Climate Change, Public Health, Health Policy, and Nurses Training

Abstract

There are few educational programs in the United States that have a primary focus on preparing nurses to engage in all levels of public health, health policy, and climate change. The United Nations sustainability development goals (SDG) and the Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (2021) report underscored the importance of key stakeholders, including nurses, engaging in advocacy and policy to promote health equity.

We discuss the role of nursing at the intersection of public health, policy, climate change, and the SDG. We also discuss the history and merger of the University of California San Francisco (UCSF) School of Nursing public health and health policy specialties, a significant innovation in our effort to promote health equity.

We provide a brief overview of the redesigning of our curriculum that meets the needs of today’s learners by including content on climate change, data analytics, and racial, social, and environmental justice. Finally, we emphasize the need to train the next cadre of nurses interested in careers in public health and health policy for us to meet the challenges facing our communities. (Am J Public Health. 2022;112(S3):S321–S327. https://doi.org/10.2105/AJPH.2022.306826)

The history of nursing is solidly anchored in nurses’ engagement in public health and in advocating changes in policy. Mary Seacole is an example of a nurse’s contribution to public health and policy. A nurse of color who rose to prominence during the Crimean War, Seacole is known for her care of wounded soldiers and her public health efforts in caring for victims of yellow fever, cholera, and dysentery.¹ Another example is Lilian Wald, who linked housing with health outcomes. Nurses’ presence in the communities they serve is frequently advocated, as nurses serve a pivotal role in public health and health policy.² These examples demonstrate a history in which nurses’ contribution to public health and policy were driven primarily by racial and ethnic discrimination, which denied them access to spaces where they could make significant differences in the field. This has changed, however, with the presence of US congresswomen Lauren Underwood and Cori Bush, both registered nurses working to address racial disparities in health and housing through policy at the federal level.

The racial uprising in the United States in 2020 as a result of the murder of unarmed Black Americans brought renewed attention and calls to eradicate systems of racism and racial and ethnic discrimination, including institutional and public policies that continue to broaden inequalities and disparities in health. The racial uprising in 2020 and the focus on health equity and climate change illuminate the continuing need to ensure that nurses are prepared to engage in advocacy to benefit the public’s health. More recently the Future of Nursing 2020–2030 report emphasized the importance of nurses’ engagement in advocacy and policy to promote health equity.³ It states that “[in] addition to addressing social needs, nurses are called upon to inform and implement policies that will ultimately affect the greatest numbers of people in the most profound ways.”³

When the World Health Organization (WHO) declared 2020 the Year of the Nurse (extended to 2021 because of the impact of the COVID-19 pandemic), it highlighted that the investment in nursing promotes equity. Significantly, it stated that nurses are critical to the global efforts to meet the sustainable development goals targets.⁴

NURSING AND SUSTAINABLE DEVELOPMENT GOALS

The sustainable development goals, adopted unanimously by the United Nations member states in 2015, established 17 targets that promote equitable social and economic development. The goals recognize the intersectionality between health, education, and economic growth. Furthermore, the SDG acknowledge that addressing climate change is pivotal to achieving all 17 targets, including the reduction of poverty (https://bit.ly/36d85h0).^5,6 The sustainable development goals also brought needed attention to gender equality, work that provides a livable wage and economic growth, reduced inequalities, decisive climate action, sustainable cities and communities, and peace, justice, and strong institutions.^5,7

Although the link between nursing and target 3 (good health and well-being) is unquestionable, the SDG offered nursing an opportunity to discuss its engagement in a broader approach to public health and policy, especially as health is threaded throughout several of the other goals as an indispensable condition to meeting all the targets. Importantly, the role of nurses in advocating the goals is supported by leading nursing organizations, including the International Council of Nurses and several US-based nursing organizations, including the American Nurses Association and the American Academy of Nursing.^8–10

Furthermore, the SDG present nurses with a unique opportunity to develop and implement nursing education and a research agenda that responds to current concerns that negatively affect health, including research on the impact of a changing climate on individuals, families, and communities in the United States and globally.^8,11–14 Moreover, the SDG offer an opportunity to further advance nursing education and research that centers equity in terms of gender, race, ethnicity, education, and the elimination of poverty and hunger, and to promote social, economic, and environmental justice by eradicating systemic racism and racial discrimination. Future leaders in nursing will be equipped with the tools to drive public health and health policy, which in turn will strengthen institutions that serve communities.^14,15

Rosa et al.¹⁶ suggest that for nurses to assume leadership roles in promoting social justice, equity, and the SDG, it is necessary that nursing education and research include the following: (1) every nursing student at all levels of education must have an integrated curricular requirement to advance their understanding of politics and policy that would provide requisite education on the workings of policy and politics and related implications to teach students how to live and work in those spheres; (2) students and practicing professional nurses must have opportunities to do internships, residencies, and placements and have other forms of experience in public health and policy forums that interface with nongovernmental organizations and other agencies in their localities, state, nation, and beyond; (3) nursing scholarship that centers antiracism initiatives, health equity, and the elimination of health disparities must be advanced; and (4) leaders in nursing must have the responsibility to build relationships with people of influence and thought leaders to fully engage and integrate nursing’s contribution in policy and public health arenas.¹⁶

The COVID-19 pandemic upended lives, economies, and health care infrastructure domestically and globally. It also provided an opportunity to increase awareness of the severe disparities in access to health care, wealth, food security, and stable housing as well as mass migration in and between countries—further exacerbating the crises brought on by climate change and the pandemic. It did, however, point to the fact that health care and public health systems cannot function without nurses and that nursing leadership is pivotal in addressing health and social crises. The pandemic also renewed calls for nurses to lead. At the UCSF School of Nursing, the masters of science graduate program includes 2 pioneering specialties that are at the forefront of equipping new generations of nurse leaders with the programmatic, policy, and political tools necessary to ensure nurses’ response to current and future crises. These 2 specialties are advanced public health nursing (APHN) and health policy nursing. Students entering our programs are either practicing registered nurses with a bachelor of science degree or a second-degree nursing student who has completed an accelerated registered nursing program before starting either the graduate APHN or the health policy nursing specialty.

THE HISTORY OF THE 2 SPECIALTIES

The focus of the APHN specialty is to learn macrolevel skills in managing aggregates of clients, communities, environments, and health systems in a clinical nursing context. The coursework and practice-based learning provide a foundation for planning and evaluating community and public health programs; learning about community and public health concepts, health promotion, population-level interventions, grant writing, health care systems, leadership, and health policy; addressing health disparities of vulnerable and diverse populations; and practicing and consulting in diverse and multicultural settings and partnering with communities. Nurses who graduate from the APHN specialty understand the complex interactions between health and the social determinants of health and are able to identify systems-level solutions that can maintain or improve the health of diverse, vulnerable, and underserved populations and communities. Some master of science graduates whose specialty is APHN have taken positions implementing programs in public health departments and in other settings, including director of a statewide initiative to increase flu vaccination rates for elementary school students, state-level public health department coordinator of COVID-19 response, senior country-level technical nursing adviser for maternal child health in a global setting, and director of public health respite and sobering center for a department of public health.

Historically, the APHN specialty has adapted to the changes in competency expectations and revisions for community and public health nurses.¹⁷ Coursework for the APHN specialty is focused on the role of an advanced public health nurse, public health practice and APHN competencies, developing theoretical understanding of structural and social determinants of community and public health, and skills that demonstrate an ability to collaborate with community members to create partnership in planning, implementing, and evaluating programs with a focus on prevention and well-being. More recently, we have included topics on social and environmental justice, structural determinants of health, police violence and its effects on mental health in communities of color, and climate change and global health impacts.

Students engage in a community-based public health residency practicum in which they are evaluated on their skills and attainment of community and public health competencies. Residencies are a minimum of 240 hours and must include APHN competencies. Some examples of residency settings are public health departments, schools and universities, parishes and faith-based programs, home care, rural health, refugee and immigrant clinics, primary care clinics, jails and prisons, ambulatory outpatient facilities, voluntary organizations, and a variety of community, public, and private agencies and organizations.

Public Health Residency Experiences

Several APHN students’ residency practicums are done in collaboration with a county-level public health nursing department. One example of a longitudinal, long-term partnership (more than 10 years) between the university and a county-level public health nursing department is a project focused on addressing mental health disparities in pregnant and postpartum women who receive WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) services. Each year the partnership responds to the needs of the community. The project began with developing an intervention called the WIC postpartum depression screen, which implemented depression screening for clients and was conducted by WIC staff. This partnership has resulted in a multiphase intervention that has been expanded to 8 WIC sites in Alameda County, California; in it, WIC staff completed depression screening for more than 20 000 pregnant and postpartum women. In 2018 through 2019, the WIC postpartum depression screen conducted 4852 client screenings, 8.6% of which were positive for being at risk for depression.¹⁸

On March 17, 2020, Alameda County issued shelter-in-place orders to curb the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is responsible for COVID-19. All WIC offices were closed to in-person appointments and given the directive to convert to remote operations and to discontinue ancillary activities, thereby stopping postpartum depression screenings. Part of this lapse in screening was attributable to the in-person paper-based format used before the pandemic. An organizational transition to a new electronic health record system called WICwise in the fall of 2019 coupled with closing county offices to in-person appointments reduced the client screenings at the county level. Responding to the impact of the COVID-19 pandemic, our APHN student intern worked with staff from the Alameda County Health Department to transition their depression screening program to a remote telehealth format. This transition facilitated the continuation of services for pregnant women in need and reinstated the depression screening program.¹⁹

APHN students have engaged in projects that included the development of a toolkit used to assist in training community providers, enabling them to screen and refer low-income women in California’s San Francisco Bay Area for maternal depression. The toolkit was developed to support the implementation of California Assembly Bill 2193, which went into effect July 2019.²⁰ AB 2193 requires all obstetric and prenatal care providers to screen their patients for depression at least once during their pregnancy or 6 months postpartum. Our APHN and health policy students will continue to support and evaluate the implementation of this new law across the state.

Health Policy Specialty

The UCSF School of Nursing established master’s and doctorate specialty programs in health policy in 2002 with initial funding from a Health Resources and Services Administration training grant. The founding faculty of the program believed that health policy education was a missing piece in nursing education and that a focused health policy specialty program would help to prepare nurses with the skills needed to play a greater role in local, state, and national policymaking and to act as policy leaders in a variety of settings.⁴ The program has met and continues to meet all the accreditation requirements, demonstrating the strength of providing policy analysis skills to nurses prepared at the postbaccalaureate level.

As in the APHN program, entering students are either practicing registered nurses with a bachelor of science degree or a second-degree nursing student who has completed an accelerated registered nursing program before starting the graduate program. Doctoral students have completed a master’s degree or enter directly after completing a bachelor of science degree in nursing.

The program focuses on theory and contemporary policy issues and provides nurses with the skills with which to address those issues. It is designed to provide the tools to understand, analyze, communicate, and advocate, and to research policy issues relevant to health, health systems, and health services delivery. The master of science degree program includes a 15-month curriculum of classroom study and a summer policy residency. Courses help students identify and critically analyze and assess the impact of laws, regulations, and policies at the institutional, local, state, and national levels; use in-depth knowledge of the history, structure, theory, and process of health policymaking in the United States (and, in some cases, internationally); evaluate the evidence base for policy proposals; and plan, implement, and evaluate policies.

Students completing the program understand the economic, ethical, and social implications of policy decisions for various affected groups and are prepared to creatively and effectively advocate evidence-based and data-driven policy change. The program emphasizes sensitizing students to the effects of policy on marginalized groups and developing students’ capacity to identify emerging issues. The program offers an intensive in-person educational experience, and as of fall 2021 has graduated a total of 130 masters and 88 doctoral students.

Program graduates have secured positions in government agencies, the biotech industry, health care institutions, private health care foundations, academic institutions (as faculty and research staff), professional nursing organizations, and other advocacy or policy organizations. Many students have been promoted to policy and leadership positions in the organizations where they conducted their residency after enrolling in the program, thus moving from the bedside to the center of policy decision-making.

Health Policy Residency Experiences

A highlight of the program is the students’ summer policy residencies, in which they spend a minimum of 240 hours working in a policy-related setting specifically selected to match their policy interests. Students have been placed in congressional offices, national advocacy organizations in Washington, DC, the WHO in Geneva, professional organizations in the United States, state legislative offices and regulatory agencies, and local public health and policy organizations. During these mentored residencies, students have the opportunity to prepare policy briefs, engage in public hearings, collect data and conduct policy analyses, and prepare policy recommendations to policymakers and decision makers at all levels, including at the global level. Additionally, these residencies offer students the opportunity to represent nurses, who play an important role in a range of policy arenas. For example, one student’s residency experience at the WHO with the chief nursing officer led to the opportunity to contribute to the data collection for and authorship of the “State of the world’s nursing 2020: investing in education, jobs and leadership” report.⁴ Another student’s residency at the WHO involved the preparation of a training program that is used to educate regulators globally on several aspects of policies to regulate tobacco products.

Additional student residency experience includes being involved in preparing policy guidance on improving maternity care through midwifery, making recommendations for policymakers at the federal, state, and territorial levels and to private health sector decision makers.²¹ Finally, a student’s residency in a state congressional office in Sacramento, California, provided the evidence-based and policy options that ultimately resulted in an expansion of access to care for all children regardless of immigration documentation status. The doctoral program in health policy is a focus area for students whose research interests are in health policy and health sciences research.

MERGING THE SPECIALTIES

The specialties we have described have operated independently of each other. However, providing our students with the collective tools they need to meet the major challenges facing health care infrastructure globally and domestically created the opportunity to merge them. Graduates of the APHN specialty are learning about policy, and it is stipulated that, without adequate systems-level change, public health cannot address health disparities, social and health inequalities, medical mistrust, medical racism, the negative effects of climate change, or food insecurities. Health disparities demand a public health workforce that is educated in policy analysis and the creation of systems-level solutions driven by nurses. Our merged specialty, which will begin enrolling students in fall 2022, will provide an opportunity for nursing educators to meet the needs of today’s learners who are passionate about the issues we have mentioned.

Although our 2 specialties were separate from each other, they have traditionally collaborated by offering students the opportunity to enroll in overlapping courses. As the current pandemic has increased the call for more nurses to be involved in leadership at the organization level, at the institutional health systems level, and in the political arena, we hope that this long collaboration on a formal merger of these 2 specialties will equip learners with the tools they need to engage with public health and policy experts in their field. The merger of the 2 specialties has provided a chance to blend both curricula to attract students with an interest in being a force for social justice and health equity.

The demand for our specialties is driven primarily by nurses who are interested in establishing a career in public health or health policy and want to be a part of systems-level change to address health and social issues upstream rather than downstream (i.e., prevention and mitigation). Our specialties were created from the perspective of nurses who are experts in the field of public health and health policy. We differ from traditional programs of masters-level public health, policy, or advanced practice registered nursing by bringing the unique nursing advocacy perspective to public health and policy.²²

MEETING THE NEEDS OF TODAY’S LEARNERS

As the climate crisis continues to affect our local, state, national, and global communities, students have consistently asked for additional resources to assist them in meeting the climate challenge. The persistent droughts, wildfires, and heatwaves in California; the racial and social uprising in summer 2020; and the merger of our public health and health policy specialties have given us an opportunity to expand our course offerings to include content on climate change and its impacts on health, equity, and social justice issues (i.e., environmental, economic, and racial issues).

Our main objective is to create a course that will be of interest to nurses and all students in the UCSF health professional schools. Our goal is to create a broad interdisciplinary survey and interactive course on climate change and its consequences that will include presentations by experts. Climate change and global warming cause extreme weather events; affect air quality, water, food production, industry, and economic and political stability; and present many other global challenges to sustainability.²³ The effects of climate change on health are broad and include communicable and noncommunicable diseases, such as childhood asthma, diseases of hunger, and HIV.

In this course, our students will gain the skills to link climate change with social justice, connecting climate change to health disparities, inequities, and other social vulnerabilities. Climate change affects every area of life and has an increased impact on vulnerable marginalized and minoritized populations. Social justice affects reach of the police state and the criminalization of poverty and homelessness, which increased in the evacuation process of the recent fires in several states across the United States. The people who are most likely to be affected by the climate crisis are least likely to be included in the conversation on how to respond to the crisis. Thus, this course will center the voice and perspective of nurse policymakers, public health officials, and local community activists.

Our merged, innovative curriculum also gives learners a foundation in data analytics to prepare them to use large public data sets so they can respond to health disparities. The volume of routine health care procedures data and population-level social determinants of health data is growing at an unprecedented pace. The availability of electronic health records, insurance claims data, and mobile health data and the ability to link these health care systems data with census, survey, and other data sources have brought fundamental changes to health care delivery, policy design and evaluation, and population-level health initiatives.

In this increasingly data-driven health care landscape, the UCSF policy and public health specialties recognize that nurses working in the public health and policy sectors must have the skills to use a variety of data sources to advance the policy process and public health strategies with data-driven solutions. We will teach this content integrated with research methods and data analysis to enable learners to prepare, use, and disseminate data in meaningful ways to inform evidence-based policy responses and public health initiatives to solve the problems of today and the future.

RECOMMENDATIONS

As our nation and our global communities continue to experience climate change, disparities in health, and structural inequalities, there is an urgent need to train the next cadre of nurses to meet the moment through decisive public health and health policy experiences.⁶ Furthermore, public health and health policy nurses are essential to meeting the SDG and eradicating systems of oppression that fuel inequalities. Thus, based on our experience and evidence, we offer the following recommendations for educating and training the next generation of nurse public health and health policy leaders:

• 1.ensure that nurses receive the knowledge and skills needed to engage in policy arenas at all levels (i.e., institutional, local, state, national, and global);
• 2.review, as needed, curricula to ensure that they are meeting the key areas recommended by the Future of Nursing 2020–2030;
• 3.recognize that not all advanced nursing roles are clinical by using language in educational competencies that includes nurses with primary roles in health policy and public health;
• 4.properly delineate the roles of nurses in public health and health policy in educational competencies;
• 5.integrate climate change and social justice content as standalone courses rather than topics embedded in an existing course;
• 6.expand the number of public health and policy programs and specialties across US schools of nursing, thus training more nurses in this area; and
• 7.enhance nursing schools’ curricula to explicitly include content that focuses on ending systemic racism, racial and ethnic discrimination, and other inequalities among minoritized and marginalized communities.

CONCLUSIONS

Although few programs in the United States have a primary focus on preparing nurses to engage in all stages and at all levels of public health and health policy, such education is aligned with the American Association of Colleges of Nursing (AACN) educational essentials, including the emphasis on the policy role and the public health role in addressing social determinants of health and health disparities and promoting equity. The AACN makes it clear that preparation in health policy and public health and population health are equally important as preparation to work in clinical settings, emphasizing the need for nurses to have the ability to “analyze systems-level and public policy influence on care coordination.”^10(p61)

Similarly, the latest AACN essentials propose that nurses be prepared to conduct policy research and understand how policy and regulations affect public health and health care delivery. Therefore, schools of nursing must evolve to meet the needs of today’s learners who are interested in public health and health policy careers. Although our merged specialties provide the first step in preparing future nurses to engage in these arenas, we hope that they will also provide a blueprint to assist other schools of nursing in developing similar specialties. We also hope that our specialties demonstrate how nursing school curricula can be enhanced to include content that focuses on ending systemic racism and racial/ethnic discrimination and on increasing access and opportunities for minoritized and marginalized communities.^11,13