“Something Must be Done!” A 20th Century Rallying Cry for the Future of Public Health Nursing

Sep 17, 2013, 9:18 AM, Posted by

Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN, is a Robert Wood Johnson Foundation Executive Nurse Fellow. She is the Theresa A. Thomas Professor of Nursing and a professor of public health sciences at the University of Virginia, chair of the Department of Family, Community, and Mental Health Systems, and coordinator of the public health nursing leadership track of the master’s in nursing program.


With the recent release of second edition of the Public Health Nursing: Scope and Standards of Practice (American Nurses Association, 2013), now is a perfect time to reflect on the past and look toward the future of public health nursing (PHN). Public health nurses have always focused on improving the health of populations through health promotion and disease prevention. Since the establishment of visiting nursing in Boston and the Henry Street Settlement in New York City in the late 1800s, public health nurses have worked with families and communities in schools and homes, with immigrant populations in industrialized cities, and with rural communities to address challenging social conditions and to promote the health of the public.

It was evident with the founding of the National Organization of Public Health Nurses in 1912 that “something must be done” to prepare nurses with a broader education and emphasis on social conditions and prevention. Today, more than ever before, when health care in the United States is shifting its emphasis from an illness care system to one focused on health promotion and prevention, we need public health nurse generalists and advance practice public health nurses prepared to lead health care reform. 

I had the good fortune to co-chair, with Joy Reed, PhD, RN, an RWJF Executive Nurse Fellow since 1998, the American Nurses Association (ANA) workgroup that revised the PHN: Scope and Standards of Practice (ANA, 2007). This dynamic group of nursing educators, practitioners, and researchers viewed the revision process as an opportunity to set the stage for public health nurses to become active, visible partners in health care. The scope and standards provide guidance to public health nurses in communities across the nation working to direct change in all health sectors, from public to private and local to global. In addition, the convergence of multiple economic, political, and social factors provides a “roadmap” for improving population health. These factors include landmark initiatives: Healthy People 2020, the Patient Protection and Affordable Care Act (ACA), the Institute of Medicine’s Future of Nursing Report, the Obama Administration’s National Prevention Strategy, and the Robert Wood Johnson Foundation (RWJF) reports on the Forum on the Future of Public Health Nursing and the Enumeration and Characterization of the Public Health Nurse Workforce.  

The renewed national emphasis on health promotion, prevention, and population health provide exciting opportunities for leadership roles in PHN education and workforce development to influence participatory community health promotion and prevention practices. Two clear directions for PHN leadership arise from the current national context.

The first involves the shifting mission of schools of nursing toward educational programs, scholarship, translational research, and service that emphasize health promotion and prevention to improve population health and reduce health disparities.

The second entails advocating for health equity through health promotion and prevention activities with communities and populations in both practice and policy at local, regional, state, and national levels. The current national health promotion and prevention-oriented climate represents the “best of times” for public health nursing education, practice, and research in the United States. 

At the same time, the current economic hardships that threaten individuals, families, communities, and organizations including universities, as well as the current negative political climate, present serious challenges for public health nursing (the “worst of times”). Financing health promotion and disease prevention is an ongoing challenge. Public health activities are traditionally underfunded; again, in 2012, the United States spent only 3 percent of health care dollars on preventing disease. Today, there are serious concerns about funding for the ACA, particularly with continued efforts to repeal the legislation. Determining what elements of the ACA will be implemented and receive recommended levels of future funding is daunting.

Other challenges face the public health workforce, where public health nurses are a majority in decline, and the nursing workforce, where baccalaureate and graduate level public health nurses are a minority in decline. An RWJF news release in 2011 indicated that the recession affected the public health nursing infrastructure in many states across the country. Underserved populations are unable to receive needed services, due in large part to the fact that public health nurses—the largest sector of the public health workforce—are often a first target for budget cuts.

In addition, the number of registered nurses employed in public and community health settings, such as schools, worksites, and health departments, decreased from an estimated 14.9 percent in 2004 to 7.8 percent in 2008. This trend holds true for PHN educators in schools of nursing across the country. As a result, at a time when health promotion and prevention initiatives are receiving renewed national attention, PHN educators, practitioners, and researchers face significant barriers.

Public health nursing leaders in education and practice must continue to promote and protect the health of communities and populations and strive to reduce health inequity through established and new avenues of advocacy, collaboration, innovation, and interprofessional collaboration. Achieving these goals will require that PHN leaders have the knowledge, skills, and competencies necessary to influence key policy-makers and to expand the public health workforce through baccalaureate, graduate, and continuing education, thus assuring an increased, effective public health workforce.

The second edition of the PHN: Scope and Standards of Practice provides essential guidance in the form of standards and competencies for the generalist and the advanced practice public health nurse. This guidance is required for PHN educators, practitioners, researchers, students, and others directly involved in public health to address the economic, political, and social challenges confronting present and future public health and health care. The goal of public health nurses remains clear: to use our knowledge, skills, competencies, and collective voices to shape innovative programs within nursing, public health, and health care to improve population health and promote health equity.

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