Revitalizing Public Health Nursing for the Future

Public health nurses have served valiantly on the front lines of the COVID-19 pandemic for the past two years, saving lives through contact tracing, educating people about self-isolation and quarantining, vaccinating communities, and interpreting for their communities vacillating guidance from the Centers for Disease Control and Prevention (CDC). They have worked long hours and assumed new and unfamiliar roles without adequate staffing. I include school nurses in my definition of public health nurses because school nurses take on similar roles to improve population health. They improve health care access; engage school communities, parents, and health care providers to promote wellness and improve health outcomes for children; and address social needs and the social determinants of health for the families and communities they serve.

Yet, the government’s decision to underfund the public health infrastructure for more than a decade has undermined the ability of public health professionals to respond to the pandemic as robustly as they could have.¹ These funding shortfalls have meant that as public health nurses have devoted their efforts to mitigating the pandemic, they have watched long-standing efforts to address maternal health care and other vital programs lose ground.² Working in underresourced communities, many public health nurses have witnessed firsthand the devastating and unequal toll that the pandemic has taken on poor and marginalized communities. They find themselves under siege from a segment of the public and some political and media figures who have threatened, cursed, and attacked them.³ Frustrated parents have criticized school nurses when their children have been subjected to quarantine and isolation. In addition, acute care nurses’ more visible contributions have received more attention than public health nurses’ efforts to combat the pandemic.

THE FIELD IS STRESSED

In many cases, their stress has reached a breaking point: a CDC survey released in July 2021 found that more than half of people working in public health at the state, tribal, local, and territorial levels during the pandemic reported symptoms of depression, anxiety, suicidal thoughts, and post-traumatic stress disorder.⁴ Many public health nurses are retiring or seeking higher-paying jobs in other health care settings. Within the public health workforce, participation by nurses has fallen faster than that of other professional groups.⁵

We must commit to a better future for public health nurses that starts with fully funding the field and recognizing that they are essential to improving population health and advancing health equity. Public health nurses intervene at early ages, focus on prevention, and connect with their communities to understand and address social needs and the social determinants of health, according to the National Academy of Medicine (NAM) report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity.⁶ School nurses, among the most visible public health nurses, are sometimes the only health professionals schoolchildren visit regularly. They detect illnesses early, help manage chronic conditions, and provide mental health support. Yet, one in four schools has no school nurse, and 35% employ a school nurse only part-time.⁷ Schools with a higher proportion of low-income families are less likely to employ a school nurse. The NAM report contains comprehensive recommendations that, if followed, would provide public health nurses with the support and structure they need to care for themselves and their communities more fully.

RECOMMENDATIONS TO REVITALIZE PUBLIC HEALTH NURSING

Perhaps most important, the NAM report recommends that federal and state governments ensure adequate funding for school and public health nursing, including paying public health nurses competitive wages compared with nursing positions in other health care organizations and sectors. “Underfunding limits the ability of school and public health nurses to extend health care services and create a bridge between health care and community health,” the report notes.^6(p176) The Biden administration has taken an important step in committing significant resources to buttress the public health nursing workforce.⁸ Similarly, the report calls on the government to rapidly increase the number of public and community health nurses. Students who plan to work in professional shortage areas should be eligible for scholarships and have their loans forgiven, the report notes. Similarly, the government and private foundations should provide major investments for nursing education and traineeships in public health.

In addition to the infusion of federal funds to support public health nursing, the report calls on federal, tribal, state, local, and private payers and public health agencies to explicitly value nurses’ contributions to care by reforming payment systems to pay for services that address the social determinants of health and advance health equity. Payment systems should reimburse for team-based care, improved communication between providers and patients, and proven interventions and strategies that can reduce health inequities.

The report recognizes that too few nurses are entering public health nursing to fill vacant positions and replace the many public health nurses who are on the cusp of retirement or leaving the field. To that end, the report calls on schools of nursing to better incorporate the social determinants of health and health equity into the curricula and to expand community learning opportunities. This will better prepare all nurses to advance health equity, regardless of the care setting in which they ultimately seek employment, and should encourage more nursing students to seek out these roles upon graduation.

The report also recognizes the need for our society to fully support nurses to enable them to advance health equity. The report includes a number of recommendations for creating structural and cultural changes, primarily that nursing education programs, employers, nursing leaders, licensing boards, and nursing organizations initiate the implementation of structures, systems, and evidence-based interventions to promote nurses’ health and well-being, especially as they take on new roles to advance health equity. One cultural change that could be particularly beneficial for public health nurses could include requiring them to take time off, because the CDC survey found that public health workers who were unable to take time off from work were nearly twice as likely as others to experience poorer mental health. Although employers allowed their workers to take time off, the workers said they did not take time off because of feelings of guilt, because no one else was available to take their place, or because they worried about work accumulating during their absence.³

Finally, the report calls on all nursing organizations to leverage the expertise of public health nurses. It calls on the Council of Public Health Nursing Organizations (composed of the Alliance of Nurses for Healthy Environments, the American Nurses Association, the American Public Health Association Public Health Nursing Section, the Association of Community Health Nursing Educators, the Association of Public Health Nurses, and the Rural Nurse Association) to work with other leading nursing organizations to develop a shared agenda for nursing to address the social determinants of health and to advance health equity. The nursing organizations should identify specific priorities across nursing practice, education, leadership, and health policy.

Taken together, these comprehensive recommendations offer a roadmap to rebuild and revitalize the public health nursing workforce to better protect our nation’s health, address the social determinants of health, and advance health equity.