Public Health Nursing
Working with the community toward a higher quality of life
When Lillian Wald, the first public health nurse, organized the Henry Street Settlement and later the Visiting Nurse Service of New York, she worked from one principle: The health of the community affects the health of the individual. That understanding still informs today’s nurses.
Then, as now, there was an overlap between public health, home health and parish nursing. All are community nursing, yet each is a distinct practice. The thrust in public health is on prevention rather than cure; the target is the population, not an individual. Public health nurses work in multiple settings and often have direct contact with patients. Much of their work, however, is through outreach programs for healthy people.
Communicable disease is always a concern, but so are substance abuse, teen pregnancy and elder abuse — along with environmental health issues. Public health nurses study the epidemiology of preventable chronic diseases such as diabetes and obesity and develop plans to combat these killers within a specific community. Increasingly, planning for bioterrorism and pandemics is part of the job; so is working with the Red Cross on disaster relief.
Education plays a huge role. Think of the hand washing signs in restaurant bathrooms and immunization campaigns at the start of the school year. In each you see the vigilance of the public health establishment. It is not a highly technical field. Instead, this specialty calls for the ability to work collaboratively while acting independently. Autonomy in nursing practice is a hallmark rather than the carrying out of delegated medical orders.
Crossing the County Line
Sharon Trucker, RN, MS, of the Los Angeles County Department of Public Health tells us more. As a nurse recruiter with 29 years of experience in this practice area, she knows what work for the health department involves. Organized around 13 field offices and satellites, the county unit has multiple clinics and employs about 500 registered nurses, of which 400 are PHNs. About 20 percent are prepared at the master’s degree level, but as many as 50 percent of new hires are new graduates. Non-PHNs form a distinct category and may work in the clinics under the supervision of a public health nurse.
Working for a county public health department means endless variety. Locally the department assigns nurses in two ways: by district based on census tracts or by program. A nurse assigned to a district has a multifaceted role in that he will do communicable disease tracking within a certain area but may also work with community coalitions to improve neighborhood health. Organizing for safer school crossings or increasing public awareness of the need for exercise would all be part of the assignment. It is a field full of surprises, Ms. Trucker said as she recalled being a new nurse and finding out it was time to do the yearly surveillance of clients in her area that had Hansen’s disease. Here, in Los Angeles? Yes, and a typhoid carrier, too!
The department also places nurses according to programs such as tuberculosis control or sexually transmitted diseases. A division of children’s services oversees the care of clients under the age of 21 who have significant medical problems. Nurses within specific programs might provide in-service, statistical analysis and interpretation of state and federal rulings.
Away from the county you can find specialty PHNs staffing a clinic on an Indian reservation, working as researchers at the Centers for Disease Control and Prevention, traveling with a hospital ship or teaching in a university.
The educational preparation is straightforward. Cynthia Johnson, RN, Ed.D., teaches at California State University, Dominguez Hills, and oversees the PHN certificate program. Ms. Johnson explains that, in California, to practice requires graduation from an accredited school of nursing, a bachelor’s degree and a certificate in public health issued through the Board of Registered Nursing. Usually nurses become eligible through study for the BSN because the course includes a full semester of community health work.
However, there is another way. At CSUDH through a distance learning arrangement that uses preceptors for individual nurses at multiple sites, candidates can earn a certificate in public health even if they did not graduate with a baccalaureate in nursing. Several other schools in California offer BRN-approved programs leading to certificate eligibility.
According to Ms. Johnson, a typical student is a registered nurse with an associate degree who has earned a baccalaureate in a subject other than nursing. By taking a series of 11 courses that includes work in statistics, research, multicultural concepts and healthcare finance, the nurse can apply for the PHN certificate. Graduates of foreign schools of nursing, while they may have a BSN, often lack critical components of community nursing and they too can apply after completing the required course work.
Analysis of individual transcripts is critical because the school will waive some requisites if the student met them in working for another degree. In addition, because California has such a hefty list of demands, CSUDH encourages interested applicants to pursue a master’s degree at the same time. Much of the course work overlaps and in Ms. Johnson’s words, “the school is very generous in the time allowed to complete the work.”
She also points out that the nursing shortage severely affects public health nursing, The nature of the job means limited visibility — most people rarely encounter a public health nurse and many clients are out of the mainstream.
The state board’s mandate of a baccalaureate and a certificate as the entry into practice is another factor. California is one of only two states with this requirement. While associate programs expose their students to community health, many never have the opportunity to see its wide range of possibilities. A dearth of teachers at the university level does not help nor do, in some locales, bureaucratic hiring practices and inadequate salaries.
The Love of the Job
Yet all the nurses we spoke to thrive in and love this field of nursing, and Karin Lightfoot, MSN, RN-BC, PHN, is one of them. She seems to have the perfect combination of fieldwork and teaching that serves so well.
With a newly earned master’s, she teaches part time at California State University, Chico, and works at the Shasta County Department of Health and Human Services. She has always found public health attractive as a practice specialty and has spent most of her nursing career in various county departments. Acknowledging that this realm does not always pay as well as nursing in private or acute settings, she is quick to add that advanced degrees lead to agency jobs that pay better.
Ms. Lightfoot says many students see the rotation as something to get through on the way to licensure. She encourages them to reconsider, pointing out that community nursing broadens their understanding of patients and diseases regardless of their ultimate career goal.
The rotations can foster student awareness of the partnership that should exist between the acute care practitioner and the nurse outside the hospital. After all, illness doesn’t start or end at the hospital front door.
Lastly, she says, it helps nurses better understand their patients if they appreciate that not all patients will return to an ideal home. “Not all new mothers have a crib for the baby. Or there may be violence in the household,” she says. Some become “enchanted,” to use Ms. Lightfoot's choice of word, when they see how their interventions really make a difference.
One cautionary note from Ms. Lightfoot is that a public health nurse does not usually see change or improvement within a day. For instance, every five years each health department undertakes a lengthy assessment of local health needs. All stakeholders participate in the evaluation, planning and implementation. The public health nurse is one member of the collaborative team and needs to work across disciplines and with many different members of the public to achieve results. Funding and staffing will have an impact on success, too, as will the community’s resources. Buy-in is essential and it most definitely is not a case of the health department deciding, “We see a problem and this is what we are going to do.”
So you don’t end a shift thinking, “Oh, I saved this life today.” Rather, there is satisfaction that comes from knowing that your nursing interventions can make a lasting change on an entire community, even though you might not see progress for years. Or you may realize that the education and resources you provided a young family will help them and succeeding generations have a vastly better quality of life.
Consider this: The increase in longevity and life expectancy that so characterized the past century in the developed world is largely attributable to the efforts of public health officials, including nurses such as Sharon Trucker, Cynthia Johnson and Karin Lightfoot.
Certificate Programs Approved by the California BRN
California State University, Northridge
Contact: Dr. Ellen McFadden
California State University, Dominguez Hills
Contact: Dr. Cynthia Johnson
Dominican University of California
Contact: Pam Bunnell
Holy Names University
Contact: Diane Stafanson
Humboldt State University
Contact: Marshelle Thobaben
San Jose State University
Contact: Sharon Lynn Hogan, DNSc
Contact: Patty Taylor
Public Health Achievements from 1900–1999
(Courtesy of the Centers for Disease Control and Prevention)
• Vaccinations, including the eradication of smallpox; elimination of poliomyelitis in the Americas; and control of measles, rubella, tetanus and diphtheria
• Improvements in motor vehicle safety due to use of seat belts, child safety seats and motorcycle helmets
• Clean water and improved sanitation leading to the control of infectious diseases such as typhoid and cholera
• Healthier mothers and babies attributable to better hygiene and nutrition and greater access to healthcare. Since 1900, infant mortality has decreased by 90 percent and maternal mortality by 99 percent.
• Recognition of tobacco as a major health hazard, leading to changes in behaviors and the subsequent prevention of smoking-related deaths
Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.
This article is from workingnurse.com.