Public Policy and Public Health Nursing
The provision of community and public health nursing takes place where people live, work, and play, said Mary C. Selecky, the secretary of Washington State’s Department of Health. Public health and community nurses are a part of prevention, primary care, emergency care, and long-term care across all settings, from isolated rural areas to bustling cities. This type of care involves hospitals, clinics, long-term care facilities, private providers, home and community settings, and even the media. All of these different actors and settings need to work together, which creates unique challenges for nurses.
In public health nursing, we are faced with the best of times and the worst of times, said Selecky. For example, public health nurses have collaborated at federal, state, and local levels across the country and across boundaries to play an essential role in addressing the H1N1 flu pandemic. Nurses also are working together to lead vaccination efforts and communication campaigns to promote hand washing and social distancing when people are sick. “Issues in Maine are also the issues in Washington,” said Selecky. “We all touch each other because of travel.”
Yet public health nursing has suffered serious setbacks recently due to economic and budget challenges across the nation. The State of Alaska has reduced public health nursing for family planning and community outreach. Connecticut has cut back the loan forgiveness program for nursing students. Florida has eliminated school nurse programs. Iowa and Maine have reduced public health nursing, and Massachusetts has eliminated the nurse’s aide scholarship program. In Washington State, 300 public health positions, many filled by nurses, have been eliminated.
“Public health nursing is very complex,” Selecky said, “because you take all of your clinical skills and you have to broaden them and look
across the community.” The Initiative on the Future of Nursing is being conducted at a critical time, said Selecky, because there will be fewer public health nurses in the future and they will face increasingly complicated problems. What kinds of skills and abilities will they need and what kinds of collaboration and partnerships will they have to forge to meet the challenges they face?
CHALLENGES FACING PUBLIC HEALTH NURSES
Selecky provided an inventory of principles that are important in public health nursing and posed a series of questions on how to better prepare public health nurses. First is a focus on community. Public health nurses are charged with improving the overall health of people in the community. Yet a comprehensive definition of community health takes into account healthy foods, physical activity, smoke-free homes and public places, and healthy environments. How can nurses be prepared to take on these broad policy challenges, she asked, in addition to helping sick people and managing clinical interventions?
Partnerships are essential for successful public health nursing. The governmental public health system is not solely responsible for ensuring public health. It has to work with many partners to achieve its objectives, including other parts of the health care system, Native American tribes, schools, social service agencies, environmental organizations, businesses, emergency management agencies, and homeland security. Establishing, maintaining, and strengthening these partnerships require particular skill. What kinds of skills do nurses have to acquire to foster team-based approaches to complex issues and handle limited-budget situations, and how do they acquire those skills?
Public health nurses need to draw to a much greater extent on evidence-based prevention strategies. An example is the community health program, Nurse-Family Partnership, that was developed by David Olds, director of the Prevention Research Center for Family and Child Health at the University of Colorado Health Sciences Center. Rigorous research has shown that the program generates substantial returns through interventions in the lives of low-income, first-time mothers and their children (Olds et al., 2007). Nurses visit these expectant mothers during their pregnancy and during the first two years of their children’s lives to teach them parenting and life skills and help them gain access to job training and education. Where the Nurse-Family Partnership program
was instituted in 10 counties across Washington State, for example, 90 percent of babies were born full term, 88 percent were fully immunized by 24 months, 86 percent of children had no visits to the emergency room in their first year of life due to injury or ingestion, and 93 percent of mothers initiated breast-feeding. Additionally, the program has been shown to save four dollars for every one that is invested (Karoly et al., 1998). “The Nurse-Family Partnership program has an evidence base,” said Selecky. “We need to stick with that. What we have to do is let some non-evidence-based programs go.”
Another example of the use of evidence to promote successful public health nursing involves school nurses. School nurses have a diverse and challenging job, and the health conditions being dealt with among student populations are increasingly complex, Selecky observed. In the Kent School District south of Seattle, 10 years ago there were 35 diabetic students and 215 students with life-threatening allergies. Today there are more than 150 diabetic students and 2,500 students with life-threatening allergies. A research review conducted by Julia Dilley found a strong correlation between school health interventions and academic achievement (Dilley, 2009). “Improved student outcomes result where schools have full-time school nurses,” said Selecky.
Nurses need to be fluent in technology. That means much more than following someone on Twitter or being competent with a BlackBerry or a computer. It involves such tasks as retrieving data, sharing information, and mining health charts for information about both patients and the community. Programs that educate nurses need to emphasize technology and how to use it not only to communicate but also to plan, provide, and evaluate care.
Nurses also need to understand the social determinants of health and recognize the importance of equity, said Selecky. The demographics of communities are changing rapidly. Washington State, for example, has 29 federally recognized Native American tribes, a high percentage of Asian-American residents, and a wide range of immigrant communities. The Seattle School District routinely translates information into 40 languages. Income levels vary widely, even in areas with high average incomes. Dealing with income inequities requires an emphasis on community, especially when also working with people who speak English as a second language. Public health nurses sometimes double as health navigators to get people in the community the right information to help them make decisions for themselves, which can be further complicated when facing language and cultural differences.
Public health nursing has entered an era of accountability and quality improvement, Selecky said. A national movement for voluntary accreditation has placed new demands on nurses and public health agencies. In addition, nurses, more than ever, need to be skilled at written and verbal communication. Nurses may be skilled at interacting with patients, but they also need to be able to write clearly and speak in front of groups to influence and effectively improve the health of people in their communities.
Public health nurses must have mastered the basics of their professions. They must promote immunization, detect emergency health threats, and prevent and respond to communicable diseases. In addition, they need to be prepared to deal with public health emergencies. For example, an increasing number of nurses need to be trained in incident command. Selecky works closely with the chief of the state police patrol and the adjutant general of the National Guard, as well as the head of the department of social and health services. In 2007 when the town of Chehalis south of Seattle experienced one of the worst floods in 100 years, a public health nurse called Selecky to ask how to deal with and dispose of dead cows, an unforeseen challenge as a public health nurse. The nurse knew she needed tetanus shots and portable toilets but had not anticipated other, less common, aspects of the emergency. “We all have to learn to deal with emergencies, no matter what they are,” said Selecky.
PUBLIC POLICY IMPLICATIONS
Ensuring public health has important implications for the involvement of nurses in public policy, said Selecky. First, public health cannot be separated from politics. Politics is part of everything public health nurses do, as demonstrated by the term “public.” Intrinsically, politics need not always have a negative connotation—it consists of the art and science of government and governing. Similarly, while some may view politicians negatively, they are not inherently devious; they are public servants elected to represent the values and beliefs of their constituents, noted Selecky.
Second, science is not policy, but science informs the development of policy. Community values also inform public policy, which again emphasizes the importance of communication and relationships. In addition, political instinct and judgment are essential skills for public health nurses to master. For that reason, public health leaders, including nurses, must
have well-honed strategy skills. They must know the public health needs of their communities and understand the science and the best policy and implementation options for meeting community needs and values. Public health leaders and nurses need to provide a buffer and a bridge between the political world and the health world. Larry Wallack, dean of Portland State University’s College of Urban and Public Affairs, once said, “I have never heard data say a word. It is people who take it and turn it into information for other people.” Selecky asked, “Who can do that better than a nurse? Who is best trusted when there is a tough health issue? A nurse.” Nurses need to understand their role in the development and implementation of public policies that impact health. They also need to inform public policy with science and evidence-based facts and be ethical, professional, and collaborative, said Selecky.
The third point Selecky highlighted is that the current investment in public health does not meet the need at a time when all expenditures are being scrutinized. Washington and many other states are facing severe budget deficits, which means that every dollar spent has to be examined. “My budget is 50 percent federal dollars and only 20 percent state general funds, but every one of those [dollars] is essential.” Accountability and performance requirements are increasing, which means that evidence-based practices will be further emphasized.
Selecky notes that nurses’ roles, in general, will continue to be essential, regardless of what happens with health care reform. Nurses affect access, affordability, and health care improvement and are the best teachers in the health care system. They need to understand politics, public health, and partnerships. They have to be comfortable with new technologies and talk plainly and clearly, said Selecky. They need to know the basics of public health and be prepared for new health threats, changing priorities, and new opportunities.
Selecky concluded by offering the committee three suggestions pertaining to the education and professional development of all nurses:
The nursing curriculum needs to change to focus on policy, technology, and community-based practice. “No matter if you are in an institution or working in a hospice or in a governmental or for-profit organization, if you are a nurse you need to understand your impact on the community,” said Selecky.
Schools of nursing need to place considerable emphasis on verbal and written communications. They also need to graduate life-
long learners who have the ability to learn new things and change course along the way.
Nurses need leadership development programs, particularly in community settings.
RESPONSES TO QUESTIONS
In response to a question about the need to diversify the public health nursing workforce, Selecky responded that it is absolutely essential. In Washington State, she participated in hearings across the state in minority communities to discuss opportunities in the health professions. Many students at those hearings recounted how they became interested in science. For example, a teacher expressed an interest in a student, a student was inspired by a role model, or a student was invited to attend an after-school science club. “I challenge every one of you to find your replacement. Talk to somebody you didn’t talk to before. Go into a different place in your community and say, ‘Are there any kids who might want to talk to me and find out what it is like to be a nurse?’ Because they may never have had that opportunity. You are part of the solution,” stressed Selecky.
Augmenting the preparation of nurses may require involving people from other parts of a university or college, such as a faculty member in political science, public policy, or communications. At the University of Washington’s School of Public Health, Selecky’s communications director often talks with students. “He shows clips from bad interviews and clips from good interviews and [describes] what you can learn and how you can handle that situation differently. You don’t have to have the same person doing the same thing to be able to expand the curriculum,” said Selecky.
In addition, many valuable written materials are available about public health and its connection with public policy, such as the Institute of Medicine’s 1988 and 2002 reports on public health (IOM, 1988, 2002). Selecky said that “there is a lot of learning for us to do, [but] there are a lot of resources to build on.”
A member of the audience asked about the role of public health nurses in community evaluations and interventions, and Selecky responded that she would like to have nurses represented in many state divisions, such as the division of environmental health. Nurses could look at issues such as asthma, which is common in Washington State.
“Nurses bring incredible diagnostic skills—what in some [contexts] is called community assessment,” Selecky said. On home visits, nurses can pay attention not just to an infant but to whether the house is littered with garbage, whether a father is present, or whether there is food in the kitchen. “The nurse of the future will have those skills.”
A question from someone watching the webcast of the forum asked about improving health beyond the bedside and in the community, and Selecky described two women who received associate degrees in nursing when she was working in a rural area of Washington State. When the women asked her whether she had jobs for them, she put them both to work knowing that nurses interested in public and community health are often swept up into acute care, where most jobs for nurses are. “Did they have all the community nursing experience that you might want them to have? No. But that was my job, to make sure that they got that type of experience and training and oversight,” said Selecky.
Selecky also was asked about the intersection between public health nursing and mental health. “We are whole bodies and whole communities,” she responded, yet the mental health system is often in a separate silo from public health nursing, partly because of how the two kinds of services are funded. “Perhaps we need to have public health nurses embedded within our mental health system, and vice versa,” she suggested.