Public Health Policy Forum

Editorial: Public Health Nursing-

The Opportunity of a Century

Maria E. Salmon, ScD, RN

This year marks both the completionof a century ofpublic health nursing in theUnited States and the beginning of na-tional health care reform. Public healthnurses across the nation are wonderingwhat these major turning points mean forthem in their practices. An even more cen-tral question is, How can public healthnursing best be used to advance the publichealth mission, particularly in the face ofhealth care reform? This is not a questionfor nurses alone. Rather, it is a questionfor health departments, public policy ex-perts, and communities as they seek toensure the health of the people in a rapidlychanging, unpredictable system of healthservices.

Perhaps this question is best an-swered by considering some ofthe lessonslearned from a century of public healthnursing services. First, we have learnedthat public health nurses are "functional."That is, the form oftheir practice has fromthe beginning followed the functions re-quired by society.' Lillian Wald's found-ing vision of public health nurses in 1893was one in which their services reflectedthe constantly changing needs of the peo-ple of those times, rather than a templateof what a nurse should do.2,3

In recent years, however, this re-sponsiveness has led public health nursesto assume a more clinical, illness-orientedrole rather than the traditional home- andcommunity-based preventive role. Thisrole has given rise to a case of mistakenidentity. For more than 20 years, healthdepartments everywhere have been en-ticed and forced into providing direct clin-ical care to people in their homes and clin-ics. Both public need and the revenueattached to these services have been mov-ing forces behind these changes.4 Publichealth nurses have been the human re-

source that has made these services pos-

sible. These new assignments, however,have diverted public health nurses fromtheir central roles in assessment, surveil-lance, policy, and health promotion anddisease and injury prevention activities.Thus, as health departments came to lookmore like other types of delivery systems,public health nurses came to resembleother nurses providing personal care serv-ices in the community.56

The visibility of public health nursesin the delivery of personal care services isnot without risk. As health officers andothers consider returning to the centralmissions of public health and discardingwhat may be increasingly redundant per-sonal care services, their public healthnursing resources may be allowed to slipaway.

This case of mistaken identity, thatis, the perception of the public healthnurse as a provider of personal care only,is particularly hazardous at this time ofnational health care reform. The roles ofhealth departments will undoubtedlychange as many of these personal careservices are provided by other sectors. Acomprehensive health care system thatprovides such services could free healthdepartments from dependence on the rev-enue from these services and allow themto reaffirm their core roles, but at the riskof overlooking what public health nursescan do beyond personal care service.

The author is with the Division of Nursing, Bu-reau of Health Professions, Health Resourcesand Services Administration, US Public HealthService.

Requests for reprints should be sent toMarla E. Salmon, ScD, RN, Division of Nurs-ing, US Public Health Service, 5600 FishersLane, Room 935, Rockville, MD 20857.

Note. The views expressed here are theauthor's and do not necessarily reflect those ofthe US Department ofHealth andHuman Serv-ices.

December 1993, Vol. 83, No. 12

PWblic Health Pricy Fonm

What is it that public health nursesoffer to the health departments of the fu-ture? First, theybrng health expertise intothe context of health departMents.7,8 Pub-lic health nurses are generalists who canbridge the gaps between science, policy,and the people. For health departmentsplagued with environmental health issues,for example, the public health nurse offersan important means of assessing the healthimpact of environmental hazards, makeslinks with communities, and communicatesinformation about hazards and their healthrisks. As trusted health professionals,nurses are rquently able to move in com-muniies in ways not possible for others.9

Public health nurses are also perhapsthe most flexible element of a fairly con-crete enterprise. Public health nurses' as-sessment, communication, and manage-ment skills allow them to expand orcontract their roles as needed. Publichealth nurses move easily across settingsand roles; they are translators among dis-ciplines and interpreters of and for com-munities. It is not surprising that a numberof public health nurses have becomehealth department managers.

Perhaps most important, publichealth nurses are both effective and cost-effective inreachingpeoplewho arekeytoensuring the overall health of the pub-lic.'101 Areformed health care systemwillnot replace comprehensive, community-based assessment, health promotion, pro-tection, and disease prevention.

Consider the health of school-agedchildren. We cannot assume that the uni-versal access expected with health carereform will ensure the health of this pop-ulation. Even if all parents are able to taketheir children for personal care services,we know that not all will. Even if parentsdo avail their children of these services,such services do not cover the scope ofhealth-related activities necessary to en-sure the health of all children. Childrenencounterviolence, substance abuse, sex-ually transmitted diseases, and the risk ofpregnancy as well as more routine healthproblems. These problems require coor-dinated macro- and microcommunity- andschool-based interventionsl2l3 ifwe are torealize the goal of health for all children.Our own experiences and those of othercountries'0have demonstrated thatnurseswhose duties take them into homes,schools, and community meeting placesare essential to such interventions. Healthdepartments deploying public health nurs-ing resources are the appropriate vehiclesto address the public health issues thatsurround children.

Other groups, too, require the coor-dinated, community-based assessmentsand interventions provided by health de-partments. Ofparticular concern are thosewhose work takes them into unregulated,high-risk settings, such as domestic work-ers and those in high-risk occupationssuch as construction and agriculture. Whowill ensure the health ofthese workers? Inthis area, too, health departments can de-pend on flexble, cost-effective contribu-tions from public health nurses.

The profession of public health nurs-ing was created in response to the social,political, economic, and environmentalforces that threatened the health ofAmer-icans a centuly ago.2 Previous generationsof public health nurses saw the need forcommunity-based programs that con-nected thework of health departments andthe people at risk. They led many of thepolicy revolutions that helped bring familyplaning workplace safety, and maternaland child health services to people in need.

How best to use public health nursesin the future? First, understand that not allhands-on services are personal care serv-ices thatwillbe taken overbyothers in thereformed health care system. Health de-partments will increasingly need healthprofessionals who can reach people incommunities for all sorts of reasons.

Second, consider the utility of publichealth nurses in public health policy. Pub-lic invisibility is a political liabilityofmanyhealth departments that public healthnurses can offset. Theycanbe communitybarometers that provide reality checks forhealth officers and policymakers. And, inthe political world at large, they have be-hind them the formidable political force ofnursing. Nursing orpgnizations, such asthe American Nurses Association, havebeen consistent and vocal allies for stateand local health departments in this timeof health care reform.14 This is not sur-prising, since the missions of health de-partments and nursing are highly compat-ible.15 The future of public health will be,in large measure, the result of effectivepolitical strategy and action. Public healthnurses can provide both.

Third, public health nurses can con-tribute to the overall management of thepublic health endeavor. As health depart-ments diversify and balance environmen-tal challenges with other health-related is-sues, more generalists with backgroundsin public health sciences, management,and the health professions will be neededto lead and to bridge many activities andmany contexts. Public health nurses canfill this bill.16

Clearly, a century of public healthnursing has given today's health depart-ments what is perhaps their single mostuseful human resource. But what of to-morrow? Quite simply, public healthnurses shouldbe the centerpiece ofaworkforce that will move health departmentsforward in theworkofpreserving and pro-tecting the health of the public. [J

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