Introduction:
Numerous nursing organizations and health care agencies have documented that a shortage of nurses currently exists. The shortage will continue to become more acute by the year 2010 when the nursing supply will no longer be able to meet the demand, regardless of distribution or educational preparation. Much of the information from the nursing profession on this shortage has focused on the institutional setting and associated working conditions. However, the shortage is impacting all areas of nursing practice. The purpose of this document, developed by the Quad Council of Public Health Nursing Organizations*, is to clarify the effects of the shortage on public health nursing in the United States.

Background:
Public Health Nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences (APHA, 1996). Education to prepare public health nurses occurs primarily in baccalaureate level nursing programs and historically, this role has been carried out only by nurses educated at that level. Nursing education in baccalaureate programs includes content, either integrated throughout the curriculum and/or in a separate Public/Community Health Nursing course, in which students are exposed to public health theory, population-focused practice, and public health nursing roles (Essentials of Baccalaureate Nursing Education for Public/Community Health, ACHNE, 2000)

However, since the 1970’s, the public health nursing workforce has become more differentiated in terms of educational preparation as the result of three interacting trends. First, as budgets were cut, local health departments shifted from providing services centered around home visits to services provided in clinics at the health department site. Second, the availability of reimbursement through Medicare and Medicaid for individual clinical rather than population-based community-focused services led many agencies to change their focus to “capture” these funds as a means of replacing dwindling local, state and federal appropriations. Third, both because many health department leaders did not see the need to hire baccalaureate prepared nurses when services were provided to individuals in the health department setting and because there were not enough nurses prepared at this level to fill positions (especially in rural areas), increasing numbers of associate degree prepared nurses were hired to work in public health agencies. As a result of these trends, only approximately 50% of the public health nursing workforce currently have a baccalaureate or higher degree in nursing.

Because baccalaureate (BSN)-prepared nurses understand the impact of health and disease at the individual clinical level and as well as the impact of health and disease at the population level, there is a need to increase the number of BSN-prepared nurses in the public health nursing workforce. These BSN-prepared nurses are critical members of the public health workforce because they have the skills to address current public health problems, such as the re-emergence of communicable diseases (i.e., tuberculosis) in more virulent forms, the emergence of new infectious diseases (i.e., mad cow disease) and the increasing threat of bioterrorism. For example, “as public health systems eroded, many larger cities replaced public health nurses with community outreach workers, responsible for the follow up of patients with tuberculosis (TB), eliminating the clinical case management model. As the epidemic re-emerged, the decline of TB control programs has severely limited the ability to safely monitor TB patients during their six to twelve months of therapy. In New York City where outreach workers have replaced public health nurses, it has been documented that 89% of patients discharged from hospitals were lost to follow-up and failed to complete therapy. In contrast, in places such as Boston, where a nursing case management model was used in TB control (often with the assistance of community outreach workers), the rates for completion of therapy are frequently above 90% and TB cases are beginning to decrease” (ANA Position Statement: Tuberculosis and Public Health Nursing, 1993.) In many communities, public health nurses are the primary providers of well child care, including immunizations, and preventive health services for pregnant women, school-aged children, and individuals at risk for or experiencing chronic diseases. They also play a key role in linking clients with other health care providers and community resources. Public health nurses are essential to health promotion and disease prevention efforts through educating communities about health risks and strategies for promoting or protecting their own health. In addition, public health nurses provide a critical linkage between families and communities and environmental issues impacting health in areas such as childhood lead poisoning.

In the wake of the 1988 Institute of Medicine’s report, The Future of Public Health, which indicated that public health should focus on the core functions of assessment, assurance and policy development, many state and local health departments eliminated nursing positions in their attempt to move away from a focus on care of individuals. They often did this without determining if these public health nurses were needed in different and perhaps even more central roles related to the core functions. This downsizing was compounded by the nursing shortage which occurred nationwide during the early 1990’s. In addition, increased salaries and additional benefits such as sign-on bonuses and educational leave created incentives which attracted nurses from public health settings into institutional settings.

There are several examples where states have successfully transitioned public health nurses from direct care services to population-focused practice, making significant progress in addressing the overall public health needs of their communities. Washington was perhaps the first state to undertake a comprehensive effort to define the roles of public health nurses related to the core functions of assessment, assurance and policy development and to transition nurses to those roles (Public Health Nursing Within the Core Public Health Functions Model, 1993.) Other states have worked to assist public health nurses to identify activities that they are currently performing which directly relate to the core functions and to enhance or expand those types of activities. Such activities include: using community assessment data to rank local health issues; working to contain viruses, such as hepatitis A, through community education; providing appropriate sex education to both parents and teens; working with communities to reduce tobacco use; and assuring quality of care through statewide monitoring programs (Public Health Nursing: A Partner for Healthy Populations, ANA, 2000.)

Data from the 2000 National Sample Survey of Registered Nurses (conducted by the Health Resources Services Administration, Division of Nursing) indicate that the number of registered nurses (RNs) employed in public/community health settings with the title “public health nurse” has decreased from 39% in 1980 to just 17.6% in 2000. Even in the overall public/community nursing group, there was a decrease of almost 16% between 1996 and 2000. Finally, the aging of the nursing population, which is of concern to the entire profession, is more critical for public health nursing. According to recent data from that survey, the average age of all RNs is 45.2, while for public health nurses it is 49 years. Nurses with a baccalaureate or higher degree represent 50% of all public/community health nurses but only 42% of all RNs. This may be due to the number of states which require a BSN or higher degree for employment in public health nursing. Since public health nurses work in and with communities to promote health and meet population-focused needs, it is even more critical that the public health nursing workforce “mirror” the population it is attempting to serve. Therefore, there is a critical need to prepare a larger and more diverse public health nursing workforce.

Issues Specific to Public Health Nursing:
The impact of a shortage on public health nursing is different in a number of respects from that in other settings. For example, job vacancy rates are not an adequate indicator of the shortage in public health nursing because vacant positions are generally eliminated to cover local or state budget deficits or registered nurse positions are converted to other types of positions. A recent survey of the Association of State and Territorial Directors of Nursing members indicated that 22 of the 36 states responding are experiencing these conversions. In Connecticut, environmental health specialists/sanitarians are in some cases responsible for follow-up of elevated blood lead levels. Their focus on inspection and enforcement, leaves out critical nursing elements related to screening and educating those at high risk, providing clinical follow-up of those with blood lead levels of 10 or higher, and working with schools to assure that children with elevated levels are not inappropriately diagnosed and treated as having attention deficit disorder (ADD). In North Carolina, social workers are being used as case managers for high risk maternity patients and children with special health care needs. While they do an excellent job of connecting these individuals with community resources, they are not able to integrate the clinical status of the client with their social needs: the skill set of nurses..

A better indicator of the shortage in public health nursing is the decreasing numbers of qualified applicants for vacant positions (resulting in agencies hiring people who are not qualified to do the job and trying to provide on the job training or leaving positions open longer and therefore increasing the risk for elimination or transition to one which does not require an RN.). If the essential contributions that nursing can make to the health of a community are to continue, it is critical to have a public health nursing workforce that is educationally prepared at the baccalaureate or higher degree level with a strong knowledge base and skills in public health nursing.

Other factors which are somewhat unique to public health nursing include:
· changes in the structure of baccalaureate nursing curricula which integrated public health concepts throughout the program in a way that resulted in students having no or “observation only” experiences in public health departments and often substituted clinical experiences in home health for more traditional health promotion, population-focused experiences.
· insufficient numbers of faculty in schools of nursing teaching public/community health who have experience working in public health settings or a background in population-focused activities. This is compounded by the shift of Master’s level education toward preparing Nurse Practitioners because of the reimbursement incentives for that type of Master’s prepared RN. Therefore, the role and function of public health/population-focused health is marginalized as a potential career option for students.
· public health nursing and population-focused nursing concepts receive inadequate attention in the nursing curriculum, in part because the faculty at large do not understand these concepts and do not value their inclusion in the curriculum because this content is not tested on the National Council Licensure EXam-RN (the licensure examination for RNs).
· insufficient numbers of baccalaureate and higher degree-prepared PHNs in practice who are willing and able to serve as mentors, preceptors and even role models for interested students and new public health nurses during their first year of employment.
· increasing incidence of violence in the home, school, worksite and community, resulting in situations where there are no other clinical or security staff for either protection or assistance. This contributes to problems in both recruiting and retaining PHN staff;
· employment in a government agency carries with it a complex set of limitations and barriers to creating positions, offering hiring incentives, raising salaries, and sustaining programs even when they are making a difference..These barriers make recruitment and retention of PHNs more difficult and also make it more difficult for faculty who teach public health to find ways to keep their own skills current.

Strategies Which are Critical for Public Health Nursing:
Strategies identified by public health nursing leaders as those having the greatest potential to effect change related to the shortage of public health nurses who are academically prepared for population-focused care include:
° identifying ways to make salaries in public health agencies more competitive with those for nurses with comparable preparation in other settings;
° assuring that all faculty teaching in baccalaureate programs understand the concepts of population-focused care and their importance for the nursing curriculum as a whole;
° improving the benefits package for PHNs, including increased annual leave, employer paid insurance, educational benefits, reimbursement of relocation expenses, etc.
° finding ways to assure that baccalaureate nursing programs, in collaboration with public health agencies, provide students with realistic, positive clinical experiences in public health nursing;
° assuring that faculty who teach public health nursing content and supervise clinical practice for students in this area have current expertise in the field;
° identifying ways of providing greater incentives to PHNs to return to school to pursue a BSN and providing flexible and creative options for accessing baccalaureate nursing education for both initial education and degree completion students
° actively recruiting men and women from traditionally underserved populations into nursing and then public health nursing so that the workforce and service provision more closely matches the needs of the populations served by public health nurses;
° creating rewards and incentives for those who come into public health nursing with a baccalaureate degree or who achieve this educational level while employed, including options for significant career mobility within the practice;
° creating options for PHN employment such as job sharing, home-basing, joint appointments, faculty practice, etc. which are attractive to the population of current PHNs;
° including service in a public health agency as a way to achieve “debt forgiveness” of loans accrued in pursuit of baccalaureate nursing education;
° working with groups that collect data on the nursing and public health workforce to obtain data on retention of public health nurses;
° establishing an internship program in public health nursing to provide for a better transition from education to practice; and
° capitalizing on the autonomy of public health nursing as a way of recruiting young people into nursing and then into public health.

In order to implement the strategies there is a need for increased flexibility and creativity in both education and in the work environment. However, the Quad Council organizations are committed to advancing these strategies in order to meet the health needs of the public by assuring the adequacy and educational preparation of the public health nursing workforce.

* Quad Council of Public Health Nursing Organizations:

· Association of Community Health Nursing Educators
· American Nurses Association, Congress on Nursing Practice and Economics
· American Public Health Association, Public Health Nursing Section
· Association of State and Territorial Directors of Nursing

 

References:
American Nurses Association (ANA). 1993. Position Statement: Tuberculosis and Public Health Nursing. Washington, DC: American Nurses Association.
Association of Community Health Nursing Educators (ACHNE), Task Force on Basic Community Health Nursing Education. 2000. Essentials of Baccalaureate Nursing Education for Public/Community Health. Pensacola, FL: ACHNE.
Association of State and Territorial Directors of Nursing (ASTDN). 2000. Public Health Nursing: A Partner for Healthy Populations. Washington, DC: American Nurses Publishing.
Institute of Medicine. 1988. The Future of Public Health. Washington, DC: National Academy Press.
McNeil, Carol (Ed). 1993. Public Health Nursing Within Core Public Health function – a Progress Report from the Public Health Nursing Directors of Washington. Olympia, WA: Washington State Department of Health.

 

Authors of this document were: Joy Reed and Sharon Moffatt, ASTDN; Marilyn King and Peggy Hickman, ACHNE; Naomi Ervin and Rita Munley Gallagher, ANA; and Colleen Hughes and Phil Grenier, APHA.