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Letter to the Editor

Cornerstone Documents, Milestones, and Policies: Shaping the Direction of Public Health Nursing 1950-2015

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

Abstract

Ruth Hubbard, a public health nursing (PHN) leader in 1950, offered a timeless comment, “To each age comes its own peculiar problems and challenges, but to it also comes the necessary vision and strength” (p. 608). Similar to the 1950s, from 1950 to 2015 unique healthcare and workforce issues continued to arise calling for public health nurses to respond with vision and strength. In Part Two of a three-part series on PHN history, we examine seminal documents, events, and policies that influenced practice. We begin by considering the time period 1950 to 1975, and then discuss healthcare transitions; social activism and community health planning; and concerns from the years 1975 to 2000 and 2000 to 2015. These milestones reflected challenges of emerging chronic diseases, re-emerging infectious diseases, immigration and terrorism, as well as post-war prosperity and improvements in health care. As in the early 20th century, response to challenges included periods of expansion and recession. We conclude by considering the past as prologue, discussing prospects for present and future PHN.

Citation: Kulbok, P.A., Kub, J., Glick, D.F., (April 18, 2017) "Cornerstone Documents, Milestones, and Policies: Shaping the Direction of Public Health Nursing 1950-2015" OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 2.

DOI: 10.3912/OJIN.Vol22No02PPT57

...unique problems and issues to which public health nurses responded with distinguishing vision and strength characterized the late 20th and early 21st centuries. In the 50th Anniversary Issue of the American Journal of Nursing, a distinguished public health nursing (PHN) leader, Ruth Hubbard, offered a timeless comment, “To each age comes its own peculiar problems and challenges, but to it also comes the necessary vision and strength” (1950, p. 608). Miss Hubbard’s statement guided her article on the history of public health nursing (PHN) in the United States (US). As in Ms. Hubbard’s day, unique problems and issues to which public health nurses responded with distinguishing vision and strength characterized the late 20th and early 21st centuries. The purpose of this article, part two of a three-part series (Kub, Kulbok, & Glick, 2015; Kulbok, Kub, & Glick, 2017) on the history of PHN, is to examine landmark social and political documents, events, and policies from 1950 to 2015 which influenced the environment and context in which public health nurses practice.

Challenges included  an emergence of chronic diseases, re-emergence of infectious diseases, global conflicts, immigration, and terrorism. This was also a time of prosperity and advances in healthcare delivery. In the following sections, we chronicle the landmark documents, events, and policies, and discuss how these shaped the evolution of PHN practice from 1950 to 2015. In part three of this series, we will examine the resultant influence of cornerstone documents and events on the changing definitions and context of PHN practice.

Prosperity, Growth, and Social and Healthcare Upheaval: 1950 to 1975

The 1950s and 1960s were both a time of prosperity and time of radical change. The 1950s and 1960s were both a time of prosperity and time of radical change. By 1950, the majority of states (28) had reached their highest total number of public health nurses up to that time (Heisler, 1950). Seventy-two percent of the counties in the United States (U.S.) were covered by full time public health services in 1955 (U.S. Public Health Service [PHS], 1955; Roberts & Heinrich, 1985). PHN numbers continued to grow, and by 1968, there were 42,541 full time public health nurses representing a 49% increase from 1957 (Roberts & Heinrich, 1985). Another Nurses in Public Health report stated that nurses employed in public health work doubled between 1950 and 1968, with the largest increase in boards of education (Doster, 1970). Table 1 lists landmark documents, events, and policies during this period.

Table 1: Landmark Documents, Events, and Policies: 1950 to 1975

1952

Event - National Organization of Public Health Nursing (NOPHN), National League for Nursing Education, and Association of Collegiate Schools of Nursing disbanded and their functions were spread between American Nurses' Association (ANA) and the new National League for Nursing (NLN).

1952

Document - Original publication, Public Health Nursing, was terminated.

1953

Event - Metropolitan Life Insurance Company stopped public health nurse home visits

1959

Event – New Division of PHN in the Bureau of State Services established.

1963

Policy - Congress enacted Great Society Programs – Community Mental Health Centers Act (P.L. 88-464) provided state mental health programs; delineated consumer roles in decision-making and professionals as advisors in planning.

1964

Policy – Civil Rights Act, Title VI forbids use of federal funds for programs that discriminate based on race, creed or nationality.

1964

Policy – Nurse Training Act for preparation of nurses signed by President Johnson.

1964

Document - Release of first Surgeon General's Report on Smoking and Health.

1965

Policy - Congress created Medicare under Title XVIII of the Social Security Act, to provide health insurance for people age 65 and older, regardless of income or medical history.

1965

Policy - Congress passed Regional Medical Program (P.L. 89-239) to upgrade quality of tertiary healthcare services for major causes of mortality; first used term “Partnership for Health.”

1966

Policy – Congress passed Comprehensive Health Planning (CHP) and Public Health Services amendments (P.L. 89-749), which developed national system for health planning.

1966

Event - The ANA House of Delegates adopted an organizational plan calling for divisions on practice including community health nursing.

1968

Document - Nurses in Public Health, PHS Publication No. 785

1974

Policy - Congress enacted the National Health Planning and Resources Development Act (P.L.93-641) to provide guidance for developing national health planning system.

 
Healthcare Transitions

PHN services were increasing during this period. However, this was also a time of transition marked by elimination of two demonstration projects which had evolved from the vision of Lillian Wald. These were eliminated partially due to an inability to engage with the medical care infrastructure (Reverby, 1993). The Red Cross withdrew its support for rural nursing due to a lack of consistent structure and, in 1953, the Metropolitan Life Insurance Company stopped public health nurse home visits because of limited evidence of cost savings related to health visiting (Buhler-Wilkerson, 1993). The National Organization of Public Health (NOPHN) was also subsumed into the National League of Nursing (NLN) and the original publication Public Health Nursing was terminated in 1952 (Abrams, 2007).

The post-war period was marked by a shift in healthcare priorities. The post-war period was marked by a shift in healthcare priorities. Earlier passage of the Hill Burton Act enabled a boom in construction of new hospitals and a resulting shift in the site of care from home to hospital (Greenberg & Blood, 1990). Consequently, there was growing concern about the shortage of nurses for hospitals and new concerns about nursing education. The National League for Nursing, established in 1952, began implementing the recommendations of the Brown Report, Nursing for the Future, which called for professional education with the inclusion of public health concepts in the basic baccalaureate curriculum (Roberts & Heinrich, 1985).

Passage of the National Mental Health Act, which identified mental illness as a public health problem, led to a growing focus on mental health. Passage of the National Mental Health Act, which identified mental illness as a public health problem, led to a growing focus on mental health. Clarity about the nurse role in mental health, however, was missing and tension existed between a focus on preventive care versus remedial care (Coleman, 1956; Donnelly, Austin, Kettle, Steward, & Verde, 1969). Kneedler, a chief nurse in the North Carolina State Board of Health, presented a paper to the PHN section of the American Public Health Association (APHA) in 1955. She stated that everyone wants a “good mental health program,” but declared that the mental health program must be defined before the role of the public health nurse could be clarified. Ms. Kneedler emphasized the preventive role of the nurse, while other programs were established to provide PHN aftercare services for psychiatric patients (Donnelly et al., 1969; Kneedler, 1955, p. 825).

The 1950s and 1960s were a time of exploring and redefining other roles, including specialized public health nursing consultation (Porter, 1951). For example, during this time, the potential contribution of providing PHN consultation services to occupational health was discussed and evaluated in Wisconsin (Chambers, 1963). A project outlined by Siegel and Bryson (1963) and article by Braun (1965) redefined the public health nurse role in child health supervision, acknowledging that public health nurses had more to contribute within this realm. At the same time, there was an increase in the number of nursing homes and the Montefiore Medical group assumed care in one proprietary nursing home. A public health nurse consultant was hired to assist the nursing home to meet the needs of chronically ill aged patients and to improve medical, nursing, and diversional therapy (Mazer & Silver, 1965). This PHN focus on chronic illness is consistent with the release of the landmark Surgeon General’s Report on Smoking and Health (U.S. Department of Health Education and Welfare [USDHEW], 1964).

One of the more significant health policy changes in the 1960s was the shift to skilled nursing care in the home... One of the more significant health policy changes in the 1960s was the shift to skilled nursing care in the home, which evolved when the Social Security Act was amended in 1965 to include insurance benefits for the elderly (hospital and home nursing) and expanded care (Medicaid) for the indigent. The bill that passed did not include health promotion or preventive care and home care of the sick was limited to treatments prescribed by the physician (Roberts & Heinrich, 1985). As a result, many local and state health departments changed policies to include reimbursable care of the sick and there was a proliferation of proprietary home health agencies (Roberts & Heinrich, 1985). By 1969, there were a total of 2,184 home health agencies certified for participation in the Medicare program and three of five were in official public health agencies (Ryder, Stitt, & Elkin, 1969).

By the 1970s and 1980s, home care was gradually transformed from a public health service to a multifaceted business, with home care services becoming essential for people discharged early from hospitals (Abrams, 2005). In many ways, there was an eventual divergence of reimbursable home health nursing from public health nursing (Lewenson, 2011).

Social Activism and Community Health Planning

The 1960s and 1970s were also marked by... an awareness of the impact of what is now known as “social determinants of health.” The 1960s and 1970s were also marked by a push toward social activism with an awareness of the impact of what is now known as “social determinants of health.” Lester Breslow, in his 1970 presidential address to the American Public Health Association, talked about racism, poverty, degradation of the environment and other blights, which were injuring health (Breslow, 1970).

Actually, the health crisis does manifest itself in many ways: a breakdown of the healthcare delivery system; smog enveloping the cities; chemical as well as enteric sewage polluting the streams; high mortality from lung cancer, coronary heart disease, chronic respiratory disease, and alcoholism; severe discrepancy in health between the poor and the affluent living in the same cities. The health crisis is no longer just threatening us; it is engulfing us. The problem is not how to ward it off but how to climb out of it (Breslow, 1970, p. 10-11).

This was a time of a “war on poverty” and a time to end hunger among the poor. It was a time of civil rights reform. Breslow stressed the need for involvement by public health professionals in these movements.

The 1960s and 1970s also emphasized involvement of the community... in health planning. The 1960s and 1970s also emphasized involvement of the community, including consumers, professionals, and the public private sectors in health planning (Arnold, 1969; Van Sickle, 1970). In 1966, Congress passed the Comprehensive Health Planning (CHP) and Public Health Services Amendments (PL 89-749), which developed a national system for health planning. In 1974, Congress enacted the National Health Planning and Resources Development Act (PL 93-641), which resulted in the development of Health Systems Agencies (HAS) for purposes of bringing order and coordination to a “fragmented non-system of American health care” (Vladeck, 1977, p. 23). This transformed view of public health was significant. It emphasized the involvement of the “community” in health planning and implementing healthcare programs. This concept of community included consumers, health professionals, public and private sector workers as partners seeking solutions and improvements for the delivery of healthcare (Robischon, 1971).

With the changing healthcare environment and growing emphasis on community involvement in health planning and delivery for all people, there was a subsequent push to expand roles for nurses in illness prevention (e.g., contraception, genetic influences, human behavior, injuries) and health maintenance. This development of new roles included nurse practitioners (Scott, 1974; U.S. Department of Health, Education, and Welfare [USDHEW], 1976). At the same time, with steady growth in hospitals and expanded reimbursement for illness care through Medicare and Medicaid, there was an increased need for nurses in hospitals and community-based home healthcare.

Many nurses practicing in the community setting did not have public health preparation. Many nurses practicing in the community setting did not have public health preparation. The ANA established the Division of Community Health Nursing. With these developments and discussions, use of the term community nurse specialist evolved (Van Sickle, 1970). These changes in the concepts of public health and in patterns of change in delivery of services were reflected in public health nursing education and in the definition of community health nursing specialty practice. (See part three of this series, Cornerstone Documents and Milestones: The Changing Landscape of Public Health Nursing 1950 – 2015 [Kulbok et al., 2017] for discussion of evolving definitions of public and community health nursing.)

Public Health Concerns: 1975 to 2000

Conflicting PHN Roles
By 2000, public and community health nurses were the second largest group of RNs. As noted, the number of public health nurses in the United States continued to rise into the late-twentieth century. By 2000, public and community health nurses were the second largest group of RNs. Of employed RNs, 18.2% worked in public and community health settings, including state or local health departments, community-based home health agencies, various types of community health centers, student health services, and occupational health services (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2000). However, the number of RNs with the official title of “public health nurse” decreased during this period from 1.7% in 1980 (U.S. Department of Health and Human Services [USDHHS], 1982) to 1.3% in 2000, a significant decline that raised much concern among PHN leaders (Spratley et al., 2000). The Association of State and Territorial Health Officials (ASTHO, 2005; as cited in the Quad Council, 2007) reported that the number of “public health nurses” decreased by more than half, from 39% of the public health workforce in 1980 to 17.6% in 2000.

Healthcare Financing
The 1980s brought major changes to the overall healthcare system, and to public health, that Roberts and Heinrich (1985) could not have imagined when they chronicled the history of PHN up to the early 1980s. From the time Medicare was implemented until 1983, hospitals were reimbursed for reasonable costs of care based on services provided. This payment arrangement led to an over use of hospital services and dramatically escalated costs of care. Growing cost of care was even more inflated for Medicare patients, covering an older population projected to grow in coming decades (Davis & Rhodes, 1988). Meanwhile home nursing services for chronically ill patients were provided by nurses working in communities, either through home health agencies or public health departments. Table 2 lists landmark documents, events, and policies between 1975 and 2000 .

Table 2: Landmark Events, Documents, and Policies: 1975 to 2000

1974

Document - A New Perspective on the Health of Canadians .

1976

Document – U.S. DHEW, The Forward Plan for Health.

1976

Event – First outbreak of Legionnaire’s disease.

1977

Event - Worldwide eradication of smallpox, led by the U.S. Public Health Service.

1977

Event - The Health Care Financing Administration (HCFA) was created to manage Medicare and Medicaid separately from Social Security Administration.

1979

Document – U.S. DHEW, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.

1981

Event - Identification of AIDS.

1983

Policy – Social Security Amendments (Public Law [PL] 98-21) established prospective payment system for hospitals based on diagnostic categories (Diagnostic Related Group [DRG]).

1988

Document - Institute of Medicine (IOM), The Future of Public Health.

1991

Policy – Special Projects Grant Program of Public Health Services Act expanded.

1990

Document – U.S. DHHS, Healthy People 2000: National Health Promotion and Disease Prevention Objectives

1993

Policy - President Clinton initiated the Health Security Act to provide for healthcare reform and planning centered on population needs.

1997

Policy – The Balanced Budget Act

2000

Document – U.S. DHHS, Healthy People 2010.

... it became apparent that patients were being discharged into communities with more severe illnesses and increased need for skilled nursing care. In 1983, in an attempt to control healthcare costs, Congress passed amendments to the Social Security Act (Public Law [PL] 98-21) that established a prospective payment system (PPS) for hospitals in which payment would be based on diagnostic categories. These diagnostic related groups (DRGs) were initially developed as a hospital management tool based on medical diagnosis. When Congress enacted the 1983 changes to the Social Security Act, the DRG classifications were used as the basis for the new prospective payment system (Quinn, 2014). The rationale for this new reimbursement system was to establish incentives for cost containment. Medicare rates were now fixed in advance so that hospitals could only make a profit if cost of care was less than the prospective payment rate for a patient medical diagnosis (Davis & Rhodes, 1988). The incentive for hospitals was to provide the least amount of care possible and to discharge patients as quickly as possible. As a result, the growth of Medicare spending greatly slowed and soon thereafter hospitals reported record profits (Quinn, 2014). From a public health perspective, it became apparent that patients were being discharged into communities with more severe illnesses and increased need for skilled nursing care. Nurses working in home health and public health agencies quickly experienced the stress of increasing numbers of patients in their homes who were much more ill than previously so.

By the late 1980s, researchers began to document the impact of these changes on public and community health services. Among the first to study the impact of prospective payment were Wood and Estes (1990) who collected data from 771 community service providers in 1986 and 1987. Respondents represented a range of community health services providing care to post-hospital discharge seniors. Results documented a change toward sicker clients requiring more acute care, which impacted the types of services provided and increased the difficulty in referring clients both to hospitals and to other community service providers (Wood & Estes, 1990).

A research study specific to PHN examined the impact of DRGs on types of discharges from a community hospital to a public health department from 1983 to 1986 (Phillips, MacMillan-Scattergood, Fisher, & Baglioni, 1988). Researchers used a retrospective record review of patients discharged from the hospital to the public health department during the first three years of DRGs and compared findings with the year immediately prior to DRG implementation. Findings revealed an increase in the number of patients referred to the health department who required more home visits for acute care. This trend reached a peak at about 18 months following the implementation of DRGs, and then began to taper off as the healthcare system adjusted to the new fiscal realities (Phillips et al., 1988). These studies are examples of the impact of changing reimbursement systems on community health resources and the changing nature of public health nursing and community health nursing across the country.

...public health agencies were left with patients with chronic health problems not eligible for Medicare reimbursement. In the 1980s, at the onset of prospective payment for hospitals, home health agencies continued to receive reimbursement for services provided and growth in home health was anticipated (Coleman & Smith, 1984). Concurrent with the trend to quickly discharge patients who were more ill, growth in private home care agencies began to spiral. These for-profit agencies were eager to provide reimbursable skilled nursing services to the most acutely ill patients discharged from hospitals. As a result, public health agencies were left with patients with chronic health problems not eligible for Medicare reimbursement.

By the 1990s, costs for home health services were growing at an unsustainable rate. By the 1990s, costs for home health services were growing at an unsustainable rate. Medicare spending for home health had more than tripled in the early to mid-1990s, while the number of patients being served had doubled. Studies were able to document widespread fraud, waste, and abuse. In 1997, Congress passed The Balanced Budget Act (Public Law 105-33), amended in 1999, which called for the development and implementation of PPS for Medicare home health services. Effective October 1, 2000, the home health PPS replaced the prior cost based reimbursement system for home care of Medicare and Medicaid patients in the community (USDHHS, 1999). Because healthcare funding had become more focused on acute care services, by the end of the twentieth century many public health departments had stopped providing PHN home visiting for care of the sick. By this time, continuing the trend that began in the 1960s, nurses doing home visits worked for agencies that provided sick care in the community and these nurses were no longer counted among the public health nursing workforce.

Healthy People
At the same time that hospital services were expanding in 1970s, the U.S. Public Health Service (PHS) recognized the need to address major health issues including controlling healthcare costs, developing knowledge for disease and illness prevention, improving the delivery of healthcare, and assuring quality of healthcare (USDHEW, 1976). To address these issues the PHS developed a series of three documents titled, The Forward Plan for Health, published from 1974 to 1976. The main goal of the PHS was to improve the health of Americans; major strategies were to increase the use of preventive services and reduce the need for acute medical care. The United States was not alone in its focus on improvements in healthcare and the health status of the population; the Canadian government also published a landmark document, A New Perspective on the Health of Canadians (LaLonde, 1974).

Fundamental ideas in these landmark documents related to determinants of health were consistent with an emerging era of social ecology and descriptions of social determinants of health. During this era, many health professionals came to believe that individuals were in a position to “produce health” (Kulbok & Botchwey, 2015, p. 379). LaLonde (1974) had introduced similar ideas and proposed four determinants of health: human biology, environment, lifestyle, and healthcare. At the same time, health policymakers in the U.S. supported efforts to promote personal healthy habits and address environmental factors as the best approaches to achieve increased longevity and improved health status (USDHEW, 1976). Fundamental ideas in these landmark documents related to determinants of health were consistent with an emerging era of social ecology and descriptions of social determinants of health (Kulbok & Botchwey, 2015).

Following publication of these documents, a national health initiative was launched in the United States, Healthy People, to determine health goals and priorities and “…develop and monitor health promotion and disease prevention objectives” (Brown, 2009, p. 3). The first Healthy People document was, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (USDHHS, 1979). The second document, Promoting Health/Preventing Disease: Objectives for the Nation (USDHHS, 1980), included 226 health-related objectives. These objectives were monitored for progress, which was regularly reported in Public Health Reports. Subsequently, Healthy People 2000 (USDHHS, 1990) with 319 objectives grouped into 22 priority areas, Healthy People 2010 (USDHHS, 2000) with 467 objectives in 28 focus areas, and Healthy People 2020 (USDHHS, 2010a), with over 1,200 objectives in 42 public health topic areas, were published. The Healthy People objectives continue to provide a roadmap for U.S. public health activities (Brown, 2009).

Infectious Diseases
In 1977, the world celebrated the final eradication of smallpox. With that success, two decades of widespread use of antibiotics, and advances in understanding the etiology of diseases, some public health leaders began to refer to the “second epidemiological revolution” (Terris, 1983). The implication of this term was that infectious diseases were under control and public health efforts could now focus on control of chronic diseases. This optimism was not entirely unjustified. From 1900 to 1980, the death rate in the United States from infectious diseases had declined significantly from 797 deaths per 100,000 to 36 deaths per 100,000.

During the final decades of the twentieth century, new infectious diseases began to emerge. Unfortunately, this optimism was short lived. By 1996, infectious disease mortality had increased to 59 per 100,000 (Armstrong, Conn, & Pinner, 1999). During the final decades of the twentieth century, new infectious diseases began to emerge. One of the first was the 1976 outbreak of Legionnaire’s disease at a hotel in Philadelphia. Then in 1981, the first cases of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) began to attract the attention of public health. While other new diseases such as Hanta virus emerged, by the end of the twentieth century, HIV/AIDS had become the focus of major public health efforts to control infectious diseases.

PHN Workforce
...by the end of the twentieth century, PHN services continued to dwindle, PHN home visits were mostly non-existent, and the PHN workforce continued to shrink. In an effort to strengthen the nursing workforce, the Special Projects Grant Program, part of the Public Health Service Act of 1964, was expanded in 1991 to support this program and to help achieve the goals for Healthy People 2000. Special project grants supported innovative and creative projects to improve nursing knowledge and skills, enhance their effectiveness, and reduce vacancies and turnover of nursing positions (Lenihan, 1993). Priorities for these grants during the 1990s and beyond supported PHN education and practice. These projects provided nursing students with unique opportunities to learn to provide public health services for underserved populations in community settings. Despite this funding effort, by the end of the twentieth century, PHN services continued to dwindle, PHN home visits were mostly non-existent, and the PHN workforce continued to shrink (Quad Council, 2007; Robertson, 2004).

While confronting the realities of a declining workforce, in 1993 the PHN specialty celebrated the achievements of its first 100 years and looked toward future opportunities. Marla Salmon discussed the roles of public health nurses at the completion of the first 100 years and the beginning of much anticipated national health reform (Salmon, 1993). Salmon talked about the need to view strengths of public health nurses, which included flexibility, ability to reach the public, health expertise from a generalist perspective, and cost effectiveness. During this period, the Institute of Medicine (IOM) authored several key public health documents, including The Future of Public Health, which gave rise to the development of core competencies of public health (i.e., assessment, assurance, and policy) (IOM, 1988). During the 1990s, public health was being redefined and there was a push for new healthcare delivery systems with movement toward managed care and population managed care approaches. A paradigm shift resulted within the public health system, demanding new roles for public health nurses (Gebbie & Hwang, 2000; Graff, Bensussen-Walls, Cody, & Williamson, 1995; Shamansky, 1995). Unfortunately, changes in the public health infrastructure, the move of clinical services to managed care, and the ensuing lack of funding sources, often resulted in elimination of PHN positions (Quad Council, 2007; Robertson, 2004).

Threats and Opportunities: 2000 to 2015

The need for public health nurses and a strong public health infrastructure to meet challenges and opportunities of the twenty-first century seems greater than ever. The early twenty-first century posed a series of threats, as well as opportunities, for public health and public health nursing. Threats included the changing healthcare system, bioterrorism, climate change, economic recession, and emerging infectious disease. Opportunities included the Patient Protection Affordable Care Act (ACA) (PL 111-148, 2010), the National Prevention Strategy (National Prevention Council, 2011), and, the Robert Wood Johnson Foundation (RWJF) Forum on the Future of PHN (2012) and Building a Culture of Health initiative (Lavizzo-Mourey, 2014). The need for public health nurses and a strong public health infrastructure to meet challenges and opportunities of the twenty-first century seems greater than ever (Bekemeier, Zahner, Kulbok, Merrill, & Kub, 2016), yet nurses and other public health officials continually “…fight to keep their services from the budgetary chopping block” (Trossman, 2003, p. 1). These battles for public health funding are timeless and mired in socio-economic and political controversy at the local, state, and national levels. Table 3 provides landmark events, documents, and policies between 2000 and 2015.

Threats
As previously indicated, the number of public and community health nurses in the United States increased through 2000. However, in the early twenty-first century this trend reversed and public and community health nurses including nurses in school health, occupational health, and home health showed a marked decline from 18.2% of the employed RN population in 2000 (USDHHS, 1982) to 14.1% in 2008 (USDHHS, 2010b). The National Sample Survey of Registered Nurses was discontinued after 2008, making it difficult to accurately estimate the number of public health nurses nationally, particularly when defined broadly. However, one study of public health nurses supported by RWJF and conducted by the University of Michigan Center of Excellence in Public Health Workforce Studies (2013) reported on all RNs working in state and local health departments (HDs). This enumeration study estimated that 34,521 fulltime public health nurses were working in state and local HDs in 2012. While it is difficult to make exact comparisons, this number is considerably lower than the 42,541 fulltime public health nurses reported to be employed in 1968 (Roberts & Heinrich, 1985).

Table 3: Landmark Events, Documents, and Policies: 2000 to 2015

2001

Event – September 11th terrorist attacks.

2001

Event - DHHS responds to delivery of anthrax through mail in nation’s first bioterrorism attack.

2003

Document - IOM, Who will keep the public healthy?

2010

Document – Healthy People 2020

2010

Policy - Patient Protection Affordable Care Act (ACA); provided comprehensive U.S. health insurance reforms.

2011

Policy – Executive Order 13544-- Establishing the National Prevention, Health Promotion, and Public Health Council

2012

Event – RWJF Forum on the Future of PHN

2014

Policy – RWJF Building a Culture of Health Initiative

2013

Document – University of Michigan Center of Excellence in Public Health Workforce Studies, Enumeration and Characterization of the Public Health Nurse Workforce: Findings of the 2012 Public Health Nurse Workforce Surveys.

2013

Event – Quad Council Invitational Forum on the Future of PHN

2014

Document – Quad Council Invitational Forum on the Role and Future of Nurses in Public Health: Final Report

2014

Document - 12th Annual Report to Congress by the National Advisory Council on Nurse Education and Practice (NACNEP): Public Health Nursing: Key to the Nation’s Health.

2016

Policy – APHA created the Generation Public Health Initiative

2016

Document - 14th Annual Report to Congress by the National Advisory Council on Nurse Education and Practice (NACNEP): Preparing Nurses for New Roles in Population Health Management

Threats once considered uncommon are now part of every public health nurse’s lexicon. Threats once considered uncommon are now part of every public health nurse’s lexicon. Contemporary PHN textbooks have a chapter on disaster management or emergency preparedness. Disasters and emergencies may be natural or human-made; hurricanes and tornadoes are examples of the former and mass shootings, climate change, and oil-spills of the latter. September 11, 2001 is etched into the memory of most U.S. citizens. Since that fateful day, America has experienced subsequent anthrax-laced mailings and devastating Hurricanes Katrina and Rita in the Gulf Coast region, yet there was a national complacency about public health preparedness (Trust for America’s Health [TFAH], 2008).

Federal funding was distributed for hospital and public health preparedness to train and mobilize nurses for disaster and emergency preparedness and response. However, a recent study found significant “…individual, organizational, and environmental barriers” to preparing a “…national nursing workforce with the knowledge, skills, and abilities to respond to disasters and public health emergencies in a timely and effective manner” (Veenema et al., 2016, p. 191). Advanced public health nurses can fill the gap in leadership, working with public health colleagues, to train nursing and healthcare workers in disaster and emergency preparedness.

Opportunities
During the first two decades of the twenty-first century, there was increased emphasis on prevention and population health from multiple public and private sectors. During the first two decades of the twenty-first century, there was increased emphasis on prevention and population health from multiple public and private sectors. However, the major policy of this period was the Affordable Care Act (ACA) (2010). Events that led to passage of the ACA were extremely political. Initial ACA legislation was defeated in both the Senate and the House. However in March 2010, Senate Democrats used the budget reconciliation process to get the bill approved by the House and the Senate. The budget reconciliation bill achieved the required 51 Senate votes in favor, to allow it to move forward for the President’s signature. The House approved the Senate version of this new healthcare plan by a vote of 219-212. On March 23, 2010, President Barack Obama signed the ACA into law.

The ACA has multiple provisions, including expanded health insurance coverage, health coverage for people with pre-existing conditions, and coverage of preventive services recommended by the U.S. Preventive Services Taskforce and the Centers for Disease Control and Prevention (CDC) without a co-payment. At the end of 2015, the number of non-elderly uninsured Americans was 28.5 million. This represents a decline from 16.6% in 2013 to 10.5% in 2015. This was the lowest rate of non-elderly uninsured in decades (The Kaiser Family Foundation, 2016).

Following the ACA legislation in June 2010, President Obama established his national prevention council with Executive Order 13544-- Establishing the National Prevention, Health Promotion, and Public Health Council. (National Prevention Council, 2011). The national prevention strategy “…envisions a prevention-oriented society where all sectors recognize the value of health for individuals, families, and society and work together to achieve better health for Americans” (National Prevention Council, 2011, p. 7.).

Seemingly following the President’s lead, foundations and national organizations proposed policies consistent with the national prevention strategy. For example, in 2014 the President and CEO of the RWJF, Risa Lavizzo-Mourey, described a new initiative, Building a Culture of Health, with the goal of healthier lives for all Americans. In addition, APHA recognized that where you live, your education, income, race and access to healthcare “…mean as much as a 15-year difference in how long you will live … even wealthy, highly educated Americans with access to quality care suffer a health disadvantage to peers in other high-income countries” (APHA, 2017). Therefore, APHA created Generation Public Health, “…a national movement of people, communities and organizations working to ensure conditions where everyone has the opportunity to be healthy” (APHA, 2017). The APHA goal is to create the healthiest nation in a generation.

These collective opportunities set the stage for a resurgence of public health nursing at the basic and advanced levels. This resurgence was also evident in two reports sent to Congress, in 2014 and 2016 respectively, by the National Advisory Council on Nurse Education and Practice (NACNEP). The NACNEP advises the Secretary of the U.S. Department of Health and Human Services and the U.S. Congress about policy issues related to the Title VIII programs administered by the HRSA, Bureau of Health Workforce, Division of Nursing.

The 12th annual NACNEP (n.d.) report was titled Public Health Nursing: Key to the Nation’s Health. Recommendations of this report included:

  1. Provide an increase in the resources and opportunities solely aimed at the education, training, and workforce development of public health nurses;
  2. Convene a summit of key public health organizations, foundations, and schools of nursing to delineate the required leadership, and professional development required to advance the field of public health nursing;
  3. Identify and remedy the gaps in the cost effectiveness of public health nursing; and
  4. Provide opportunities to advance public health practice and research.

The 14th annual NACNEP (2016) report was titled Preparing Nurses for New Roles in Population Health Management. Recommendations of this report included:

  1. Coordinate undergraduate nursing education and expand access to a variety of clinical opportunities in rural areas;
  2. Provide funding for a comprehensive public health infrastructure in underserved areas including access to health information;
  3. Provide funding opportunities that integrate population health competencies into curricular innovations across all nursing educational levels;
  4. Provide grants for students from underrepresented backgrounds and for minority-serving schools of nursing to prepare the nursing workforce for practice in underserved communities with diverse populations;
  5. Invest in the population health science infrastructure and training, and fund research on population health management, measures and metrics; and,
  6. Convene a federal working group to address population health. It is notable that the 14th NACNEP report on population health did not refer to preparation of public health nurses specifically.

However, it is clear that the recommendations highlighted public health and complemented the 12th NACNEP report, which focused on preparing nurses to promote the nation’s health.

Past as Prologue: Prospects for Present and Future PHN

In the conclusion to a book chapter on the History of Public Health and Public Health Nursing, a contemporary PHN leader, Dr. Betty Bekemeier, stated:

The potential exists for public health nurses to capitalize on the respect with which they are held in their communities and the knowledge and skills they have in understanding populations, to reinvigorate the spirits of our foremothers, and to boldly act on social structures to seek justice and eliminate socially constructed inequities in health (2008, p. 22).

This assertion holds true today. Modern public health nurses are forward-looking and uniquely positioned with knowledge, skills, and an understanding of the impact of social determinants on health. These nurses are set to improve health through community- and population-level health promotion and disease prevention (Kulbok et al., 2017).

Modern public health nurses are forward-looking and uniquely positioned with knowledge, skills, and an understanding of the impact of social determinants on health. Evidence from this historical review suggests that public health nurses have been confronted with significant challenges from 1950 to the present. These challenges were apparent in important documents, events, and policies of the late twentieth and early twenty-first centuries. Similar to the early twentieth century, in response to many challenges the specialty of PHN has experienced periods of expansion, recession, and consolidation (Roberts & Heinrich, 1985). It was also evident that PHNs have adapted to changing times and roles, manifested by competing values and longstanding tensions between sick care and prevention, or between the drive for profit and social justice. Whether public health nurses will prosper in the present and in future decades, may ultimately depend on their ability to capitalize on mutually respectful relationships with communities and populations and on their determination to act boldly to secure healthcare access, social justice, and health equity for all.

Authors

Pamela A. Kulbok, DNSc, RN, APHN-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 a recipient of the 2016 Ruth B. Freeman Distinguished Career Award from the APHA Public Health Nursing Section. She coordinated the Public Health Nursing Leadership track of the MSN Program at UVa from 1994 to 2017 and co-directed two advanced education nursing (AEN) training grants: one using distance education to prepare leaders in Health Systems Management (HSM) and Public Health Nursing (PHN); the other using distance technology to prepare rural nursing leaders in HSM, PHN, and Psychiatric Mental Health. She was Chair of the ANA workgroup to revise the Public Health Nursing: Scope and Standards of Practice (2013). Her current research is focused on sustainable wellness and health behavior transitions from adolescence to adulthood. 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 holds a BS in Nursing and an MSN in Community Health Nursing from Boston College; earned her doctorate at Boston University; and, did postdoctoral work in psychiatric epidemiology at Washington University in St. Louis, MO.

Joan Kub, PhD, RN, PHCNS-BC, FAAN
Email: kub@usc.edu

Joan Kub is an Adjunct Professor at the University of Southern California. Her research focuses on health promotion, behavioral health, and public health nursing interventions with vulnerable populations. Dr. Kub served on two revisions of the Public Health Nursing: Scope and Standards of Practice (2007 & 2013). She previously served as President-Elect and President of the Association of Community Health Nursing Educators and currently serves as Chair of the Quad Council Coalition of Public Health Nursing Organizations. Dr. Kub is certified by the American Nurses Credentialing Commission (ANCC) as a public health clinical nurse specialist. 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. Prior to her faculty appointment at USC, Dr Kub taught public health nursing at Johns Hopkins University (1985-2017) coordinating the MSN/MPH joint degree program and undergraduate public health nursing at the University of Maryland (1976-1982).

Doris F. 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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© 2017 OJIN: The Online Journal of Issues in Nursing
Article published April 18, 2017


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