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Letter to the Editor

Cornerstone Documents, Milestones, and Policies: Shaping the Direction of Public Health Nursing 1890-1950

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Joan Kub PhD, MA, PHCNS-BC, FAAN
Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN
Doris Glick, PhD, RN

Abstract

The interplay of policy, milestone events, and cornerstone documents was critical in the evolution of the specialty of public health nursing (PHN) from 1890-1950. Using our contemporary lens, this article examines PHN development from an historical perspective, including events and milestones driving growth in the early 20th century. Some of the challenges faced by our founding public health nursing leadership are not unlike challenges we face today. In 1950, Ruth Hubbard, a former leader in the National Organization of Public Health Nurses and Director of the Visiting Nurse Society of Philadelphia, spoke of the value of examining the past to forge a new future. This article calls for contemporary public health nurses to act upon the lessons learned from the past, to strengthen the renewed focus on prevention, to develop policies that impact population health, and to foster a vision that will guide us into the future.

Citation: Kub, J., Kulbok, P., Glick, D., (May 31, 2015) "Cornerstone Documents, Milestones, and Policies: Shaping the Direction of Public Health Nursing 1890-1950" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 2, Manuscript 3.

DOI: 10.3912/OJIN.Vol20No02Man03

Key words: Public Health Nursing, Nursing history,  Public Health History, Prevention, National Organization for Public Health Nurses ,  Lillian Wald, District Nursing, Children’s Bureau, Sheppard-Towner Act, Social Security Act, Hill Burton Act

District nurses not only provided physical care for patients with infectious diseases and acute conditions, but also recognized the importance of economic, environmental, and social circumstances in addressing these issues. Prior to the twentieth century, public health nursing emerged from “district nursing,” a type of nursing focused on care of the sick poor in their homes (Fulmer, 1902). The iconic example of district nursing was the Henry Street Settlement founded by Lillian Wald. District nurses not only provided physical care for patients with infectious diseases and acute conditions, but also recognized the importance of economic, environmental, and social circumstances in addressing these issues (Buhler-Wilkerson, 1985). The aims of the visit were to care for the sick, especially when the patient could not be sent to a hospital; teach the family how to care for the patient; and to protect the public from the spread of disease (Buhler-Wilkerson, 1991).

By the first decade of the twentieth century, however, there was a growing emphasis on preventive care, providing public health nurses the opportunity to further develop and clarify their role in what was being called the public health campaign (Crandall, 1915). The campaign was concerned with advancing public health not only by addressing specific illnesses such as tuberculosis, but also providing public education and social reform (Fitzpatrick, 1975a). Dr. C. E. Winslow, a prominent public health leader at the time, outlined the three phases of the public health campaign as that of environmental sanitation, the bacteriological phase, and the educational phase. With the move to the educational phase, Winslow stated that the nurse had the most important role to play in public health (Fitzpatrick, 1975a).

We have an opportunity to examine the state of public health nursing today at a time when the value and importance of prevention has once again surfaced... Nearly 100 years ago the Rockefeller Foundation sponsored a meeting focused on the desirable education and training needed for the specialty of public health nursing in the United States (Fitzpatrick, 1975a). This subsequently resulted in the Goldmark Report on nursing education (Rockefeller Reports, 1918; Fitzpatrick, 1975a). Similar to the situation in 1918, we are at an important juncture one hundred years later. We have an opportunity to examine the state of public health nursing (PHN) today at a time when the value and importance of prevention has once again surfaced with the Patient Protection Affordable Care Act (ACA) (2010). The provision of clinical preventive services with the goal of improving population health is one of the benefits of the ACA (Fox & Shaw, 2015). In addition, the ACA has promoted the importance of home visiting, something near and dear to the heart of the specialty of PHN (Adirim & Supplee, 2013; Thompson, Clark, Howland, & Mueller, 2011). Ironically, these healthcare changes are occurring at a time of fewer public health nurses in the workforce (AMN Healthcare, 2012).

... the value of turning back the pages and taking a look at the past [is] to set new sights for the future. In 1950, Ruth Hubbard, the president of the National Organization for Public Health Nursing (NOPHN), presented a review of PHN from 1900-1950 (Hubbard, 1950). Hubbard stressed the value of turning back the pages and taking a look at the past to set new sights for the future. The purpose of this article is to revisit the development of PHN and examine it closely using our unique contemporary lens, and to reflect on insights gained during that time, which may have particular relevance to PHN today. Specifically we will 1) describe from an historical perspective the development of PHN as a specialty by examining the interplay of significant milestone events in its development from 1890-1950; 2) describe the cornerstone nursing and healthcare documents affecting the development of PHN during that same period; and, 3) discuss new insights gained and lessons learned from the past as we look to the future. This is part one of a two part series that will address PHN history using cornerstone documents and events. This article addresses 1890-1950 while a second article later in 2015 will address 1951-present.

Events and Milestones Driving the Growth of Public Health Nursing in the Early Twentieth Century

Much is written on the history of PHN in the early twentieth century. The works of Ruth Hubbard (1950), M. Louise Fitzpatrick (1975a), and Karen Buhler-Wilkerson (1985; 1987; 1991), provide us with a rich depiction including landmark events and policies during an era when “…public health nursing came into its own” (Tinkham & Voorhies, 1972, p. 48). The early half of the twentieth century marked considerable growth in the public health system and in PHN. This was a time of growing industrialization and urbanization, infectious disease, and large waves of immigration (Buhler-Wilkerson, 1987). In this section, we provide a description of landmark events and milestones that drove the growth of PHN (see Table 1).

Table 1. Milestone Events, Nursing and Healthcare Documents and Policies

1893

Event - Lillian Wald established the Henry Street Settlement House – began an era of development of district nursing and the role of nurses in the settlement movement; first to use the term “public health nurse.”

1910

Event - Teachers College of Columbia University - offered the first university post-graduate training program for nurses - in Public Health Nursing.

Event - Mary Beard led the district nurses’ training school in Boston - offered an 8-month advanced course.  

1912

Event  - Founding of National Organization for Public Health Nursing - to establish standards, services, and education for the new role of “public health nurse.”

Document - Bill establishing the Children’s Bureau - to address the health of infants and mothers. 

Event - Founding of the Red Cross Public Health Nursing Services.

1913

Book -  A book by Delano and McIsaac (1913) addresses care for the sick in their homes and emphasizes prevention and practical knowledge.

1917

Event - The Committee on Education of the NOPHN began its work in Philadelphia to formulate and maintain a standard for post-graduate PHN education throughout the country.

1918

Document - Goldmark Report - Nursing and Nursing Education in the United State resulted from a meeting sponsored by the Rockefeller Foundation that focused on the state of Public Health Nursing and required education.

1921

Document - Shephard-Towner Act – Provided funds for states to enable establishment of programs for the promotion of welfare and hygiene of mothers and infants.

1923

Event - Public Health Nursing became a section in the American Public Health Association.

1929

Document - NOPHN defined public health nursing as a community service provided by specially prepared graduate nurses to individuals, families, and communities; developed objectives for PHN.

Event - Great Depression began - the most severe and longest lasting economic depression in the industrialized world. Lasted for a decade until the beginning of World War II in Europe.

1933

Document - Federal Emergency Relief Act - a precursor to Social Security, this Act addressed social problems resulting from the depression.

Policy - Civil Works Administration (CWA) established - employed more than 10,000 nurses, primarily in official health agencies.

1935

Document - Public Health Title VI of the Social Security Act of 1935 - strengthened state health organizations and accelerated growth of local health services.

1940

Event - Pearl McIver became the first public health nurse employed by the U. S. Public Health Service.

1941

Event - U.S. entered World War II - Expanded demand for PHN services, in the Army, in factories and in communities.

1946

Document - Hill Burton Act passed Congress (Hospital Survey and Construction Act), enacted health planning and increased hospital construction.

1949

Document - NOPHN position statement on Public health nursing responsibilities in a community health program - outlined three types of responsibility.

Roots of PHN – 1890 to 1920

From the late nineteenth century, home visiting was an important component of PHN in the United States. The tremendous growth of various groups hiring visiting nurses to care for the urban poor, often in overcrowded tenement buildings, grew out of the social context of the era. The home visiting nurse or “district nurse” brought skilled care, resources, training and knowledge to the home environment of the patient (Carr, 1901). The number of philanthropically sponsored groups hiring nurses grew from 104 in 1900 to 565 in 1909 (Buhler-Wilkerson, 1987). The main supporters of home visiting before 1900 were hospitals, visiting nurse associations, and churches--sometimes organized by “lady managers” who privately financed these efforts. With time, boards of health and education took a more active role in sponsorship. By 1910, the role of the nurse had also expanded to include a number of preventive services, originating within voluntary organizations such as visiting nurse societies (Buhler-Wilkerson, 1985).

During this era of district nursing development, the role of nurses in the settlement movement was also moving forward. The most famous was the Henry Street Settlement founded by Lillian Wald in 1893. Ms. Wald was a visionary leader who recognized the need for social reform with an understanding of the relationship of social conditions and overall health. Within eight years from the founding of the Henry Street Settlement, Ms. Wald spoke of accomplishments including 3,991 nurse calls to homes of the sick; 26,600 other nursing visits; 694 individuals treated in the First Aid room; and interventions to address the social needs of the immigrants including housing, the need for playgrounds, and the development of boys’ clubs (Wald, 1902).

Lillian Wald was also active in the establishment of the Children’s Bureau in 1912. In addition to infectious diseases, the problems and challenges in the early part of the twentieth century revolved around the care of infants and mothers. With the exception of New York City and Louisiana, little was done through governmental agencies to promote the health of mothers and children prior to 1912 (Deutsch & Willeford, 1941). In 1914, the Children’s Bureau’s first task was to reduce infant mortality and it went about this by collecting statistics and implementing an educational campaign (Clement, 1998). The Children’s Bureau also focused on the reduction of maternal mortality. The growth of PHN during this time can be seen clearly in Table 2. In 1926, J.G. Townsend, Surgeon General, United States Public Health Service, documented growth in the number of public health nurses from 1890 to 1922, i.e., from 130 to 12,000 nurses (Townsend, 1926) (see Table 2).

Table 2. Number of Public Health Nurses from 1890-1950

Year

Number of PHNs

Source

1890

130

Townsend, 1926

1909

1,413

Townsend, 1926

1912

3,000

Townsend, 1926

1916

6,019

Townsend, 1926

1917

6,568

Townsend, 1926

1918

7,501

Townsend, 1926

1919

8,552

Townsend, 1926

1920

10,100

Townsend, 1926

1921

11,000

Townsend, 1926

1922

12,000

Townsend, 1926

1931

15,915

Deming, 1939

1942

21,123

Census of Nurses in Public Health Work (Heisler, 1946)

1943

20,772

Census of Nurses in Public Health Work (Heisler, 1946)

1944

19,821

Census of Nurses in Public Health Work (Heisler, 1948)

1945

20,818

Census of Nurses in Public Health Work (Heisler, 1948)

1946

20,672

Census of Nurses in Public Health Work (Heisler, 1950)

1947

21,499

Census of Nurses in Public Health Work (Heisler, 1950)

1948

22,605

Census of Nurses in Public Health Work (Heisler, 1950)

1949

23,373

Census of Nurses in Public Health Work (Heisler, 1950)

1950

25,081

Census of Nurses in Public Health Work (Heisler, 1950)

 

A Period of Program Expansion – 1920-1935

The Sheppard-Towner Act... extended services for mothers and children in the rural areas by federal grants-in-aid to states. The Children’s Bureau supported the enactment of The Federal Maternity and Infancy Act, which was also called the Sheppard-Towner Act. The Sheppard-Towner Act, which was in operation from 1921-1929, extended services for mothers and children in the rural areas by federal grants-in-aid to states. The Sheppard-Towner Act also infused the organization of state health departments with the hiring of PHN consultants to provide services to states and the establishment of 2,978 centers for prenatal and child health services (Deutsch & Willeford, 1941; Roberts & Heinrick, 1985). After World War I, the Red Cross Public Health Nursing Service was developed to provide nursing care in rural areas and nursing services in schools and industries also expanded (McNeil, 1972).

During the 1920s, although the need to expand services to rural areas was recognized, financing problems hindered progress on achieving goals. In addition, nurses were not prepared to participate in rural public health programs (Fitzpatrick, 1975a). Red Cross Public Health Nursing Services met the needs of the population the best that they could.

When the Depression occurred, there was an even greater need for effective utilization of the public health nurse (Fitzpatrick, 1975b). Because of fiscal constraints, the number of public health staff and clinics decreased (Kulbok & Glick, 2014). This resulted in questions about establishing priorities, eliminating services, and making hard decisions about which populations most needed services. The American Public Health Association (APHA), Public Health Nursing Section, which was formed in 1923, recommended that bedside care be an integral part of the nursing program and that official agencies provide these services in addition to the voluntary agencies (McNeil, 1972).

A series of federal programs was developed that influenced public health nursing at this time. These included the passage of the Federal Emergency Relief Act (1933) and the creation of the Civil Works Administration (CWA), which employed more than 10,000 nurses primarily in official health agencies. These policies brought relief to the populace through funding for employment programs and provided incentives for public health (Fitzpatrick, 1975b).

Shaping Services to Address Evolving Needs – 1935-1950

Despite rapid program expansion, public health nurses still lacked field experience, training, and supervision. Subsequently, Public Health Title VI of the Social Security Act of 1935 strengthened state health organizations and stimulated the growth of local health services for protection and promotion of the health of the people (Roberts & Heinrick, 1985; Tinkham & Voorhies, 1972). The Social Security Act of 1935 specifically focused on extending services for mothers and children in rural and distressed areas, resulting in a drop in the maternal and infant mortality rates (Deutsch & Willeford, 1941). The maternal mortality rate was 32 percent lower in 1939 compared to 1934 and the infant mortality rate was 20 per cent lower. Public health nursing services were augmented through these efforts (Table 2).

In 1941, Deutsch and Willeford wrote of PHN work to promote maternal and child health at this time. They suggested that the PHN “…pendulum swings far in one direction, only to turn and swing equally far in another” (p. 898). Public health nursing shifted from “care of the sick poor in their homes,” to a focus on “educational aspects of public health,” to a time when governmental programs did not include “actual nursing care to patients,” then to “extending official health services to include some bedside nursing” (p. 899). Deutsch and Willeford (1941) predicted that with the expansion of maternal and child home nursing services “…care to patients in their homes appears to be a definite trend in public health services for the future” (p. 899). Another trend during this period was increasing emphasis on multiple services to meet the needs of the community.

Although this was a time of great upheaval during and post-World War II, it was also an era of rapid scientific and technological advances and social reforms.World War II was another significant event that shaped public health nursing practice. The Executive Director of the Visiting Nurse Association in 1941 described the two competing duties for nurses with a social conscience as that of the Army or the community (Fox, 1941). Augmented services were needed in the community to address new industrial centers that sprung up, industrial nursing, large disasters, and care for rejected draftees. All of these added responsibilities were in addition to services for maternal child focused care as well as sick care within homes or hospitals.

The passage of the Hill Burton Act by Congress in 1946 ushered in an era of hospital construction and growth (Greenberg & Blood, 1990). This Act (Hospital Survey and Construction Act), provided funds for hospitals, for regional and national planning for healthcare, and a new focus on mental health services. This increasing focus on hospitals as the nexus of healthcare in the late 1940s, began an extensive expansion in medical care with increased hospital construction. Tinkham and Voorhies (1972) made an important distinction between the history of nursing and PHN during this period: “Reform took place within the context where nursing was practiced. Institutional nursing was greatly influenced by the hospital with its boundaries and problems, whereas PHN, which was practiced outside of the hospital, was more closely related to the community and the forces affecting society as a whole” (p. 58). Advances in medicine and nursing were applied to improve the care of individuals in institutional settings and for the benefit of families and communities in public health nursing.

The public health nurse was clearly a key player in the public health movement in the early part of the twentieth century and continued to play an important role post World War II when there was a call for increased numbers of nurses to meet the needs of families within the community (Hubbard, 1950). Hubbard stressed that the public health nurses were no longer working alone however but were working alongside many workers in different disciplines at this point. Although this was a time of great upheaval during and post-World War II, it was also an era of rapid scientific and technological advances and social reforms.

Public Health Nursing Leadership: Critical to the Field

Just as these milestone events and policies shaped the specialty of PHN, the nursing profession, and healthcare, cornerstone documents guided the conceptualization of functions and roles of public health nurses during this time. In addition, the growth of PHN was due to extraordinary nursing leadership. This section highlights PHN leadership and the evolving definitions of PHN in the context of nursing and healthcare documents, as well as major events and policies in the early twentieth century.

Early Leaders Define PHN – 1890 to 1920

The leadership of Lillian Wald was widely recognized. It was often reported that Wald was the first to use the term “public health nurse” in 1893 (Buhler-Wilkerson, 1993; Tinkham & Voorhies, 1972; Wales, 1941). Later, Wald described the “enterprise” of public health nursing in the Forward of The Public Health Nurse in Action (Wales, 1941): “Our basic idea … the nurse’s peculiar introduction to the patient and her organic relationship with the neighborhood should constitute the starting point for our universal service to the region. …We planned to utilize, as well as to be implemented by, all agencies and groups ... working for social betterment …Our scheme was to be motivated by a vital sense of the interrelation of all these forces (Wales, 1941, p. xi).

In 1913, the American Red Cross published the first edition of Elementary Hygiene and Home Care of the Sick, which provided valuable lessons about caring for the sick in their homes while emphasizing prevention and practical knowledge. Wald was also instrumental in the founding of the National Organization for Public Health Nursing (NOPHN) in 1912 bringing PHN into a national consciousness (Crandall, 1922). Factors leading to the establishment of the NOPHN were the development of postgraduate training courses in PHN; the Metropolitan Life Insurance Service, which emphasized the need for common standards, records, and methods; and, the need for coordination and training for specialized services (Crandall, 1922). The NOPHN consisted of both nurses and non-nurse members to “set standards, develop services, and establish a sound pattern of education for this new nurse who is now called a public health nurse” (Hubbard, 1950, p. 609).

It is notable that the first university program of study in nursing — PHN — was established in 1910 at Teachers College of Columbia University in New York City. Mary Adelaide Nutting was the chair of nursing and health. Also in 1910, Mary Beard led the district nurses’ training school in Boston, which offered an 8-month advanced course. In 1913, the American Red Cross published the first edition of Elementary Hygiene and Home Care of the Sick, which provided valuable lessons about caring for the sick in their homes while emphasizing prevention and practical knowledge. As demand for public health nurses grew, many universities began offering training programs (Kulbok & Glick, 2014). The NOPHN recognized that “something must be done” to create standard training programs for public health nurses (Stewart, 1950, p. 228). The Committee on Education of the NOPHN began its work in Philadelphia in 1917 to formulate and maintain a standard for post-graduate PHN education throughout the country (Kulbok & Glick, 2014). Public health nursing leaders guided the discipline in establishing standards for curriculum and preparation for nursing practice.

Clarity about defining PHN was at times obscure, not only in the literature, but also among the nurses themselves. Crandall (1922) addressed “… acceptance of the term ‘Public Health Nurse’ a) As a name; b) As a factor, in developing 1, private programmes … such as tuberculosis and child hygiene; 2, programmes directed by governmental agencies; c) As having specific functions namely: 1, follow-up agent, 2, interpreter, 3, scouting agent” (p. 641). Clarity about defining PHN was at times obscure, not only in the literature, but also among the nurses themselves. An article by Durkee (1920) entitled, “Am I a Public Health Nurse?” summarized a conversation including six nurses, each of whom supported their claim that they indeed were public health nurses. These nurses served in different agencies and in a variety of leadership roles: instructor in the Red Cross; superintendent of a visiting nurse association (VNA); a staff nurse of a VNA; a board of health nurse; a hospital superintendent; and a nurse combining laboratory and dispensary work. One common factor in each of these roles was the need to work collaboratively with other agencies and professionals to solve health problems. Tinkham and Voorhies (1972) noted that this collaboration and leadership was “…vividly demonstrated in 1923 when Public Health Nursing became a section in the American Public Health Association” (p. 60).

PHN Definitions During Era of Program Expansion – 1920 to 1935

“Time after time in her written reports … with admirable persistence…” she included this definition of PHN. In 1929, the NOPHN defined PHN as “… organized community service rendered by especially prepared graduate nurses to the individual, the family, and the community. This service includes the interpretation, application and teaching of sanitary, medical and social procedures, to promote health, prevent disease, and correct defects; it may include care of the sick in their homes” (“Definition of Nursing Services,” 1929, as cited in ‘‘The Objectives in Public Health Nursing,’’ 1933, p. 244; The New York Health Commission, 1932). Gregg (1947) attributed this definition to Beard in his address at her memorial service: Mary Beard – The Humanist. “Time after time in her written reports … with admirable persistence…” she included this definition of PHN (1947, p.104). Ms. Beard used this PHN definition as director of the Rockefeller Foundation, which “…spent four and a quarter million dollars for nursing education and public health nursing in not less than 18 countries” (p. 104). In the early twentieth century, there are numerous examples of PHN leaders such as Ms. Beard serving on the Boards of charitable organizations or foundations, something that the discipline strives to do today.

The NOPHN also developed objectives of PHN to guide supervisors, teachers, staff, and students including general objectives and specific objectives for maternity services. The general objectives were assisting in: “educating individuals and families to protect their own health;” “adjustment of family and social conditions that affect health;” “correlating all health and social programs for the welfare of the family and community;” and, “educating the community to develop adequate public health facilities” (“The objective of public health nursing,” 1933 p. 244). The objectives of maternity nursing services addressed medical and nursing supervision prior to, during, and after delivery, and instruction in maternal hygiene and care of the infant (“The objective of public health nursing,” 1933).

Evolving PHN Definitions to Meet Community Needs – 1935 to 1950

Education of public health nurses continued as a major concern in the mid-twentieth century. In 1940, Pearl McIver, the first public health nurse employed by the U.S. Public Health Service (Tinkham & Voorhies, 1972) and Senior Public Health Nursing Consultant, described the need to advance preparation of public health nurses. In her leadership role as senior PHN Consultant, she reported “…the Public Health Service works closely with the Education Committee of the NOPHN and the Collegiate Council on PHN Education.”  These groups saw the need for a “…survey of the present facilities for the preparation of public health nurses and an evaluation of the preparation…” required to participate in public health programs. “At the request of the NOPHN, the Surgeon General agreed to a “…study of public health nursing curricula. This study…should assist the public health nursing schools to meet more effectively the need for better qualified public health nurses” (pp. 998-999).

Trends addressed during the first half of the twentieth century were affirmed by Abrams in an article chronicling the change in the definition of PHN... Trends addressed during the first half of the twentieth century were affirmed by Abrams (2004) in an article chronicling the change in the definition of PHN, from the 1929 definition by NOPHN (and Mary Beard), to a 1949 position statement by the NOPHN Subcommittee on Function, Public health nursing responsibilities in a community health program. The statement outlined three types of responsibility: “The first was nursing care and health guidance for individuals and families across settings, including home, school, work, hospitals, and clinics. The second … involved collaboration with other professionals and citizen groups in the study, planning, and operationalization of community health programs. The third … lay in education for nurses, allied health professions, and community groups” (Abrams, 2004, p. 509).

Abrams argued that the 1949 statement was an expansion of the 1929 definition and also a precursor to the competencies that guided PHN practice in 2004, i.e., Public Health Nursing Competencies (Quad Council of PHN Organizations, 2004). Abrams (2004) pointed to important distinctions in the two definitions. The language in 1949 emphasized “community health,” which involved “…dissemination of medical benefits and scientific advances of the postwar period” to the care of individuals and families; while “public health” was population-based and viewed as the more restrictive term (p. 508). Another change was use of the terms “areas of action” and “responsibility,” as opposed to more subservient language, which described the nurse’s role as “assisting” in provision of services, such as education, to individuals, families, and communities.

The emphasis on community health in the 1949 statement may have set the stage for distinctions between definitions of PHN and community health nursing ... Regardless, during the twentieth century public health nurses were consistent in their connection with individuals and families in the community, collaboration with other agencies and professionals, and focus on health teaching. The emphasis on community health in the 1949 statement may have set the stage for distinctions between definitions of PHN and community health nursing (CHN), which occurred later in the twentieth century, and are still part of the discourse about the PHN specialty today.

Today’s Public Health Issues: Renewed Focus on Prevention

In Hubbard’s 1950 review of PHN, she stressed “To each age comes its own peculiar problems and challenges, but to it also comes the necessary vision and strength” (p. 608). This raises critical questions about how we as a specialty will address the challenges that we face today. It also raises the question of whether we are prepared to create the vision and provide services necessary to confront those challenges. Many health and social problems of today are much like those at the dawn of the twentieth century. Lillian Wald would recognize our extant problems such as immigration and social disparities, and concerns about infectious diseases such as measles and Ebola, which are part of current daily news.

Many health and social problems of today are much like those at the dawn of the twentieth century. Disparities in child health and infant mortality have yet to be fully resolved. In 2012, the infant mortality rate in the U.S. was six per 1,000 and child mortality under age five was seven per 1,000 live births, rates that are among the highest in the developed world (United Nations Human Development Programme, 2014a). Additionally, in 2013 average life expectancy in the U.S. was 78.9 years; over 30 other countries report longer lives (United Nations Development Programme, 2014b). Over a century after Lillian Wald began PHN work in communities, huge challenges remain unresolved.

There is new and growing public recognition that prevention not only improves the health of communities, but also reduces healthcare costs and improves quality of life. The current proliferation of gyms and health clubs, the quest for healthy food, and the attention to protecting the environment are testaments to the growing public interest in enhancing overall health and well-being, rather than waiting to cure illness.

From a policy perspective, President Obama signed the Patient Protection and Affordable Care Act (ACA) (P.L. 111-14) in March 2010. This law ensures more affordable, accessible, and higher quality healthcare for the uninsured and for people who had insurance without adequate coverage and security. It provides benefits for many Americans by specifically providing for immunizations, preventive care, and screenings for infants, children, and women (U.S. House of Representatives, 2010). It requires that breast cancer screening, mammography, and prevention be guided by recommendations of the United States Preventive Service Task Force (U.S. Preventive Service Task Force, 2014).

The ACA emphasizes chronic disease prevention and wellness through support for state and community initiatives for evidence-based interventions to prevent heart attacks, strokes, cancer and other health risks by reducing tobacco use, preventing obesity, and reducing health disparities. At the community level, ACA focuses on health-related factors such as housing, education, transportation, food availability, and workplace and environmental conditions. In addition, the law provides some funding for Public Health Infrastructure and Training. Specifically, it supports: public health infrastructure for improved information technology, workforce training, and policy development; public health workforce training; and, public health capacity for improved epidemiology and laboratory capacity for infectious disease control (U.S. Department of Health and Human Services, 2011).

Shaping the Future of Public Health Nursing: Lessons Learned

... ongoing tensions between curative versus preventive care have existed from the beginning, often leading to controversy. Public health nurses have a renewed opportunity to act upon the lessons from the past in forging a new future. The interplay between policy and events and the shaping of the field of PHN is evident in this historical analysis. First, it is clear from this brief glimpse of our history that the ongoing tensions between curative versus preventive care have existed from the beginning, often leading to controversy. Some believed, for example, that nurses reach people during illness and “so have the best opportunity of forcing home lessons in hygiene and right living that no amount of talking to or teaching under other circumstances could induce them to heed” (Smith, 1902, p. 190).

The public health nursing pendulum does seem to swing far in either direction (Deutsch and Willeford, 1941). Initial developments in PHN were largely concerned with in-home care of patients both sick and poor. Thus bedside nursing became an integral part of the early programs. Later as the importance of the educational aspects of public health was realized, the emphasis changed to such an extent that actual nursing care to patients was “usually not incorporated in governmental programs as they came into existence” (Deutsch & Willeford, 1941, p. 899). This controversy at times has led to various definitions of PHN and discussions of clarifying the question, “Am I a public health nurse?” (Durkee, 1920).

Second, it is clear that PHN has gone through periods of expansion, recession, and consolidation (Roberts & Heinrich, 1985). The interplay of policy and events and the growth or decline of PHN is clearly evident over time, although a specific pattern has not been observed (Heisler, 1950). We are now at a point where there is a shift from the hospital to homes and communities. This presents us with challenges in convincing the public of our important role in the community over time as well as assuring the public that we have skills to address evidenced-based, preventive care. The latter issue raises questions similar to those that public health nurses dealt with in 1910 about adequate preparation of nurses. For example: do today’s public health nurses have the skills to meet one of the key challenges of our times, impacting health behavior in an aged population with chronic illness?

There were diverse agencies and programs in the evolution of PHN. Many of the underpinnings of PHN that evolved during this time period are still challenging today. These include the need for sound financing; engagement of key community members in creating and financing programs; programs based on health and social needs of the community; collaboration with other professionals and agencies to avoid gaps or duplicative services; and, tools such as statistics and records (Tinkham & Voorhies, 1972).

Although many challenges of today are similar to those that our former leaders faced, we also have new challenges, including chronic illness, an aging population, increasing healthcare costs, new and resurging communicable diseases, growing health disparities, and an intensifying call to influence and promote healthy behavior. Our nursing forerunners a century ago were undaunted in the face of poor health and social conditions. They fought disease and ignorance among patients and families in ghettos and among the political and governmental forces of the time. Likewise, today our task is to attempt to alleviate poor health and social conditions in communities, to promote healthy living, and to educate policymakers and the public. Education and advocacy are needed as much as ever, whether the issue is the value of immunizations to protect the health of children, the importance of avoiding tobacco and obesity to prevent chronic diseases, or ongoing advocacy for the most important provisions of the ACA. The work of PHN is a vital link to a healthier future.

[PHN leaders] advocated for policy and developed definitions of PHN that provided the cornerstone documents, milestones, and policies that underpin PHN even today. What can we learn from our PHN leaders and the rich history of our past? We have rich history to draw from. As Hubbard so wisely stated in 1950, the value of examining the past allows us to set our sights on the future (Hubbard, 1950). Early PHN leaders were able to strengthen concepts of prevention, not merely to react, but to be in the vanguard, developing policies to impact population health outcomes and to foster the vision for the specialty that guided it for one hundred years. They advocated for policy and developed definitions of PHN that provided the cornerstone documents, milestones, and policies that underpin PHN even today. They were also in the community forming the partnerships, developing demonstration projects, and providing needed clinical care.

Public health nurses have a very important role to play in coordination of care at this time of healthcare reform. Interventions that encompass all roles at all levels of care (individuals, families, communities) provide evidence of the relevancy of public health nurses to the healthcare system and the populations served. Today we once again need extraordinary leadership to provide vision, to improve population health, and to shape a sustainable future for the specialty of public health nursing.

Authors

Joan Kub PhD, MA, PHCNS, BC, FAAN
Email: jkub1@jhu.edu

Joan Kub is an Associate Professor at the Johns Hopkins University School of Nursing in Baltimore, MD with joint appointments in the JHU School of Medicine and Bloomberg School of Public Health. She coordinates the MSN in PHN track of the MSN program and the MSN/MPH joint degree program at Johns Hopkins. Dr. Kub has served on two revisions of the Public Health Nursing: Scope and Standards of Practice (2007 & 2013). She is currently serving as President of the Association of Community Health Nursing Educators and is a member of the Quad Council of Public Health Nursing Organizations. Dr. Kub is certified by the American Nurses Credentialing Commission (ANCC) as a public health clinical nurse specialist. Her research has been focused on health promotion, behavioral health, and public health nursing interventions with vulnerable populations. Dr. Kub holds a BS in Nursing from South Dakota State University, a MSN in Community Health Nursing from the University of Maryland and PhD from the Bloomberg School of Public Health at Johns Hopkins University.

Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN
Email: pk6c@virginia.edu

Dr. Kulbok is the Theresa A. Thomas Professor of Primary Care Nursing and Professor of Public Health Sciences at the University of Virginia (UVa) in Charlottesville, VA. She is Chair of the Department of Family, Community, and Mental Health Systems and Coordinator of the Public Health Nursing Leadership track of the MSN Program. Dr. Kulbok currently represents the American Nurses Association (ANA) on the Quad Council of Public Health Nursing Organizations. She was Chair of the ANA workgroup to revise the Public Health Nursing: Scope and Standards of Practice (2013). She was principal investigator of an inter-professional, cross-institution, community-based participatory research project funded by the Virginia Foundation for Healthy Youth to design a substance use prevention program in a rural tobacco-growing county. While at UVa, she has co-directed two advanced education nursing (AEN) training grants: the first focused on distance education and leadership in Health Systems Management (HSM) and Public Health Nursing (PHN), the second used distance technology to prepare rural nursing leader in HSM, PHN, and Psychiatric Mental Health. Prior to her appointment at UVa, she was faculty at The Catholic University of America in Washington, D.C. and the University of Illinois at Chicago, where she directed community/public health nursing AEN training grants. She previously served as President-Elect and President of the Association of Community Health Nursing Educators and member and Chair of the Quad Council. She also completed a four-year term on the ANA, Congress of Nursing Practice and Economics. She holds a BS in Nursing and an MSN in Community Health Nursing from Boston College. She earned her doctorate at Boston University and did postdoctoral work in psychiatric epidemiology at Washington University in St. Louis, MO.

Doris Glick,  PhD, RN
Email: dfg6x@virginia.edu

Dr. Glick is an Associate Professor Emeritus of Nursing at University of Virginia (UVa) in Charlottesville, VA. She served as Director of the MSN program from 2002 to 2011 and as founding Director of the DNP program from 2007 to 2011. At the University of Virginia, she was PI of several nurse training grants, including: Nursing Leadership in Rural Health Care for MSN & DNP education for nursing leaders in Public Health Nursing, Health Systems Management, and Psychiatric Mental Health Nursing in rural areas (Division of Nursing, HRSA, 2009): and, Primary Care Nursing Center for Residents of Public Housing> to establish two nursing clinics for low income residents of public housing (Division of Nursing, DHHS, 1993). She was the recipient of the UVA School of Nursing Distinguished Professor Award in 2006, and the Faculty Leadership Award in 2011. >Dr. Glick taught public health nursing at UVa at the BSN, MSN and doctoral levels from 1981 until 2012. Prior to her faculty appointment at UVa, she taught public health nursing at the Pennsylvania State University in State College, PA, and worked as a public health nursing consultant in the State of Florida Health Program Office.

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© 2015 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2015


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