Public Health Nursing
PUBLIC HEALTH NURSING
Public health nursing is a specialized form of registered nursing that combines nursing and public health principles. According to the American Public Health Association, the primary focus of public health nursing is improving the health of the community as a whole rather than just that of an individual or family. Public health nursing is sometimes called a type of community health nursing. Some experts use the terms "public health nursing" and "community health nursing" interchangeably.
Public health nursing traces its roots to England where, in 1859, Florence Nightingale assisted in organizing district public health nursing. Each nurse was assigned a specific geographic area of London and was responsible for the health of the people living in that neighborhood. This type of organization finds its echo today in many public health departments, where public health nurses organize their work by groups of census tracts called districts and the nurse is known as the district public health nurse.
In the United States, modern public health nursing was defined by pioneering nurse Lillian Wald in the late 1800s. She established the Henry Street Settlement in New York City, where nurses lived in the neighborhoods where they worked. In the beginning, public health nursing was primarily concerned with taking care of the sick poor in their homes. Lillian Wald came to the realization that sickness found in the home had its origin in larger societal problems. She set about directing nursing efforts toward employment, sanitation, recreation, and education. It was Lillian Wald who coined the term "public health nurse." Hospital-based schools of nursing which granted nursing diplomas provided the educational preparation for nurses at this time.
In the early part of the twentieth century, Visiting Nurses Associations were formed to continue the tradition of providing care for the sick in their homes, which eventually became known as home health nursing. Public health nursing began to be practiced in both voluntary agencies such as the American Red Cross, and governmental agencies, such as local county and city health departments. Serving the needs of the poor remained a key aspect of public health nursing. In the mid twentieth century, care shifted from the home to the clinic, where nurses worked in well baby and immunization clinics for the uninsured and were active in controlling communicable diseases such as tuberculosis.
In the latter part of the twentieth century, nursing education began to move out of hospitalbased programs and into community colleges and universities. Educational preparation for public health nurses varies widely in the United States with some jurisdictions requiring a bachelor's degree in nursing and others accepting a hospital diploma or associate degree from a community college. A bachelor's degree in nursing is considered a minimum requirement for public health nursing practice by many nursing professionals and professional nursing organizations. A bachelor's degree in nursing is thought to provide the background in social science and public health science such as epidemiology and environmental health that a public health nurse needs. Increasingly, public health nurses are enrolling in advanced degree programs in public health, community health nursing, and other public health specialties.
THE ROLE OF THE PUBLIC HEALTH NURSE
Ideally, the work of public health nurses is defined as "primary prevention," which means preventing disease, injury, disability and premature death. Public health nurses work as a team with other public health professionals such as environmental health specialists, health educators, epidemiologists, public health physicians, and nutritionists. As members of this team, they work with local communities to assess and prioritize the major health problems and work on a plan to alleviate or eliminate these problems and the conditions that contribute to their development.
Public health nurses are able to assist individuals and families to take action to improve their health status. Often this takes the form of teaching about healthy lifestyle choices in the home, in the workplace, and in community settings. Public health nurses assist people in applying improved health behavior choices to their everyday lives. Examples of personal behaviors that can contribute to health problems are tobacco use, improper diet, lack of physical exercise, unsafe sexual practices, and driving while intoxicated.
Public health nurses also recognize that the community and environment in which people live can affect their ability to make healthy lifestyle choices and can affect whether or not such choices exist at all. Thus, public health nurses may spend a significant portion of their time on ensuring healthy living conditions in the neighborhoods where they work and on improving the health status of the entire community, not just that of individuals. Examples of community issues on which the public health nurse may work are reducing tobacco sales to minors, fluoridation of drinking water, identifying and reducing workplace hazards, immunization of all children against communicable diseases, and reducing the risk of drowning through community education, pool safety, and construction regulation.
Public health nurses are found in a variety of settings, including schools and the workplace. Public health nurses who assist workers at the job site are called occupational health nurses. Some nurses work in local government health departments as general practice nurses in neighborhoods. In some health departments, the community intervention role of public health nurses is not well established and their work is confined to home visits and clinic work. Their primary role is that of case manager and they have a varied caseload of individuals and families whom they assist with illness-oriented concerns, such as communicable diseases and health problems of mothers and children. Sometimes, these case manager public health nurses specialize in one area, such as follow up of cases of lead poisoning or sudden infant death syndrome. Much of the funding for public health work has been fragmented, coming to local government jurisdictions from state and federal sources for a specific problem or intervention only. As a consequence,
Many public health nursing experts feel that this emphasis on caring for people with a disease or condition has hindered public health nurses from being full participants in public health and has diverted public health nursing away from its prevention role. Some in public health nursing would even argue that, as a result, the practice of public health nursing has lost its way and needs to refocus on the true mission of public health: to look at the health problems of a community as a whole and work with the community in alleviating those problems. They would argue that there is the mistaken perception of public health nurses as providers of personal care only. The challenge for public health nurses in the future is to apply the nursing process (assessment, diagnosis, planning, implementation, and evaluation of interventions) to improve health, not just of individuals, but also with larger segments of the population in partnership with the community.
TRENDS AND FUTURE DIRECTIONS
The practice of public health nursing has been greatly affected by sources of funding. Much of the past focus on clinic work and personal health care for the indigent and uninsured has been driven by the need to limit nursing work to what was reimbursable by a third party, such as Medicaid in the United States. Many public health nurses practice in local health departments, which are seen as the providers of last resort for care of the sick poor and the uninsured. County hospital care and out patient services have taken much of the public health funding and attention away from the primary goal of public health, that is, improving the health of the entire community. However, this is gradually changing, with a major shift in the 1990s to health plans (managed care) and the movement of Medicaid populations, in most states, into managed care programs. This has made caring for sick low-income people more financially viable for the private sector. Consequently, local health departments and their public health nursing staff have been encouraged to shift their activities back toward the primary mission of public health, which is to work on the causes of health problems and to prevent them.
KATHLEEN N. SMITH
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