Public Health Nurses: Positioned to Lead Health System Transformation

Jul 11, 2013, 12:00 PM

Shirley Orr, MHS, APRN, NEA-BC, is a public health consultant and an alumna of the Robert Wood Johnson Foundation Executive Nurse Fellows program (2009–2012).

According to President Hoover’s Research Committee on Social Trends, public health nurses numbered just 1,413 in 1909. That number skyrocketed to 15,865 by 1931. In the midst of the Great Depression, the President’s committee articulated the value of public health nursing to the nation by declaring that, “. . . the importance of the public health nurse cannot be overestimated.” In that difficult time, those familiar with the work of public health nurses saw great value in their commitment to social and humanitarian causes, evident through outreach to populations in greatest need of health improvement.

The Enumeration and Characterization of the Public Health Nurse Workforce report, just released by the Robert Wood Johnson Foundation (RWJF), tells us that approximately 34,500 nurses currently practice in local and state governmental health departments, making public health nurses one of the largest segments of the public health workforce. While today’s public health nurses maintain the commitment to social and humanitarian causes evident in the 1930s, public health nursing practice has changed significantly in the ensuing decades. The major trends and shifts we see in the public health system today are key factors influencing the ongoing evolution of contemporary public health nursing practice. For today’s public health nurses, the challenge of the future is systemic change.

So, what exactly lies ahead for public health nursing? Some have speculated that the movement of uninsured populations into health care homes and away from public health clinics will mean the end of public health nursing. Others have suggested that this shift in focus away from provision of clinical service is an opportunity to send public health nursing “back to the future,” with a renewed emphasis on population-focused services, along with community outreach and engagement. Which vision of the future is most likely to become reality?

In many communities today, public health departments have transitioned the clinical care of individuals to a range of primary care providers, freeing up limited public health resources to tackle priority issues in the population served, including epidemics of communicable and chronic diseases. At the 2012 RWJF Forum on the Future of Public Health Nursing, the overwhelming majority of participants described the trend away from clinical services as a “positive” trend that should continue.   

The new enumeration report paints a somewhat different picture. It finds that, while a significant number of health departments are reducing or eliminating clinical services, others are actually expanding those services. The transition away from clinical services and to population-focused services is likely to continue at varying rates and stages in various parts of the country for the next several years, largely driven by supply and demand for primary care services. Given this uneven transition, how can public health nurses best prepare for future practice? The answer lies, in part, in the ability of nurses to be flexible and to build a broad range of public health competencies and leadership abilities. 

Today, population health and prevention are emerging as priorities as the nation’s health system transforms and increasingly focuses on health outcomes and cost savings. In communities across the country, public health nurses are positioned to lead health system transformation with skills in clinical and population health.

Now is the time to expand the reach and impact of public health nurses (PHN) to improve the health of all Americans. The new enumeration report provides specific recommendations to make this goal a reality.  Among those recommendations are the following: 

1.       Develop strategies to encourage additional education and training for PHNs, particularly those educated at the ADN/diploma level.  Full national implementation of baccalaureate preparation for PHN practice must be a top priority.

2.       Implement strategies to improve the racial and ethnic diversity of the PHN workforce.  The public health nursing workforce must reflect the population served, in terms of race and ethnicity. 

3.       Determine the extent to which changes in the functions of health departments, due to health care reform, will impact the tasks and functions of PHNs. This understanding of practice trends is essential to assure that PHNs are prepared, in adequate numbers, for current and future practice.

4.       Identify mechanisms for addressing organizational concerns related to PHN recruitment, compensation, and promotion opportunities. Expand options for PHNs to serve in leadership roles in health departments.   

5.       Regular studies should be conducted to monitor size, composition, capacity and function of the PHN workforce, including supply and demand projections. The 2012 PHN enumeration report creates a foundation for efforts that should be ongoing. 

To achieve these goals, public health nurses at all levels must actively support the recommendations and engage partners, including policy-makers, in action-oriented dialogue. The Future of Nursing: Campaign for Action is a key resource and provides an opportunity to leverage additional resources in support of the recommendations.

Public health nurses are a universal community asset that can be better leveraged to improve the health of communities if we join forces to make the recommendations a reality and accept the challenge of change.  

Read more about Shirley Orr’s work, and see a 2012 Q&A with Orr on NewPublicHealth.
Read more about the Robert Wood Johnson Foundation’s work on public health nursing.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.