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Population Health for Nurses

3.1 Defining Public/Community Health Nursing

Population Health for Nurses3.1 Defining Public/Community Health Nursing

Learning Outcomes

By the end of this section, you should be able to:

  • 3.1.1 Define community health nursing practice.
  • 3.1.2 Describe major historical events and factors that have shaped public health nursing practice.
  • 3.1.3 Identify nurse leaders who have influenced public health practice.

Community health refers to a community’s physical, mental, and social well-being and involves health promotion, risk reduction, and disease prevention efforts to support health. Nurses in community health care for an entire community. They identify, assess, and respond to the health needs of populations (Kulig, 2000). A community is a group of people with at least one characteristic in common. The characteristic may be a place, a personal attribute, or a common goal. Every community has individuals with health problems and health risks. For example, members of communities that lack access to clean drinking water share health risks related to the harmful chemicals in their water, dehydration, and concern about a water crisis. A community situated near a busy highway may notice increased rates of hearing loss. Yet another community may see high rates of gun violence, leading to fewer children engaging in outdoor play. All communities, regardless of location or their members’ personal characteristics, have health risks and health needs and can benefit from the involvement of nurses with expertise in providing population health care. Remember, population health is an approach to supporting the health of people through research, data analysis, and health programming that considers the impact of public policy, environmental, social, behavioral, and other factors that might facilitate or hinder health for all.

Case Reflection

Addressing a Water Crisis

Read the scenario, and then respond to the questions that follow.

The Lee family lives in a two-bedroom apartment in a quiet residential neighborhood. They can walk to a playground and walk or take public transit to other community spaces, but their city has a major problem. For years, the city has lacked adequate safe drinking water. Alexandra or Christopher must go to a city building once per week to obtain drinking water for the family. The family is supposed to bathe in this water, but the city does not provide enough water to satisfy drinking, cooking, and bathing needs.

  1. What are the consequences of not receiving enough water to support drinking, cooking, and bathing?
  2. Given the health status of Alexandra, Christopher, Sunshine, and Woody described in What Is Population Health? and Foundations of Public/Community Health, what risks do they face living in a city with a water crisis?
  3. How can nurses contribute to addressing water crises?

Public/Community Health Nursing Historical Perspectives

In 1949, the National Organization of Public Health Nurses (the leading organization at the time) distinguished community health nursing from public health nursing (Kub et al., 2015). In a position statement, the organization stated that community health nursing involved caring for individuals and families with the latest available interventions of the post–World War II era, whereas public health nursing was primarily concerned with population-based strategies (Abrams, 2004). Some nursing experts consider that community health nursing fully emerged as a distinct specialty in the 1960s, describing the work of nurses who provided care not offered through government organizations (University of Maryland School of Nursing, 2023). Two decades later, the American Nurses Association (1980) convened an expert panel to develop a conceptual model of community health nursing. The panel defined community health nursing as a synthesis of general nursing practice and public health with a purpose of promoting and preserving the health of the population. Today, nurses who provide myriad services to communities across settings are recognized as community health nurses. Still, discourse continues within the nursing discipline regarding how public and community health nursing can be fully defined and distinguished as separate fields (Goodman et al., 2014; Kub et al., 2015; Schofield et al., 2011). As noted, the ANA (2022) views community and public health nursing as indistinguishable.

Many historical events have shaped public/community health nursing practice. Public/community health nurses have a role in responding to events that impact the population’s health, whether the events center around war, struggle, progress, infectious diseases, or evolving social, cultural, and political influences. World War II, the emergence of HIV and AIDS, and the COVID-19 pandemic are three examples of events that presented opportunities for public/community health to change lives and for public/community health nurses to demonstrate their value.

World War II

In 1946, U.S. President Harry Truman described public/community health nurses as “one of the most important groups of health workers” following their contributions during the second World War (Associated Press, 1946). During that war nurses delivered care to the military and their families, the general public, and refugees. The independent nature and opportunities for leadership during combat care provision prompted many nurses to seek new professional roles with greater autonomy upon their return to the United States, and many found that public/community health nursing met this need (Barnum, 2011). Beyond the care nurses provided to manage acute and chronic health conditions, they educated the public to raise awareness of health and health issues, prevent the spread of diseases, and promote vaccine uptake (the proportion of the population receiving a vaccination).

The war era ushered in a baby boom, with 76 million births in the United States between 1946 and 1964 (Population Reference Bureau, 2023). This led to overcrowded labor and delivery units, and quick hospital discharges for birthing parents necessitated postpartum care as a part of public health. Public/community health nurses conducted home visits to provide postpartum care and led prenatal classes to support maternal/child health. Lawmakers and the public supported such nurse-led services due to a wartime rhetoric of maternal-child health as critical to military morale (Temkin, 1999).

Public/community health nurses were also critical in supporting veteran care and rehabilitation efforts following the war. As part of the national economic reconstruction, public/community health nurses became instrumental in addressing veterans’ physical and emotional health needs (Buffum & Wolfe, 1995). As the oldest World War II veterans still need care, public/community health nurses continue to be involved in supporting community access, inclusion, and health for this population. From delivering care to promoting health through education and bringing care out of the hospital and to the public, public/community health nursing during this era highlighted the significant contributions of nurses in supporting a healthy population.

Legionnaires’ Disease

Americans across the United States celebrated the nation’s 200th birthday throughout 1976. The American Legion, a national nonprofit group supporting military veterans, held a convention of over 2,000 members in Philadelphia, Pennsylvania (Markel, 2018). Following the convention, several attendees sought care at the local Veteran’s Administration hospital for a type of pneumonia that was unfamiliar to clinicians, was not diagnosed with typical testing, and failed to respond to antibiotics. Following four client deaths from this puzzling condition only 10 days after the convention ended, the hospital consulted the Centers for Disease Control and Prevention (CDC) for help in determining what was affecting the clients and why. In another two weeks, a total of 182 convention attendees (called Legionnaires) were ill, and 29 had died. In addition to the Legionnaires, a city bus driver, pedestrians who had been close to the convention hotel, and the hotel air-conditioning technician were ill. Ultimately, 182 people were infected and 29 died (Fraser et al., 1977). Investigations eventually identified a new deadly bacteria named Legionella pneumophilia (McDade et al., 1977). The bacteria were able to cause a particularly concerning level of harm because they could be aerosolized and spread via the air-conditioning system. Today, the CDC continues to monitor rates of Legionnaires’ disease in the United States, which have been on the rise since 2000 (CDC, 2021).

HIV and AIDS

In the 1980s, the first recognized cases of human immunodeficiency virus (HIV) emerged in the United States (Dorwick et al., 2023). This new disease, about which little was then known, significantly impacted public/community health nursing, as the speed and reach of infections reached pandemic levels. Similar to Legionnaires’ disease, clients initially presented with an atypical pneumonia that puzzled clinicians. The lack of knowledge about the disease and how it spread contributed to a great deal of fear, stigma, and homophobia among members of the public and the health care community. Public/community health nurses needed to learn as much as possible about the virus quickly to help prevent its spread and manage the condition. They also needed to combat the fear and misconceptions that led to social isolation, medical neglect, or worse for people with HIV or autoimmune deficiency syndrome (AIDS) or those thought to be at risk for having or spreading HIV. Some clinicians and members of the public even refused to shake hands with a person who they thought might have contracted HIV or might have developed AIDS for fear of contracting it. Compassion and setting an example were key aspects of the work of public/community health nursing in response to the HIV epidemic. Public/community health nurses provided direct care to individuals who were living with HIV or had developed AIDS. They were also involved in developing centers and units dedicated to providing care for those with HIV or AIDS in a safe, supportive, and comprehensive manner.

Cliff Morrison, a nurse who was instrumental in collaborating with the public health department and developing the first unit for people with HIV or AIDS in San Francisco, has said, “This is a disease that is more geared toward nursing than anything else that we’ve ever seen because there isn’t that much that medical science can do, but there’s a lot that nurses can do . . .the most important thing we can do is to touch our patients” (Vieites, 2020, para 9). Cliff and his nurse colleagues were subjects of the documentary 5B about this first HIV and AIDS unit. Today, treatments for both HIV and AIDS have improved, and the stigma associated with the disease in the United States has abated, but there is still progress to be made. Modern nurses have been called the “backbone” of the successful delivery of services to people living with both HIV and AIDS, especially in the most affected areas of the globe (Guilamo-Ramos et al., 2021). Public/community health nurses provide education to prevent HIV transmission and to promote testing, treatment monitoring, and counseling as part of the ongoing efforts to combat HIV and AIDS globally. Pandemics and Infectious Disease Outbreaks covers the HIV and AIDS pandemic in more detail.

COVID-19 Pandemic and Beyond

Public/community health nurses were pivotal in the U.S. response, adaptation, and continued flexibility to the COVID-19 pandemic. Public/community health nurses have provided care and guidance to affected clients and families, shared information about evolving knowledge and best practices for disease mitigation and management, and worked exceptionally hard to prevent the spread and impact of the virus (Edmonds et al., 2020). One key role of public/community health nurses during the first 18 months of the pandemic was contact tracing and disease surveillance. Disease surveillance may consist of many data collection activities that aim to inform a disease response plan. Contact tracing involves identifying the people who may have been around a client with a particular disease and are therefore at risk of acquiring or spreading it. As part of their role in contact tracing, nurses identified community contacts of clients with COVID-19. Once they had identified the close contacts, nurses would inform them of their exposure to a person with COVID-19, review their risk of infection, and share information on the importance of testing and isolating.

Public/community health nurses were also instrumental in ensuring that as many Americans as possible could be protected, and protect others, from infection through COVID-19 vaccination. These nurses were at the forefront of disseminating information to the public about the importance and availability of vaccinations, managing pop-up vaccine clinics, and administering vaccines to millions. Public/community health nurses also addressed vaccine hesitancy and misinformation through public presentations and via social media to ensure clients were accurately informed and ready to become vaccinated (Jones & James, 2021). Throughout the COVID-19 pandemic, public/community health nurses advocated for policies supportive of health for community members and fellow clinicians. Many nurses used their collective voices to lobby policymakers and collaborate with elected officials to ensure organizations had proper guidelines to support disease mitigation, sufficient personal protective equipment, and exclusion and return policies in line with rapidly evolving evidence.

Today, public/community health nursing practice must remain flexible in the face of the changes that major events may bring about. The passage of the Affordable Care Act (ACA) in March 2013 marked a pivotal moment in American history and health care, aiming to increase care accessibility for all. Now, over a decade later, a record number of Americans subscribe to health plans available per the ACA (Luhby, 2023). Efforts to address health disparities and promote health equity have been central to the practice of progressive leaders and health care clinicians alike. However, these objectives gained a renewed sense of urgency in the public and professional eye following a national reckoning with racism and equity in the wake of the murder of George Floyd (Ayanian & Buntin, 2020). Amid these major events, the concerning crisis in mental health care has persisted. An ongoing national epidemic of substance use disorders (National Institute of Mental Health, 2023), a shortage of mental health care clinicians (Counts, 2023), stigma about mental health (American Psychiatric Association, 2020), and the evolving influence of social media on well-being have exacerbated this crisis (Mass General Brigham McLean, 2023). Through public health events like the HIV and AIDS epidemic and the COVID-19 pandemic, history offers nurses valuable lessons to apply to contemporary health problems. Despite progress in many areas of public/community health, research, innovation, expanded access to care, and a national commitment to health promotion and disease prevention are essential to meeting population health goals. Leading the Way to Improving Population Health provides more information on these and other contemporary health challenges.

Public Health Nurses: The First Line of Prevention

This video profiles public health nurses who discuss some of the challenges present before COVID-19 and some that were precipitated by the pandemic.

Watch the video, and then respond to the following questions.

  1. Which activities discussed in the video were most easily adapted to remote implementation? Which activities were likely challenging to implement in a remote setting?
  2. How did you interact with public/community health nurses during the pandemic?
  3. How should public/community health nurses, other health care providers, and the public leverage the increased visibility of public/community health nursing in the wake of the pandemic to secure support for this specialty?

Public Health Nurse Leaders

From advocating for policy reform and addressing health equity, to developing innovative approaches to bringing health to all, public/community health nurses throughout decades of practice have built a foundation for modern public health practices. Harriet Tubman, Sojourner Truth, and Lillian Wald are select examples of historical nursing leaders who have advanced public/community health nursing, while Cori Bush and Bonnie Castillo are contemporary nursing trailblazers. While this section includes information about these five exemplary nurses, they represent a fraction of the larger collective of nurses who have advanced client care and population health through numerous professional activities.

The Roots of Health Inequities

Florence Nightingale

Although nurses around the globe recognize Florence Nightingale as a pivotal figure in shaping modern nursing, her views perpetuated prejudiced, colonial, and classist ideals. In her publications, she demonstrated a belief in the superiority of British people over Indigenous populations. She used these notions to justify the disproportionate rates of death for Indigenous individuals in schools and health-care settings as necessary for societal progress. An alternate version of her Notes on Nursing text titled Notes on Nursing for the Labouring Classes reinforced exclusionary practices that marginalized individuals based on socioeconomic status.

The legacy of Florence Nightingale is marked by exclusionary and biased ideals, which perpetuate systemic disparities that contribute to contemporary health inequities. Given this context, this chapter will abstain from discussing her professional contributions to public/community health.

(See Bell, 2021; National Commission to Address Racism in Nursing, 2022; Robinson-Lane & Patel, 2022, and Sake-Doucet, 2020.)

Harriet Tubman and Sojourner Truth are often associated with their accomplishments as abolitionists, but they were also enslaved nurses. Although they, along with other Black nurses during the Civil War era, made great contributions to nursing and public health, those contributions are largely disregarded. Sojourner Truth practiced nursing as the private, enslaved nurse for a family in New York (Figure 3.2) (Painter, 2007). Freed following the state's Emancipation Act of 1827 (Baptiste et al., 2021), she spent the rest of her life advocating for the abolition of slavery, women’s rights, humanitarian causes, and funding for nurse training. The U.S. War Department appointed Truth to work as a nurse at Freedman’s Hospital in Washington, DC (Davis, 1999). The philosophy underpinning Truth’s practice was the belief that hospitalized clients would not be able to get well in unclean environments (Baptiste et al., 2021). That belief aligns with current public health efforts to promote infection control, clean air, and the importance of environmental factors in maintaining health across the population.

Photograph of Sojourner Truth.
Figure 3.2 In addition to advocating for the end of slavery, Sojourner Truth worked as nurse with the National Freedman’s Relief Association. (credit: modification of work “Sojourner Truth” by National Portrait Gallery, Smithsonian Institution, Public Domain)

Harriet Tubman was an enslaved nurse who ultimately escaped slavery (Figure 3.3). Her direct nursing care involved treating injured Black soldiers during the Civil War (Baptiste et al., 2021) and opening a care home for older Black adults in Auburn, New York (Donnelly, 2016; Matthias, 2023). Tubman notably and heroically worked to lead other enslaved people to freedom. Her efforts to fight oppression and promote human rights align with contemporary social justice and equity in access public health priorities (Donnelly, 2016).

Photograph of Harriet Tubman.
Figure 3.3 Harriet Tubman provided nursing care to soldiers during the Civil War. (credit: modification of work “Harriet Tubman” by Horatio Seymour Squyer/Wikimedia Commons, Public Domain)

Some consider nurse Lillian Wald (Figure 3.4) to be the founder of modern public health (Buhler-Wilkerson, 1993). In 1893, she founded the Henry Street Settlement in New York City, which helped members of the public obtain resources such as nursing care in their homes, medicine, food, cab fares, loans, childcare, cleaning, and job training (Pittman, 2019). Wald was also a pioneer in upstream interventions, as she recognized that social reform, more than medical treatments, could bring about great change in health. She was a nurse dedicated to policy reforms to improve workplace conditions, housing, education, and recreation for the public. Lillian Wald believed that people in need must be met where they were, that partnerships between public and private organizations must be forged to support health, and that community resilience must be supported as a means of promoting health (Waters, 2022). These principles may look familiar, as they align with the 10 Essential Public Health Services discussed in Foundations of Public/Community Health that guide modern public health. The Henry Street Settlement remains in operation in New York City today, addressing the effects of urban poverty and promoting health for many families (Harris, 2019). Wald’s groundbreaking and enduring work addressing social determinants of health lives on through the Henry Street Settlement and contemporary public/community health nursing. Caring Across Practice Settings discusses Wald’s work as a public health nurse in more detail.

Photograph of Lillian Wald.
Figure 3.4 Lillian Wald was a public health nurse, social activist, and humanitarian who believed in bringing care and resources to the community. (credit: “Wald, Lillian, Miss” by Harris & Ewing/Library of Congress, No Known Restrictions)

Cori Bush is a member of the U.S. House of Representatives and registered nurse, representing Missouri’s first congressional district (About Cori, 2022). Following the murder of Michael Brown in Missouri in 2014 (Associated Press, 2019), she became an influential figure in the local and national movements against police brutality and racial injustices, which inspired her entry into the political arena. Her lived experiences as a Black woman, a mother, being unhoused, surviving assault, working in low-wage jobs that did not support the cost of living, and background as a nurse influence her work and policy positions (Rothberg, 2022). In alignment with the central tenets of public/community health nursing and justice in health care, she supports legislation for a national $15 minimum wage, tuition-free college, criminal justice reform, and Medicare for All (Adams, 2021; Chávez, 2022, Rothberg, 2022). In 2023, Representative Bush was joined by Lauren Underwood of Illinois as a nurse serving in the U.S. Congress (ANA, 2023). As legislators, nurses are expertly positioned to support legislation that supports the health of the public and advances health equity for the nation.

Bonnie Castillo is a registered nurse and executive director of the largest nurse’s union and professional association for registered nurses in the United States, National Nurses United (2023). She has been a leader in promoting health care for all and safety for nurses. In public/community health and beyond, if nurses cannot safely care for clients and communities, population health will not advance. For example, in January 2020, two months before the WHO declared COVID-19 a pandemic, she was already working to determine how prepared the U.S. health system was to protect nurses and other professionals from the virus (Sharma Rani, 2020). As it turned out, the nation’s health system was ill-prepared to protect nurses, as there was a shortage of adequate personal protective equipment (Schlanger, 2020). In response to this shortage, Castillo was one of the first nurse leaders to draw public attention to the personal protective equipment emergency (Huerta, 2020). Beyond her work to support nurses, she was also the director of the Registered Nurse Response Network, a professional group that sends registered nurse volunteers to places affected by disasters.

The Roots of Health Inequities

Misrepresentation in Congress

Given their significant power and influence in the realm of laws and regulations, elected officials play a crucial role in shaping public health policies. Elected officials should represent their constituents—the people who live and vote in their districts. Representation occurs when elected congresspeople support their constituents’ interests and needs and ensure that policies align with the health and preferences of those who elected them. One of the ways this representation can be compromised is when a mismatch occurs between the characteristics of constituents and the characteristics of a congressperson or congress at large.

Although diversity within the U.S. Congress has gradually increased over time, it falls short of adequately representing the U.S. population. In 2023, 13 percent of House members were Black, which approximates the percentage of the population that is also Black. However, the number of non-Hispanic White individuals in Congress is disproportionately high. Though non-Hispanic White people make up only 59 percent of the general population, 75 percent of congresspeople are non-Hispanic White (Schaeffer, 2023). Underrepresentation of groups and communities in Congress has implications for health policy decision-making.

At the local level, researchers recently studied the impact of Native American political representation during the COVID-19 pandemic. In places where Native American political representation and political power were more substantial, the number of COVID-19 cases on tribal lands was lower (Evans et al., 2022). Increased political representation can lead to effective and supportive public health policymaking.

Regardless of the national, state, local, or even institutional level, addressing misrepresentation and promoting diversity is a critical element of creating inclusive and equitable public health policies.

(See Evans et al., 2022; Schaeffer, 2023.)

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