Enumeration of Public Health Nurses in the United States: Limits of Current Standards

Abstract

Recent national initiatives in nursing and public health have emphasized the need for a robust public health nursing (PHN) workforce. In this article, we analyze the extent to which recent national enumeration surveys base their counts of this workforce on the definitions, scope, and standards for practice and practice competencies of the PHN nursing specialty.

By and large, enumeration surveys continue to rely on practice setting to define the PHN workforce, which is an insufficient approach for meeting the goals of major nursing and public health initiatives.

We make recommendations for the development of new standards for PHN enumeration to strengthen the broader public health infrastructure and evaluate PHN contributions to population-level outcomes. (Am J Public Health. 2022;112(S3):S292–S297. https://doi.org/10.2105/AJPH.2022.306782)

Over the past several years, an ongoing series of complementary yet independent efforts have directed the nation and the nursing profession toward an emphasis on health promotion and disease prevention. These include the Department of Health and Human Services’ Public Health 3.0 initiative (PH3.0),¹ the American Association of Colleges of Nursing’s (AACN’s) Enhancing Public Health Concepts in Nursing curricula,^2–5 the American Nurses Association’s updating of Public Health Nursing: Scope and Standards of Practice,⁶ and the National Academy of Medicine’s Future of Nursing 2020–2030 report.⁷ The lack of standardized criteria for determining which nurses in the nation should be “counted” as a public health nurse has hindered efforts to generate a more robust public health nursing (PHN) workforce for decades.⁸ While enumeration surveys have yielded some insight into the specialty role of PHN, the data are not sufficient to determine if an adequate PHN workforce is available to respond to current population health challenges and plan for future needs.

NATIONAL TRENDS IN PUBLIC HEALTH AND NURSING

PH3.0 is a national effort that returns public health to its population-based origins.¹ PH3.0 strategies include improving the social determinants of health (SDOH) by engaging with multiple sectors and community partners to generate a collective, positive effect on population health with a focus on “upstream” factors. By necessity, embracing PH3.0 requires the transformation of local public health funding away from the provision of clinical, disease treatment‒oriented services within local public health departments toward prevention and health promotion activities.

Specific to the nursing profession, the AACN—a leading national organization focused on nursing education—has increased expectations that core public health concepts are elevated to essential components and integrated throughout nursing curricula for undergraduate and graduate nursing programs nationwide.^3,4 Current revisions to the AACN Essentials in 2021 continue to promote public health core concepts in nursing education.⁵ Despite these curricular mandates, there has been a drastic reduction in graduate nursing programs that prepare nurses for advanced PHN practice roles,^9,10 while at the same time the demand for masters of public health programs has increased.¹¹

Finally, over the past 3 years, the Council of Public Health Nursing Organizations has updated the PHN practice competencies,⁶ and the American Nurses Association has drafted a new scope and standards for PHN practice.⁶ External to the profession, the Robert Wood Johnson Foundation funded the National Academy of Medicine to “[chart] a path forward for the nursing profession.”^7(p4) The report recognizes the expertise of PHNs in addressing SDOH and identifies the need to ensure a sufficient distribution of nurses with a public health specialty to tackle the challenges of the next decade.⁷

Although each of these initiatives began before the arrival of COVID-19, the pandemic brought a sense of urgency and renewed interest in a PHN workforce able to adequately respond to population health trends, community needs, and national emergencies. With the persistent demands of COVID-19, public health as a discipline with a distinct set of competencies within the nursing profession has, at least temporarily, brought some recognition to the central role public health nurses have in protecting the health of people in the United States.^12,13 Against the backdrop of what feels like a perpetual state of needing to justify PHN’s existence as a specialty area of nursing practice, particularly from within our own discipline,⁹ some nurse scholars have questioned whether there is a future for PHN at all.¹¹ Taken together, the pandemic and the national impetus to move public health toward addressing SDOH as outlined in PH3.0, a window of opportunity exists to strengthen the PHN workforce. To seize this opportunity, however, clear, measurable, and standardized criteria that reflect accepted definitions of the PHN specialty are needed to discern which nurses, among the greater nursing workforce, are doing the actual work of public health.

DEFINING VS ENUMERATING PUBLIC HEALTH NURSING

Professional organizations representing the nursing workforce have written definitions of PHN in key documents used to guide PHN practice (Table A, available as a supplement to the online version of this article at http://ajph.org, provides a detailed list of select definitions). Used to direct PHN scope and standards of practice and practice-based competencies, a common denominator across definitions emphasizes population-based functions. As these definitions make clear, the population-focused roles are what differentiate PHN from other specialty areas of nursing practice. The well-known Public Health Intervention Wheel (aka The Minnesota Model)^14,15 defines the scope of PHN practice by the population-based work nurses do at the individual, community, and systems levels that delineate it as a specialty practice.

Although widely accepted definitions for PHN are readily available, a chasm exists between the roles and functions reflected in them and how we identify which segment of the nursing workforce fulfills these roles. Since 1915, there have been regular efforts to enumerate the PHN workforce¹⁶ through national surveys of the nursing and public health workforce conducted or contracted by the Health Resources Services Agency Bureau of Health Professions, the National Sample Survey of Registered Nurses, the National Council of State Boards of Nursing, and the National Association of County and City Health Officials. To our knowledge, only 1 survey has sought to profile the PHN workforce in a more extensive and detailed manner than that conducted by the national sources identified here.¹⁷

Despite the extent to which we rely on these surveys for planning workforce needs in the United States as Tilson and Gebbie⁸ noted almost 2 decades ago, and restated by others more recently,¹⁸ enumeration surveys have been plagued by highly variable criteria for determining whether to “count” a nurse as a member of the PHN workforce. This lack of precision has severely impeded our ability to determine the actual number or supply of public health nurses in the workforce. Moreover, it has left us unable to assess if communities meet the recommended national minimum standard of a public health nurse-to-population ratio of 1 to 5000 in the United States, and, as COVID-19 has so painfully taught us, it rendered us unable to determine if this standard is adequate to meet the needs of the population during regular times and in times of crisis.¹⁹

Given the population-based initiatives described previously and the public health challenges that we face as a nation, we analyzed how national workforce enumeration studies have operationally defined PHN and measured the roles, functions, and job tasks or activities engaged in by public health nurses. Table B (available as a supplement to the online version of this article at http://ajph.org) details the measurement approaches taken for enumerating public health nurses across 7 national enumeration surveys from sources listed previously.

Notably, surveys designed to enumerate the public health workforce did not differentiate nurses by the level of licensure (licensed practical nurse or registered nurse) or educational preparation, whereas those enumerating the nursing or PHN workforce did so. Regardless of the target workforce, all surveys used practice settings to define public health nurses. Only 1 included a formal operational definition of PHN that used practice setting as a criterion;¹⁷ others defined public health nurses through their primary practice setting by default. Among surveys of the nursing workforce, response options used to count public health nurses by their settings spanned “public health,” “public health/community health agency” (and specified these agencies were not clinic-based agencies), and those working in “justice, public order, and safety.”

Relevant to the roles and functions that are prominent in defining the PHN specialty (Table A), no surveys of the public health workforce capture the roles public health nurses fufill within their primary practice setting. Among surveys of the nursing workforce that include tangential indicators of the roles and functions that are part of formal definitions of the specialty, either “position held” or the “specialty area of a nurse’s primary practice position” were most often used. Notably, the University of Michigan’s Center of Excellence in Workforce Studies¹⁷ survey is the only one since 2000 that was designed to enumerate and characterize public health nurses, specifically. The survey did include a “job function” item, although the response options were limited in number (n = 9). This was the only item among the included reports that captured data to delineate job function in a way that can be mapped onto both individual and population-level role functions specified in the definitions that guide the PHN specialty (Table A).

When included, measures of percentage full-time equivalent (%FTE) were most often used to sum the total %FTEs of public health nurses at the organizational level or identify the proportion of time spent in a primary and secondary setting. Only the National Sample Survey of Registered Nurses²⁰ asked nurses to estimate the percentage of their time in a typical work week spent carrying out several different job functions or tasks. Even the far more comprehensive University of Michigan survey¹⁷ of public health nurses restricted the %FTE questions to the proportion of time nurses spent across program areas, rather than the job functions or tasks carried out within program areas.

REENVISIONING MEASUREMENT CRITERIA FOR PUBLIC HEALTH 3.0

Our analysis indicates that, for the past 2 decades, practice setting is primarily used to identify which members of the public health or nursing workforce are doing the work of PHN. With a single exception, the measurement strategies used for enumeration do not reflect the defining features of PHN that undergird the specialty’s definition for professional practice, the scope and standards of practice, or practice competencies. Measuring the PHN workforce in this manner is problematic on 3 fronts: (1) the use of setting as a proxy for roles and function, (2) the limited taxonomies used to characterize roles and functions, and (3) the minimal capture of %FTE spent carrying out multilevel job functions—particularly among positions, specialty areas, or program areas where nursing job functions may vary widely across individual and population levels of care. In what follows, we recommend 3 directions for reenvisioning how to more accurately enumerate the PHN workforce moving forward.

Moving Beyond Setting for Roles and Functions

We argue that setting may be acceptable when the sampling frame is restricted to governmental health departments whose core missions and functions are to achieve the Essential Public Health Services²¹—all of which occur at the population level. As such, it can be reasonably assumed that the nurses working within them or employed by them are carrying out the vision, mission, and functions of public health and are guided by the scope and standards and practice competencies of the PHN specialty.

When we attempt to enumerate which nurses function as public health nurses outside of health department agencies, the waters become murky, and setting alone is inadequate to identify which nurses are carrying out, and how frequently they are carrying out the roles and functions defined in each of the soon-to-be-released scope and standards’ 8 salient areas for PHN practice:

• 1.health promotion and protection,
• 2.emergency preparedness and disaster recovery,
• 3.environmental safety and quality,
• 4.clinical interventions,
• 5.care coordination,
• 6.cross-sector collaboration and community engagement or partnership,
• 7.research, and
• 8.policy and advocacy.⁶

Inconsistencies in how national surveys^21,22 define settings outside health department agencies add to a lack of precision and likely bias data in the direction of overinflating estimates of the PHN workforce. Ultimately, a setting-centered approach fails to accurately enumerate public health nurses whose roles and functions focus on broader population-level determinants and adversely affects our ability to ensure the health of the US public.

Developing Taxonomies of Roles and Functions

The use of non‒public health taxonomies to assess the roles and functions of nurses cannot tell us if nurses are practicing in a manner consistent with PHN definitions, scope and standards of practice, or practice competencies. In acute care or hospital settings, there is a fairly narrow, well-defined, and relatively uniform range of roles and functions that nurses carry out when working in, for example, a “critical/intensive care” setting or specialty.^20(p7) In community-based and public health settings and specialties, there is significantly greater variation in the roles and functions of nurses across levels of care that span the range of individuals, families, communities, and larger populations.

Given this, we recommend that more definitive categories of job roles and functions, such as those being developed in the Public Health Workforce Taxonomy Revision Project,¹⁸ are widely adopted in surveys intended to enumerate or characterize the PHN workforce. Ongoing since 2014, this project now includes 46 common daily job functions carried out by the public health workforce—all of which are categorized within the Essential Public Health Services.²¹ Applying public health‒specific taxonomies to identify the roles and functions nurses are engaged in would likely substantially reduce measurement error and more accurately reflect the population-based activities that define PHN practice.

Percentage of Time Spent on Public Health

A final recommendation is to shift the paradigm of enumeration in a way that can account for nurses carrying out PHN roles and functions based on an allocation of the %FTE they spend on them. Adopting this as a standard moving forward can also serve as a benchmark for the extent to which our nation is meeting the visions put forward in PH3.0 and the many nursing education and practice initiatives that seek to center a population health orientation within the profession. Capturing %FTE allocated to carrying out roles and functions will, for example, enable us to determine whether nurses working in community-based settings are, in fact, doing the work of addressing SDOH lauded in both the AACN Essentials^2–5 and the Future of Nursing 2020–2030 report.⁷ Moreover, combining measures of %FTE with the more granular taxonomy of roles and functions such as those in the Public Health Workforce Taxonomy Revision Project¹⁸ will allow us to discern whether nursing efforts to tackle SDOH (regardless of setting) reflect the upstream focus required to make meaningful progress toward achieving health equity.

Each measurement feature that is problematic for enumerating the PHN workforce can be remedied with increased and strategic collaboration between nursing and public health workforce researchers. As the many initiatives currently underway seek to shift nurses practicing outside the governmental public health system toward the provision of more population-focused care, methods for assessing this change are urgently needed. Similarly, adopting more precise approaches for understanding the roles, functions, and activities that public health nurses working within or for governmental public health systems are engaged in can assist administrators in these agencies to assess the extent to which they may be understaffing or underutilizing their own PHN workforce, or both.

While certification might be proposed as a strategy to identify public health nurses in workforce surveys, we do not believe this is viable for 2 reasons. First, PHN-specific certifications have been recently discontinued, despite opposition from those within the PHN specialty.²³ Second, while registered nurses in a small number of states may obtain a registration certificate as a public health nurse from their board of nursing, their registration is voluntary, and there is an associated cost when registering.^24,25 If this approach were used, nurses who decide not to register as a public health nurse through the board of nursing despite working in a population-focused role would go uncounted. As such, the absence of a national approach to licensing and the variation in state rules and statutes make this strategy unfeasible.

CONCLUSIONS

At this critical juncture when awareness of public health is heightened and the role of nurses in health care is celebrated, organizations must ensure accurate enumeration of public health nurses. There is an urgent need for a uniform national framework for data collection, analysis, and reporting to more accurately quantify the size, distribution, and contributions of the PHN workforce. While the exact methodological specifications need development, measurement criteria grounded in PH3.0, the 8 updated roles and functions in the revised PHN scope and standards of practice, and the developing Public Health Workforce Taxonomy Revision Project¹⁸ is crucial, where setting and actual engagement in activities related to PHN roles and functions would be combined for PHN enumeration purposes moving forward.

We envision an approach that provides enhanced clarity and allows for comparable, standardized data to be used by decision-makers, policymakers, and public health strategists who depend on assessments of public health nursing supply and demand. Moreover, future work to pinpoint where these 8 roles and functions intersect with PH3.0 strategies could provide insight into public health nurses’ current and future contributions to public and population health.

Public health nurses are professional registered nurses whose practice has an impact on individual-, community-, and systems-level outcomes.²⁶ Their multifaceted engagement, through their specialty-delineated roles and functions, distinguishes them from many other nurse colleagues working in community-based settings. There is now a clarion call through PH3.0 for organizations to align PHN practice roles with the scope and standards of this nursing specialty, and we must be able to measure the extent of the PHN workforce moving in that direction. This will require incorporating standardized definitions, roles, and functions that are specific to public health nurses into surveys so the results will be more useful for creating workforce plans that integrate public health nurses into the broader public health infrastructure and can inform how we evaluate the PHN contribution to population-level outcomes. While health workforce needs and resources differ by geography, population demographics, and political will, a desired outcome remains one that prioritizes public health organizational practices that move PHN roles in the direction of PH3.0. To achieve this goal, however, public health nurses must be included in decision-making processes for determining new enumeration approaches going forward.