primary, secondary, and tertiary care in community settings. Both are specialties within nursing in general, and each embraces a distinct philosophy and mission. Although both focus on improving the health of the community through a multidisciplinary approach, a person who is prepared as a community health nurse may not perform the roles of a public health nurse credibly, especially in such areas as community development and population-based practice. The minimum educational preparation for public health nurses is either a baccalaureate degree in nursing or a diploma in public health nursing; community health
Matuk and Horsburgh: Re-Definition of Public Health
nurses require only their registered nurse certification to practice in the community. For years, public health nurses have debated whether their profession should be defined as a specialist or as a generalist area within nursing (Salmon, 1989; Tansey & Lentz, 1988; Williams, 1977). Unfortunately, the term “public health nursing” has often been interchanged with “community health nursing” in the literature (Clemen-Stone et al., 1991; Jarvis, 1985; Login & Dawkins, 1986; Stanhope & Lancaster, 1992; Williams, 1977). Some have contended that “community health nursing” is a modern term for “public health nursing” because it signifies the focus of care on the populace. Others have felt that the use of “community health nurse” avoids the association with caring only for the poor that “public health nurse” implies. Salmon’s (1987) suggestion that “community health nursing” might be more appropriately renamed “community and public health nursing” appears to have merit. This option would foster the development of specific nursing theory and course content reflecting the missions and goals of both specialties.
I5 1
and they must give careful attention to community needs, consumer participation, and public policy. They must empower the community with the responsibility for the health of its members. To fulfill their new and evolving roles, nurses are being called on to integrate the philosophy and concepts of public health and nursing with those of epidemiology, biostatistics, sociology, anthropology, and psychology to assess the health and needs of the community as these needs are affected by the health, social, political, and economic systems (Josten, 1989). The resulting broad perspective will increasingly place them in a position to exert leadership roles within multidisciplinary teams. ENSURANCE OF A CADRE OF WELL-QUALIFIED PUBLIC HEALTH NURSE EDUCATORS
It is crucial that graduates be prepared adequately to model and market a positive and comprehensive image of public health nursing. Thus, it behooves every school of nursing to have educators who possess dexterity in both public health and community health nursing REDEFINITION OF PUBLIC HEALTH knowledge and skills. NURSING ROLES Failure to distinguish public health nursing practice At the 1990 Canadian Annual Federal/Provincial/Terri- from that of community health nursing has contributed torial Nursing Consultants’ meeting, many senior com- to the development of multiple standards and conflicting munity and public health nurses identified the need to demands on public health nurse educators teaching address the apparent discrepancies between the edu- community health nursing courses at the baccalaureate cational preparation of community and public health level. Educators are expected to possess both the depth nurses and emerging practice requirements. The nurses of knowledge and skills demanded for public health were frustrated by their lack of skills in community de- nursing, and the range of concepts and skills required velopment and population-based approaches, including for community health nursing. Lack of community disease-prevention and health-promotion strategies, and health nurse educators qualified in public health can interdisciplinary collaboration (Working Group, 1991). deny students the opportunity to receive comprehenThe Working Group (1991) identified two major edu- sive public health nursing education. cational requirements as foundational to the success of Thus it is vital that public health nurse educators poscommunity development models for community-based sess the following: a strong knowledge base of family planning and contemporary health-promotion strate- and community nursing; ability to cluster public health gies. First, a major emphasis on direct personal health issues and identify determinants and barriers that affect services through traditional one-to-one teaching and the health of the community; ability to target intervencounseling was deemed too costly and inefficient for to- tions for at-risk aggregates to promote health; and abilday’s public health nursing practice. They suggested ity to employ sound teaching strategies to facilitate that future public health nursing students learn to imple- positive attitudes toward health promotion in nursing ment effective group processes, identify group health students. Furthermore, they must take an active leadproblems among various aggregates, and collaborate on ership role to instill the value of public health nursing multidisciplinary teams to promote healthy populations. practice in students and in the larger community. This Second, they noted that consumers are more sophis- demands that educators have a strong commitment to ticated and knowledgeable. The public will not al- the profession; a clear vision of the scope and trend of ways come to public health nurses with problems and the health values of the public, politicians, and the meseek out their services. Therefore, future public health dia; a sound understanding of the funding of health care nurses must be prepared to use effective health-promo- and the development of government health policy; and tion and social marketing strategies to describe their role modeling to demonstrate effectively how nursing services. They have to exercise their role as health-pro- may affect both health values and health policy. Commotion consultants in working with well populations munity and political activities of public health nurse ed-
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ucators must be viewed as essential and credited for professional and scholarly merits (Salmon, 1989). ENHANCEMENT OF THE RESPONSIVENESS OF THE NURSING CURRICULUM In planning for a curriculum that is responsive to the needs of evolving practice, public health nursing must go beyond the traditional personal health services rendered to individuals and families and expand its focus to encompass population health. Nonetheless, individual and family care skills should remain integral to the identification of population profiles and community needs, and should be retained in the curriculum. As a basic unit of a society, the family is made up of individual members and is the smallest group for epidemiology investigation. It is also the most effective medium by which to deliver personal health and population health services. The United States’ experience warns that with the program-based structures in local and state health departments, nurses must follow program guidelines to offer a limited set of services to well-defined populations. Fewer nurses are available to provide family-centered services (Smith, 1989). Another area of consideration is the incorporation of nursing theory into course content. Although many nursing frameworks have defined their client system as individual, family, and/or community, the focus for assessment and intervention remains primarily individuals. This approach continues despite integration of public health nursing concepts into basic nursing programs (Salmon, 1989; Williams, 1977). Furthermore, because of the lack of expert nurse clinicians, attempts to extend or modify existing frameworks to incorporate family nursing theory and community health concepts are often unsatisfactory. Discrepancies exist between contemporary nursing theories and public health theories. Thus, nurse educators are challenged to assist students to apply only the relevant content of models and theories to public health nursing practice (Hanchett & Clarke, 1988; Rogers, 1984; Selby et al., 1990). Many nursing leaders (Donaldson & Crowley, 1978; Suppe & Jacox, 1985; Wooldridge et al., 1983) have stressed the need for the development of more practiceoriented nursing theories. The development of such theories would benefit contemporary public health nursing by articulating its goals and areas of interest, and serving as a guide for research and practice. Effective implementation of public health nursing practice lies in realistic curriculum planning that embodies a proactive vision of the profession’s potential. Educators are challenged to equip graduates with a diversity of skills to provide health-promotion and illnessprevention services to individuals, families, and communities. Some of these competencies include pro-
fessional marketing, computer literacy, and business administration skills. Graduates must be able to understand their diverse communities and to create accurate population profiles to support appropriate health-promotion behaviors. Educators must ensure appropriate opportunities for students to apply theory and test their new skills in reallife situations. They must use clinical settings consistently to facilitate students’ application of practiceoriented theories to public health and community health nursing. Since a desirable curriculum presumes a knowledge base that is acceptable to the profession at large, educators must first consider what constitutes the theoretical base for public health nursing practice, and encourage students to master both theoretical concepts and clinical competence (Blank & McElmurry, 1986). The success of this goal must be monitored through evaluative research studies (Clark, Underwood, & Chambers, 1991). Some argue that in generalist-focused baccalaureate degree programs it may not be crucial to introduce both public health and community health concepts beyond a cursory overview. Rogers (1984) contended that caring for the community and aggregates provides a challenge better met by postbasic baccalaureate education, and that the focus at the baccalaureate level should be caring for individuals, families, and, to some degree, aggregates. Others also agree that expanded public health and community health programs should be offered at a graduate level (Anderson, 1989; Salmon, 1989; Williams, I 977). We agree, too. However, to meet today’s demand for public health nurses within the financial constraints currently imposed on Ontario’s educational and health systems requires that competent, entry-level public health and community health nurses be prepared at the undergraduate level. In 1990, of the 80,946 registered nurses in Ontario, 13,625 (16.8%) worked in community settings. A review of their educational preparation suggests that larger-scale graduate level education is not feasible at present (College of Nurses of Ontario, personal communication, 1990). As depicted in Figure 1, although nurses are striving to meet the demands of public and community health nursing, few are obtaining graduate degrees. Educators, administrators, and practitioners must recognize that a four-year baccalaureate program cannot reasonably produce proficient nurses beyond entry level (Dieman, Jones, & Davis, 1988). After entering practice, in-service, continuing-education, and graduate education programs are critical avenues to foster continued professional and self-development. Through joint appointments and other collaborative mechanisms, educators and administrators might de-
Matuk and Horsburgh: Re-Definition of Public Health
Graduate 1
Graduale 2 2%
ax
BDCClll",
18 ,p,oma 5.1 %
79.1%
Public Health Nurses
(excluding Public Health Nurses)
n = 1862
n=1962
in Ontario are bound only by its commitment and creativity. The call for all public health nurses to carve out their roles within the evolving health care system is urgent. Education is a key to facilitate these changes, and public health nurse educators must serve as the catalysts.
REFERENCES
61 1 %
Community Health Nurses
I53
Figure 1. Educational preparation of community health and public health nurses in Ontario in 1990 (College of Nurses of Ontario, 1990).
velop programs to assist students and practicing public health nurses to acquire new knowledge and skills and effectively implement new roles and functions (Black et al., 1989; Kerner, 1985; Zink, 1989). Collaborative team work between education and practice will provide the cornerstone on which mechanisms for continued professional development may be built (Selby et al., 1990). The merging of these two forces will strengthen both education and practice, and sensitize public health nursing students and practitioners to the needs of the profession. Resources for clinical learning, practice, and research may be shared and maximized to the benefit of all. Such collaboration could provide mutual benefits to both public health nursing students and practitioners, and foster collegial relationships between education and service.
CONCLUSION The challenges confronting contemporary public health nursing practice in Ontario are multifaceted. How they will be met will influence the nurses, their practice, and the health of Ontarians. The issue of whether public health nursing should be a distinct specialty will bear no significance if the nurses are unclear about their collective roles and functions in the rapidly evolving health care system. Public health nurse educators' commitments to the profession will nurture graduates to seek the knowledge and skills required for practice. Well-prepared graduates will provide competent population-focused care and use community-based processes to work effectively with various aggregates while still engaging in individual and family assessment and intervention. Most important, they will confidently articulate their expanded roles to the community and proactively shape future health care policy. The prospects for the future of public health nursing
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Nightmare of the $500,000 ulcer. (1992, February 1). London Free Press, p. B 1. Ontario Ministry of Health. (1989a). Deciding the future of our health care, April 1989. Toronto: Author. Ontario Ministry of Health. (1989b). Mandatory health programs und services guidelines (2nd ed.). Toronto: Author. Podborski, S. (1987). Health-promotion matters in Ontario: A report of the Ministry’s advisory group on health promotion. Toronto: Ontario Ministry of Health. Rachlis, M., & Kushner, C. (1989). Second opinion: What is wrong with Canada’s health care system and how tofix it. Toronto: Collins. Rogers, S. (1984). Community as client: A multivariate model for analysis of community and aggregate health risk. Public Health Nursing, I , 210-222. Salmon, M . E. (1989). Public health nursing: The neglected specialty. Nursing Outlook, 37, 226-229. Selby, M. L., Riportella-Muller, R., Quade, D. Legault, C., & Salmon, M. E. (1990). Core curriculum master’s-level community health nursing education: A comparison of the views of leaders in service and education. Public Health Nursing, 7 , 150-160. Smith, G. R. (1989). Using the public agenda to shape public health nursing practice. Nursing Outlook, 37, 72-75. Spasoff, R. A. (1987). Health for all Ontario: Report of the panel on health g o d s for Ontario. Toronto: Ontario Ministry of Health.
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