An Overlooked Strategic Powerhouse: How Nurses Can Rise to the Challenge of Integrating Public Health and Primary Care

Although the United States is one of the wealthiest countries in the world and a leader in biomedical innovation, its health care system is consistently ranked among the worst in terms of cost and health outcomes. Americans have short life expectancies, high infant mortality and obesity rates, and soaring chronic disease rates compared with other wealthy nations. In 2021, the National Academy of Medicine (NAM) was charged with examining what it would take to improve US primary care. The NAM report described the practice of siloing public health from primary care or treating these areas as separate fields of scientific inquiry, practice, and billable service.¹ NAM identified this separation as a key driver of poor health outcomes and health inequities in the United States. The Institute of Medicine (IOM) examined similar phenomena in a 2012 report, noting how the two fields tend to operate independently, despite complementary functions and common goals.²

Where these silos persist, we see communication and process breakdowns at the point of care. For instance, when large swaths of Americans turned to trusted primary care providers for COVID-19 vaccine insights, their primary care providers did not always have the most up-to-date information, in part because of a lack of interprofessional cohesion (including fragmented public health messaging and data systems). If we are to remedy such issues, a substantive paradigm shift must take place: We must move toward what DeSalvo et al.³ termed “Public Health 3.0.” In this model, multiple sectors, specialties, and stakeholders form coalitions to mobilize data, people power, and resources in a strategic manner to advance health for all. To be truly strategic, we must think carefully about how to leverage nurses—who care for patients across the lifespan and in nearly all public health nursing (PHN) and primary care settings—within these coalitions.

The 2021 NAM report urges health care teams to undertake the mission of integrating systems. However, NAM stops short of describing exactly how teams ought to accomplish this aim and the proposed makeup of said teams. Like any group project, success will depend on the ability of teams to identify leaders and clearly delineate responsibilities. The purpose of this editorial is to explore the potential of PHN and primary care nurses and to describe the roles they might assume in the collaborative integration of their respective silos.

WHO ARE PUBLIC HEALTH AND PRIMARY CARE NURSES?

PHN is “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences.”^4(p1) Between 37 000 and 41 000 public health nurses practice in the United States across all states and territories, with many employed by state and local departments of health.⁵ Although public health nurses often provide direct clinical services, their roles vary greatly, depending on community needs. Public health nurses may focus on health promotion, disease surveillance, community-based participatory research, or health advocacy, among other areas.⁵ In addition to health departments, they may be found working in “schools, homes, community health centers, clinics, correctional facilities, worksites, out of mobile vans and even dog sleds.”^4(p1)

Primary care nurses, on the other hand, are found in primary care offices, telehealth and concierge health practices, retail health clinics, and community health clinics. These nurses promote primary prevention, manage chronic conditions, and support quality of life across disease trajectories. They often work with people and families over many years, providing important continuity of care within fragmented health care systems. Of the 3.5 million nurses practicing in the United States, only about 9% practice in ambulatory care, which encompasses primary care.⁶ This includes approximately 55 625 primary care nurse practitioners.⁷

Primary care nurses often work alongside public health nurses in community clinics and departments of health. Both may occupy roles spanning organizational levels from patient care, to care coordination, to office management, and to senior leadership. All nurses receive information on PHN and primary care in their prelicensure programs. However, few nurses are exposed to integrated models of care in communities; rarely is the power potential of fully integrating these two areas covered sufficiently either. Nurses can embrace their power and influence by developing education and certification programs that integrate these silos, teaching emerging nurses how to work across disciplines to improve health care.

THE VALUE OF LEADING FROM THE FRONT LINE

The 2021 NAM report clearly stresses the importance of placing patients, families, and communities at the center of measures for improved primary care (Box 1). This approach aligns with the nursing paradigm, which imagines optimized care as a web of considerations (one’s family, culture, lived environment, finances, etc.), with the patient or community at the center. Nurses are therefore primed to consider how interlocking systems bear on individual and population health outcomes. At all levels, nursing preparation assumes this paradigm and emphasizes competencies relevant to public health leadership, including interprofessional collaboration, stakeholder engagement, and data analytics. These factors position nurses as ideal early adopters and influencers of professional integration.

BOX 1—

Opportunities for Public Health–Primary Care Integration

•Improve treatment and management of chronic complex medical and psychosocial conditions •Improve effectiveness of dissemination and prevention and health promotion •Increase primary care capacity to influence public health goals •Bring larger focus to health of a community through connected healing and trusted relationships •Reach families that do not have primary care through diverse integrated teams •Meet people where they live and work, including settings such as schools and day care, senior citizen settings, places of worship, barber shops, salons, and libraries

Source. Based on data from National Academies of Sciences, Engineering, and Medicine.¹

Public health nurses and primary care nurses bring an intimate, human understanding of illness and barriers to care as well. Nurses live and work every day in the microtrenches of care, and they are trained to understand how everyday frustrations fit into a “macro” picture of fragmented systems and professional silos. We cannot underestimate the value of this perspective in strategic planning and change management. Nurses ought to be recognized and supported as frontline leaders with the skills, acumen, and lived experience necessary to achieve reforms.

ACTION AT EVERY LEVEL

Nurses can demonstrate this leadership potential through simple steps, including the following:

• •Nurses of all levels can pursue continuing education opportunities in PHN or primary care.
• •Nursing employers should cover continuing education costs, along with professional development opportunities (such as conferences).
• •Nurses of all levels can advocate for integration and educate colleagues via engagement with professional associations, social media, op-ed writing, workplace events, and in-services, among others.
• •Nurse managers can lead campaigns to promote work cultures where primary care is seen not as a specialty, but rather as essential to the implementation of all health care.
• •Nurse leaders can shift their organization toward an integrated model through the careful selection of data systems, the formation of strategic partnerships, and interprofessional staffing.

Nurse leaders should collaborate with primary care, public health, and community organizations to cultivate Public Health 3.0 coalitions.

SUSTAINING INTEGRATION THROUGH EDUCATION

Nurse educators will play a pivotal role in sustaining this work. In most nursing programs, there is too much focus on acute care and not enough focus on both primary care and public health. From the undergraduate level to the doctoral level, academic nurse leaders and faculty should critically examine curricula for such oversights. To start, nursing faculty should incorporate data analytics—a core public health competency—into curricula, regardless of the subject at hand. This will show future nurses that, with the right data, they can influence and continuously evaluate change from the individual level to the population level. It will also create a pipeline of nurses who are prepared to build data conduits from PHN surveillance to primary care practice. Any opportunities for weaving analytics and PHN science into doctoral dissertations should be considered.

In clinical settings, nursing students need to witness and participate in the integration of public health and primary care through hands-on learning. Students should have exposure to positive role models functioning at the top of their license in primary care. In fact, before home health nurses moved to staffing under private home care companies, students would have rotations with providers managing complex care at home. Limited hospital stays have further separated nurses practicing in hospitals from the communities where their patients live, work, and play. It is time to collaboratively revamp clinical education to ensure immersion across practice environments and disciplines.

CONCLUSION

For nearly three decades, the IOM, NAM, and other leading organizations have called for greater primary care–public health integration. Despite this urging, no one entity—educational or professional—has assumed accountability for implementation. Nurses are familiar with stepping up to wicked problems in health care when leadership is needed. Change will happen at the front lines of care; if true integration is to occur, it will take place in senior centers, places of worship, adult daycares, barbershops, beauty salons, and libraries. Nurses, already a trusted presence in these spaces, will be there to lead the way.