Shoring Up the Frontline of Prevention: Strengthening Curricula With Community and Public Health Nursing

The terms “frontline” and “prevention” are now common everyday household words heard across America. However, the most exigent focus for investments in prevention is unclear, as is the location of the true frontline. County Health Rankings demonstrate that 80% of our health outcomes are not resolved within clinical or acute care settings.¹ However, the number of nurses practicing in community and public health settings has been consistently declining, from 4% of the workforce in 2013 to 2.9% in 2020.² Existing disparities in nursing salaries may be a contributing factor to the decline. In 2021, the US Bureau of Labor Statistics³ reported the average national registered nurse salary to be $75 330, whereas the average public health nursing salary is $68 661.⁴ Furthermore, public health funding decreased substantially across the nation prior to the pandemic, leading to lost staff positions, which resulted in a weaker public health workforce and infrastructure.⁵ Each successive surge of the COVID-19 pandemic has exposed the dire need for more nurses in public health and community settings. For years to come, concerns about the nursing workforce are likely to persist as we witness intensifying health care demands created by changes in the delivery of health care services, population shifts, and health care transformation.

In spite of these trends, many schools of nursing across the nation design and deliver a curriculum with a central focus on illness care or disease treatment to be rendered in inpatient settings.⁶ As a result, our nation’s essential health interests beyond the bedside remain unequivocally compromised.

In this article, we argue that the predominant and pervasive curricular focus of nursing education on acute care has limited the ability to prepare a workforce ready to address public health threats, which has become more evident since the onset of COVID-19. We advocate for (1) intentional changes in nursing curricula designed to reinforce didactic teaching of public health sciences and social determinants of health, and (2) deeper investments in three-way community–academic–practice partnerships to promote a nursing workforce equipped for intersectoral practice in settings outside of the hospital, leading to a far-reaching impact on population health.

ADDING POPULATION HEALTH TO CURRICULAR CONTENT MAPPING

Mapping population health in the nursing curriculum requires academic and health institutions to shift from a singular focus on individual holistic needs to a framework that emphasizes social and structural determinants of health, both in didactic and clinical training. Simply put, it is insufficient to address social needs, which represent the downstream effects of root causes. Instead, a robust nursing curriculum requires a critical examination of the upstream social determinants of health that directly and indirectly cause poor health outcomes.⁷ To inform the development of national nursing education guidelines, the Council of Public Health Nursing Organizations⁸ issued a statement in 2019 outlining priority social determinants of health and recommending key action steps for implementation in academic and practice settings. The consistent refrain of these recommendations is the need to increase faculty development in community and public health, population health, advocacy, and policy to shape action-oriented curricula that will equip students to address racism, poverty, environmental injustice, and violence.

The American Association of Colleges of Nursing⁹ and the National Academies of Sciences, Engineering, and Medicine¹⁰ recently published revised guidelines for nursing education; the cross-cutting theme of both documents is not a call for greater investments in acute care but rather a reinvigoration of public health values and principles for population health and health equity. Hailed by some as a paradigm shift in nursing education and practice, this emphasis is not new for public health nurse educators. Since 1965, community and public health nursing content has been part of the required baccalaureate nursing curriculum.¹¹ However, advancing the quality and augmenting the impact of community and public health nursing education, practice, and research is critical for improved local to global health outcomes.

To prepare nursing students for practice through the lens of public health, we propose weighting, leveling, and distributing epidemiology, biostatistics, environmental science, emergency management, disaster preparedness, social determinants of health, health equity, care coordination, and disease prevention as the didactic core throughout the nursing curriculum. In addition, we assert the need for the clinical core of the nursing curriculum to include opportunities for intervention at all levels of practice: preparing nurses to design and deliver care at the level of the individual, family, community, systems, and populations.¹²

To implement this directional change, essential knowledge and skills in systems awareness, change management, cost containment, resource allocation, communication, team building, equity, and inclusion are required for competent, evidence-based practice, as is the development of competencies in informatics, data science, design, and systems thinking. Furthermore, an understanding of how local, national, and global structures, systems, politics, and rules and regulations contribute to the health outcomes of individual patients, populations, and communities will support students in developing agility and advocacy skills.

Additionally, effective advocacy requires consideration of the social needs of individuals, which are inextricably connected to structural determinants at the community, society, and policy level. Therefore, to affect the health of populations, nurses are called upon to make this broader, more integral connection between policies, systems, and environmental impact.

LEVERAGING COMMUNITY–ACADEMIC– PRACTICE PARTNERSHIPS

Didactic teaching provides nursing students with the conceptual foundation to achieve competency, whereas clinical practice allows students the opportunity to develop and demonstrate competency.¹³ To ensure effective clinical experiences, deliberate investments of time and resources are needed to support the development of mutually beneficial partnerships between community practice sites and academic institutions. This intentional work results in high-quality, positive experiences for students, practice sites, and clients alike.¹⁴

Evidence suggests that academic–practice partnerships positively affect outcomes for patients, staff, and student learners, providing a formalized means for translating evidence-based practice principles to improve clinical decision-making, increase staff knowledge of evidence-based practice and experiential learning, and inspire the growth of evidence-based population health initiatives.^6,15

Student learners immersed in academic–practice partnerships have unique opportunities to become experienced in evidence-based practice analysis and translation while growing their ability to become skilled, compassionate caregivers and attentive patient advocates. These partnerships provide opportunities to seek external funding to address population health concerns, build community capacity, and expand the existing public health nursing workforce. Overall, the published literature highlights the benefits of academic–practice partnerships to clinical agencies, school-based settings, ambulatory care, and health departments by providing an eager, competent student workforce to address individual, family, and community concerns.¹⁵ Although academic–practice partnerships have traditionally focused on health care environments, there is now an opportunity to invest ardently in 3-way community–academic–practice partnerships based in communities and community agencies. The priority for these partnerships is relationship building through the lens of equity, capacity building, and reciprocal service-learning benefits.

We encourage nursing faculty to pursue intersectoral partnerships beyond traditional clinical sites, exposing students to a wide variety of practice environments that deliver essential public health services. Examples of nontraditional partners include faith-based communities, where evidence has shown improved access to care and community capacity through the teamwork of nurses and community health workers.^16,17 Partnerships with libraries promote community connections for those experiencing food insecurity, homelessness, and mental health crises¹⁸ while educating community and public health nurses on the application of evidence to inform practice.¹⁹ Additional partners could include commercial businesses, housing programs, governmental or nongovernmental organizations, transportation, and urban planners. By investing in unique partnerships, nurse educators challenge the stereotypical role of bedside nurse and affirm the upstream role of and place for nurses, who are bringing health to where people live, learn, work, play, worship, and age. Successful partnerships with sustainable outcomes will expand awareness of nurses’ full scope of practice beyond the acute care setting, where many nursing schools and faculty currently limit their clinical training. A recent report issued 10 recommendations to prepare faculty to teach community and public health nursing, including the call to revise recruitment, hiring, orientation, and professional development practices to reflect public health nursing guidelines and competencies.²⁰ Developing structures and processes for successful community–academic–practice partnerships will strengthen clinical education and improve the preparation of the future public health nursing workforce. Additionally, the realities of structural determinants of health are more apparent in community settings, providing students with a real-world perspective about precursors to health outcomes and barriers to access.

In addition to providing learning opportunities for students, community–academic–practice partnerships are a mechanism for continuing professional development for the current community and public health nursing workforce across practice settings. Many community and public health nurses work in small, local public health departments unaffiliated with large academic institutions or hospitals and have limited access to evidence-based resources or financial support for professional development. Since 2017, the Nursing Experts Translating the Evidence project, an interprofessional collaborative effort between nurses and librarians, has been educating public health nurses on the acquisition, translation, and application of evidence to inform their practice.¹⁹ Through active community–academic–practice partnerships, community and public health nursing educators and governmental and nongovernmental public health agencies can build capacity for community and public health nursing practice for the future, as we continue to apply evidence-based, data-driven problem solving through the pandemic and beyond.

CONCLUSION

In schools of nursing across the country, administrators face dual expectations: managing faculty shortages and centering population health in curriculum revision focused on competency-based strategies.^9,10 Given the small percentage of nurses who presently practice in community and public health, it is increasingly difficult to find faculty with expertise. However, instead of decreasing community and public health nursing clinical education hours and replacing them with more acute care clinical education hours, we urge schools of nursing to respond to the call for deeper investments in public health nursing, both in didactic and clinical courses, as outlined in this article. Furthermore, we implore administration, accrediting bodies, and educators to audit the inclusion of public health nursing guidelines in curriculum development and to mandate continuing professional development through leading public health nursing organizations, as highlighted in the Future of Nursing 2020–2030 report.¹⁰

The time is right for the profession of nursing to influence the direction of health care delivery and health outcomes for populations and communities. Leading nursing organizations agree that population health and social determinants of health are drivers of change within the profession. May we not lose the opportunity to move forward boldly, not in appeasement but in authentic, robust curriculum reform that will shore up the frontline of prevention and propel the role of nurses and the profession of nursing from the bedside to the community. For nurses to be fully competent to address the social and structural determinants of health—in the context of all communities where 80% or more of health decisions happen in everyday life, work, and play—we must strengthen and reform the nursing curriculum to fully include these concepts and competencies. People, communities, and health systems are waiting on us to do it differently. Public health nursing educators are the leaders who can influence this future. Our time is now.