American Academy of Nursing on Policy

Increasing the capacity of public health nursing to

strengthen the public health infrastructure and to
promote and protect the health of communities and
populations
Joan E. Kub, PhD, MA, PHCNS-BC, FAAN*,
Pamela A. Kulbok, DNSc, RN, PHNA-BC, FAAN, Sarah Miner, RN, PhD,
Jacqueline A. Merrill, PhD, MPH, RN, FAAN, FACMI
Environmental and Public Health Expert Panel

Executive Summary a healthier future and better health outcomes. In 2014,

the National Advisory Council on Nurse Education and
Practice (NACNEP) submitted its 12th Annual Report to
The American Academy of Nursing recognizes the Congress, Public health nurses: Key to our nation’s health,
need for strengthening the U.S. public health work- asking both Congress and the Secretary of the U.S.
force and supports efforts to increase the capacity of Department of Health and Human Services (USDHHS)
public health nursing (PHN) to promote and protect to enhance supports for PHN education and practice as
the health of communities and populations. PHN has a means to ensuring a healthier future and better
distinguished itself as a nursing specialty by defining health outcomes for all Americans (NACNEP, n.d.). In
its practice as that of “promoting and protecting the 2016, the NACNEP reinforced this position in its 14th
health of populations using knowledge from nursing, Annual Report to Congress, Preparing nurses for new roles
social, and public health sciences” (American Public in population health management (NACNEP, 2016) by
Health Association, PHN Section, 2013). PHN, the calling for increased investment in population health
largest profession within the public health workforce, science and training and increased funding for
has a long and successful history of promoting and research on population health management, mea-
protecting the health of the public. Over the past sures, and metrics. Renewed support and economic
decade, however, the public health infrastructure investment in PHN is expected to improve the capacity
has been decimated by budget cuts and declining re- of the public health workforce to build a culture of
sources affecting the capacity of PHN to effectively health as the United States strives to meet the triple
impact population health outcomes. Ironically, this aim goals of health care reform.
comes at a time when the U.S. has adopted a
comprehensive set of health system reforms focused
on the “triple aim” of improving population health, Background
lowering per capita costs, and improving the patient
experience of care. The triple aim, first outlined
in 2007 by the Institute for Healthcare Improvement, Despite a century of public health advances in reducing
calls for a shift from clinical services to the prevention and eliminating diseases and increasing life expec-
of the deleterious effects of chronic illness tancy, the U.S. health system faces many challenges
and an increased emphasis improving overall popu- today. These challenges include an aging population
lation health outcomes (Institute for Healthcare increasingly burdened with chronic illness, declining
Improvement, 2016). life expectancy, and inferior health systems perfor-
PHN’s proven potential to contribute to population mance on measures of quality, access, efficiency, eq-
health outcomes is crucial to the ability of the public uity, and healthy lives compared with other high-
health infrastructure to support a renewed focus on income countries (Institute of Medicine [IOM], 2012).
health promotion and disease prevention within Challenges specific to the public health infrastructure
health care (Hassmiller, 2014). As a result, there is a call include increasing health care costs, limited resources,
to specifically enlist public health nurses as leaders in and a declining public health workforce (Bekemeier,
population-focused health improvement as the key to Zahner, Kulbok, Merrill, & Kub, 2016).

* Corresponding author: Joan E. Kub, 1103 Spy Glass Dr. Arnold, MD, 21012.
E-mail address: [email protected] (J.E. Kub).
0029-6554/$ - see front matter Ó 2017 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.outlook.2017.08.009
662 Nurs Outlook 65 (2017) 661e664

Population Health and PHN and less likely to have had teenage pregnancies
themselves (Eckenrode et al., 2010). This is only one
These U.S. health system challenges are occurring at program but demonstrates the lasting impact of stra-
the same time that there is a growing focus on what is tegic and appropriate use and training of the PHN
called population health. Although the term “popula- workforce and the critical need and potential of public
tion health” is not new, its definition is a source of health nurses to assist with the health of those who
some debate. It has been defined as the distribution of most need it. The loss of PHN for such communities
health outcomes within a population, the de- could be devastating, especially in rural areas and with
terminants that influence distribution, and the pol- at-risk populations who most depend on the work of
icies and interventions that affect determinants public health nurses for the health and well-being of
(Kindig & Stoddart, 2003). PHN has a rich history of themselves and their families.
caring for populations within communities, beginning In addition to traditional roles of public health
with Lillian Wald’s work at the Henry Street Settle- nurses in home visiting, with the advent of the
ment in New York City in the early 1890s. Further- Affordable Care Act, there has been a national health
more, PHN has distinguished itself as a nursing care shift toward primary care. Public health nurses are
specialty by defining its practice as that of “promoting making substantial contributions to the implementa-
and protecting the health of populations using tion of the Affordable Care Act and the expansion of
knowledge from nursing, social, and public health primary care. Their efforts include the integration of
sciences” (American Public Health Association, PHN primary care and public health, providing clinical pre-
Section, 2013). ventive services, care coordination, patient navigation,
For well over a century, public health nurses have establishment of private and public partnerships, and
been critical to the functioning of our health care sys- focusing on population health assessment, analysis,
tem by improving the health of vulnerable populations and health planning strategies (Edmonds, Campbell, &
and entire communities. Not unlike other public health Gilder, 2017).
efforts, however, evidence of these achievements has
not always been well documented or studied. A recent Enlisting PHN to Strengthen the Public Health
review of studies focusing on health education, Infrastructure and Improve Health
behavior change, and screening over a period of
20 years (1990e2010) found evidence for the effective- Although the focus on health care reform and primary
ness of PHN interventions in close to half of the studies care has been positive, there have been unintended
(Swider, Levin, & Reising, 2017). Public health nurses consequences of these efforts. The continuing decline
have the ability to care for individuals and commu- in the number of public health nurses, as a result of
nities through effective case management, which has budget cuts, the use of less expensive providers for
been shown to improve chronic illness outcomes services, and changing PHN roles (Association of State
(Kneipp et al., 2011). In addition, a systematic literature and Territorial Health Officials, 2014), has resulted in a
review of home visiting interventions published be- public health nurse-to-population ratio that would
tween 2005 and 2015 found that home visitation in- concern early leaders of the field. Although provider-
terventions can mitigate social determinants of health to-population ratios were once critical in the plan-
and empower people to avoid injury and manage and ning of workforce adequacy in PHN, these ratios have
prevent illness (Abbott & Elliott, 2017). received little attention for some time. In 2008, the
One home visitation program, the NurseeFamily Association for State and Territorial Directors of
Partnership, targeting at risk mothers and infants, is an Nursing (ASTDN) (now the Association of Public Health
example of the long-term benefits of PHN interventions Nurses) prepared a detailed report on the history of
(NurseeFamily Partnership, n.d.). Started in the 1970s public health nurse-to-population ratio expectations.
as a nurse visitation program targeting at-risk first- Their recommendation was to establish a minimum
time mothers, this program has been implemented at “standard national ratio of 1 public health nurse to
the policy and practice level and continues to be 5,000 population” (ASTDN, 2008, p. 1). The report also
delivered throughout the United States as well as in pointed out that this ratio would need to be lower for
other countries. Although evidence has demonstrated communities with more vulnerable or impoverished
the ability of the program to improve maternal child populations.
health outcomes of the mothers and newborns taking Public health nurses remain the largest group of
part in the 2-year intervention, even more striking are health professionals of the public health workforce
the long-term effects of this program on those who (Beck, Boulton, & Coronado, 2014). However, with an
participated and have long since left the program. estimated 47, 270, public health nurses in local, state,
Participation in the NurseeFamily Partnership has and federal agencies and a population of 316.4 million
been found to have continuing health benefits for in 2013, the ratio of public health nurses to population
children as far out as 15 and 18 years after their is 1 to 6,693. This ratio is well above the recommended
participation, including being less likely to be involved minimum of 1:5,000 and does not account for com-
in criminal activity, less dependent on social welfare, munities with at-risk populations. To meet this
 Nurs Outlook 65 (2017) 661e664 663

minimum recommendation, the United States would future and better health outcomes. The NACNEP report
need more than 63,000 public health nurses. Additional asserts that the health of a nation is strongly depen-
significant recommendations that would further in- dent on the strength of its public health workforceda
crease the number of public health nurses needed to workforce with PHN as its largest profession. Moreover,
promote population health is a ratio of “1 supervisor to the 14th Annual Report to Congress (NACNEP, 2016)
no more than 8 public health nurses” and the highlights the need to prepare nurses for roles in
requirement for the baccalaureate degree for PHN population health management, which are historically
practice (ASTDN, 2008, p. 52). within the purview of PHN.
More broadly, unintended consequences of the These two reports are complementary and provide
emphasis on primary care has been decreasing atten- strong arguments for investment in public health
tion to the role of the public health nurse in the com- and population health science infrastructure,
munity, a loss of Title VIII funding for public health training, and research. Such action would acknowl-
nurses, and a loss of traineeships for advanced edu- edge and leverage the capacity of the nursing pro-
cation of public health nurses. With the dynamic fession to lead population health and quality
changes in health care reform and attention to the improvement in diverse and changing communities
triple aim of improving population health, lowering per in the United States and around the world. PHN led
capita costs, and improving the patient experience of the nursing profession with its focus on social de-
care, it is time to refocus care once again on the com- terminants of health in the early 20th century. With
munity and to renew the role of PHN. enactment of the NACNEP recommendations, PHN
Strengthening the public health workforce, howev- will assume a transformative role in achieving
er, requires renewed efforts to increase funding op- healthy populations through primary prevention and
portunities to provide education for public health population-based efforts.
nurses and create career pathways for advanced public
health nurses. Funding is critically important, espe-
cially considering the 2012 eligibility changes made to The Academy’s Position
Title VIII, outlining traineeship preferences for nurse
practitioners and nurse midwives (USDHHS, 2012).
Renewed support and economic investment in PHN The American Academy of Nursing (the Academy) fully
will strengthen the public health workforce to promote supports efforts to increase PHN capacity, to
a culture of health as the U.S. health care system strengthen the public health infrastructure, and to
strives to meet the triple aim and assure the effective promote and protect the health of communities and
implementation of health care reform. Public health populations. The Academy endorses the 12th Annual
nurses will have the capacity to care for individuals in NACNEP report, Public health nursing: Key to our nation’s
the community, as well as vulnerable communities health, and the 14th annual NACNEP report, Preparing
and populations. Well-prepared advanced public nurses for new roles in population health management. One
health nurses will be able to address care management of the most essential aspects of these NACNEP reports
needs of individuals, a renewed priority of health care is the recommendation for increased training and ed-
reform, as well as population and system level factors ucation for nurses in the area of public health and
including social determinants and health disparities population health management, under Title VIII of the
through PHN practice and research. Public Health Services Act.

Responses and Policy Options Recommendations

PHN’s proven potential to contribute to population B Encourage key stakeholders including the Amer-
health outcomes is crucial to the ability of the public ican Nurses Association, American Association of
health infrastructure to support a renewed focus on Colleges of Nursing, National League for Nursing,
health promotion and disease prevention within Quad Council Coalition, American Public Health
health care (Hassmiller, 2014). The NACNEP, which is Association, Association of State and Territorial
authorized by Section 851 of the Public Health Service Health Officials, Center for Disease Control and
Act and amended by Public Health Law 105 to 392, is Prevention, National Association of County
charged with providing recommendations to Congress Health Officials, Public Health Foundation, and
and the Secretary of the USDHHS concerning policy the Robert Wood Johnson Foundation to review
matters relating to the nurse workforce, education, and and respond to the 12th and 14th Annual NACNEP
practice improvement. The 12th Annual Report to reports.
Congress (NACNEP, n.d) outlined this strategy clearly B Urge Congress to enact legislation and appro-
and succinctly. This report calls on Congress and the priate funding for the development of advanced
Secretary of the USDHHS to strengthen PHN education PHN traineeships, repayment programs, and sti-
and practice and identifies PHN as key to a healthier pend support through Title VIII.
664 Nurs Outlook 65 (2017) 661e664

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