Recession Takes Bite Out of Nation's Public Health Nursing Infrastructure

Budget cuts are latest challenge to public health nurses at a time when the sick, the poor, the elderly and the underserved are relying on their services.

    • November 28, 2011

Earlier this year, a homeless woman in the seventh month of her pregnancy walked into a prenatal clinic in Washington state with a toddler in tow. She walked out with a prenatal care appointment and a few brochures—but not the wider range of health services she really needed.

Why the brush-off? The nurses on staff could not treat her greater needs themselves and they could not connect her with a public health nurse who could help her. State and local legislators struggling to balance ever tighter budgets had cut funding for public health nursing, leaving those who rely on their services without full access to them.

“Here we have a mother who is trying to get help and who is pregnant,” said Betty Bekemeier, PhD, MPH, FAAN, a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar (2010-2012) who is familiar with the case. “Under normal circumstances, she would be a very high priority for service. But they could do little more than get brochures to her.”

Public health nurses are indeed in short supply these days in Washington state—and in many states across the country—in large part because of the recession, Bekemeier and others say.

State and local legislators around the nation have cut funding for local health departments, where many public health nurses work. In July of this year, 45 percent of the nation’s local health departments reported reduced operating budgets compared to the previous year, and more than half expected cuts in the next fiscal year, according to the National Association of County and City Health Officials (NACCHO).

Public health nurses are the largest segment of the public health workforce. The budget cuts have led to a weakened public health nursing infrastructure that has nurse leaders concerned about the health of the public and the future of the field of public health nursing.

Public health leaders say that funding cuts to local public health departments mean fewer services, and poorer health, for vulnerable people—precisely at a time when, because of the high unemployment rate, government-funded help is needed most.

The weakened public health nursing infrastructure also gives rise to concerns about the future of a field that has a long and storied history of serving—and saving—the sick, the poor, the elderly, and the underserved. The field got off to a start in the late 19th century when Lillian Wald moved to New York City to bring nursing services to the overcrowded homes of immigrants and the working poor and to bring about health-related policy changes.

Public health nurses have continued her legacy of service and advocacy ever since, and have successfully worked to improve maternal and infant health, reduce the spread of infectious diseases, respond to national emergencies and natural disasters, and educate the public about disease prevention and health promotion. Public health nurses have also been actively involved in social change campaigns to end unsafe labor practices, promote gender and racial equality, and advocate against war.

Multiple Challenges Today

Now, budget cuts threaten to slow the work of public health nurses, and come at a time when other challenges are facing the field. Like the general nursing workforce, the public health nursing workforce is aging, but there aren’t enough young nurses going into the field to replace those reaching retirement age. Public health nursing salaries are also lower than salaries for nurses in acute-care settings, making recruitment and retention difficult. And public health nursing scholars say the nurse education system does not adequately prepare student nurses to work in public health systems.

“I’m very concerned,” said Linda Olson Keller, DNP, APHN-BC, FAAN, an RWJF Executive Nurse Fellows alumna (2001-2004) who is a clinical associate professor at the University of Minnesota School of Nursing. “We want to make sure we have leaders and staff ready to be public health nurses.” Without them, she said, communities suffer.

Rebuilding the public health nursing infrastructure may not happen even when the economy fully recovers, warns Joy Reed, EdD, RN, FAAN, another RWJF Executive Nurse Fellow alumna (1998-2000) who is head of public health nursing for the North Carolina Division of Public Health. Policy-makers do not have a firm understanding of the essential services provided by public health nurses, she said. “It’s really time to get this message out. If we don’t…the number of public health nurses will continue to decline.”

The news isn’t all bad, however.

The health reform law passed last year included provisions that emphasize prevention and health promotion, which is largely the work of public health nurses. The new law is expected to draw attention to the work done by public health nurses and create demand for their services.

Also last year, the Institute of Medicine (IOM) released a report on the future of nursing that included recommendations in the areas of nurse education, nurse leadership and scope of practice that public health nurse leaders say would aid the field. The IOM report says that allowing nurses to practice to the full extent of their abilities and education will enable nurses to be more effective and in greater demand at public health agencies. Better educated nurses will be able to provide better care. And public health nurses in positions of leadership will have a greater influence on policies that affect population health and may be able to fend off deeper cuts to state and local health departments and to public health nursing positions in particular.

“We have to make sure that our legislators understand the role of public health and public health nursing in supporting the well-being of communities,” said Alison Colbert, PhD, APRN, BC, an RWJF Nurse Faculty Scholar (2010-2012) who teaches nursing at Duquesne University. “When they start to make cuts, they have to know firsthand the repercussions of those cuts.”

The Robert Wood Johnson Foundation has launched a campaign to support the implementation of the IOM report recommendations and is also supporting public health nursing through a variety of programs that provide funding for nurses, including those who specialize in public health. RWJF programs that support public health nurses include the Executive Nurse Fellows program, the Nurse Faculty Scholars program, and the Community Health Leaders Awards program. Partners Investing in Nursing’s Future, a program supported by the Foundation, supports grantees working to bolster the public nursing workforce. One in particular worked to expose more students to public health nursing to generate more interest in the field among aspiring nurses.

Public health nurses themselves are also taking on the challenge by organizing into formal advocacy groups, conducting research on public health nursing outcomes, assessing the new health care reform law for opportunities for public health nurses, and partnering with private and public organizations. There are currently two parallel efforts to form national and international associations of public health nurses.

Says Olson Keller: “We are definitely trying to change and have a voice at the table.”

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