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Increasing the capacity of public health nursing to strengthen the public health infrastructure and to promote and protect the health of communities and populations

      Executive Summary

      The American Academy of Nursing recognizes the need for strengthening the U.S. public health workforce and supports efforts to increase the capacity of public health nursing (PHN) to promote and protect the health of communities and populations. PHN has distinguished itself as a nursing specialty by defining its practice as that of “promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (
      American Public Health Association, Public Health Nursing Section
      The definition and practice of public health nursing: A statement of the public health nursing section.
      ). PHN, the largest profession within the public health workforce, has a long and successful history of promoting and protecting the health of the public. Over the past decade, however, the public health infrastructure has been decimated by budget cuts and declining resources affecting the capacity of PHN to effectively impact population health outcomes. Ironically, this comes at a time when the U.S. has adopted a comprehensive set of health system reforms focused on the “triple aim” of improving population health, lowering per capita costs, and improving the patient experience of care. The triple aim, first outlined in 2007 by the Institute for Healthcare Improvement, calls for a shift from clinical services to the prevention of the deleterious effects of chronic illness and an increased emphasis improving overall population health outcomes ().
      PHN's proven potential to contribute to population health outcomes is crucial to the ability of the public health infrastructure to support a renewed focus on health promotion and disease prevention within health care (
      • Hassmiller S.
      Leveraging public health nursing to build a culture of health.
      ). As a result, there is a call to specifically enlist public health nurses as leaders in population-focused health improvement as the key to a healthier future and better health outcomes. In 2014, the National Advisory Council on Nurse Education and Practice (NACNEP) submitted its 12th Annual Report to Congress, Public health nurses: Key to our nation's health, asking both Congress and the Secretary of the U.S. Department of Health and Human Services (USDHHS) to enhance supports for PHN education and practice as a means to ensuring a healthier future and better health outcomes for all Americans (

      National Advisory Council on Nurse Education and Practice (NACNEP). (n.d.). Public health nursing: Key to our nation's health. Retrieved from http://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Meetings/12thannualreportpublichealthnursing.pdf

      ). In 2016, the NACNEP reinforced this position in its 14th Annual Report to Congress, Preparing nurses for new roles in population health management (
      National Advisory Council on Nurse Education and Practice (NACNEP)
      Preparing nurses for new roles in population health management.
      ) by calling for increased investment in population health science and training and increased funding for research on population health management, measures, and metrics. Renewed support and economic investment in PHN is expected to improve the capacity of the public health workforce to build a culture of health as the United States strives to meet the triple aim goals of health care reform.

      Background

      Despite a century of public health advances in reducing and eliminating diseases and increasing life expectancy, the U.S. health system faces many challenges today. These challenges include an aging population increasingly burdened with chronic illness, declining life expectancy, and inferior health systems performance on measures of quality, access, efficiency, equity, and healthy lives compared with other high-income countries (
      Institute of Medicine (IOM)
      For the public's health: Investing in a healthier future.
      ). Challenges specific to the public health infrastructure include increasing health care costs, limited resources, and a declining public health workforce (
      • Bekemeier B.
      • Zahner S.J.
      • Kulbok P.A.
      • Merrill J.
      • Kub J.
      Assuring a Strong Foundation for our Nation's Public Health Systems: A Commentary.
      ).

      Population Health and PHN

      These U.S. health system challenges are occurring at the same time that there is a growing focus on what is called population health. Although the term “population health” is not new, its definition is a source of some debate. It has been defined as the distribution of health outcomes within a population, the determinants that influence distribution, and the policies and interventions that affect determinants (
      • Kindig D.
      • Stoddart G.
      What is population health?.
      ). PHN has a rich history of caring for populations within communities, beginning with Lillian Wald's work at the Henry Street Settlement in New York City in the early 1890s. Furthermore, PHN has distinguished itself as a nursing specialty by defining its practice as that of “promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (
      American Public Health Association, Public Health Nursing Section
      The definition and practice of public health nursing: A statement of the public health nursing section.
      ).
      For well over a century, public health nurses have been critical to the functioning of our health care system by improving the health of vulnerable populations and entire communities. Not unlike other public health efforts, however, evidence of these achievements has not always been well documented or studied. A recent review of studies focusing on health education, behavior change, and screening over a period of 20 years (1990–2010) found evidence for the effectiveness of PHN interventions in close to half of the studies (
      • Swider S.
      • Levin P.
      • Reising V.
      Evidence of public health nursing effectiveness: A realist review.
      ). Public health nurses have the ability to care for individuals and communities through effective case management, which has been shown to improve chronic illness outcomes (
      • Kneipp S.M.
      • Kairalla J.A.
      • Lutz B.J.
      • Pereira D.
      • Hall A.G.
      • Flocks J.
      • Schwartz T.
      Public health nursing case management for women receiving temporary assistance for needy families: A randomized controlled trial using community-based participatory research.
      ). In addition, a systematic literature review of home visiting interventions published between 2005 and 2015 found that home visitation interventions can mitigate social determinants of health and empower people to avoid injury and manage and prevent illness (
      • Abbott L.S.
      • Elliott L.T.
      Eliminating health disparities through action on the social determinants of health: A systematic review of home visiting in the United States, 2005-2015.
      ).
      One home visitation program, the Nurse–Family Partnership, targeting at risk mothers and infants, is an example of the long-term benefits of PHN interventions (

      Nurse–Family Partnership (n.d.). Positively transforming the lives of babies, mothers and families. Retrieved from http://www.nursefamilypartnership.org/

      ). Started in the 1970s as a nurse visitation program targeting at-risk first-time mothers, this program has been implemented at the policy and practice level and continues to be delivered throughout the United States as well as in other countries. Although evidence has demonstrated the ability of the program to improve maternal child health outcomes of the mothers and newborns taking part in the 2-year intervention, even more striking are the long-term effects of this program on those who participated and have long since left the program. Participation in the Nurse–Family Partnership has been found to have continuing health benefits for children as far out as 15 and 18 years after their participation, including being less likely to be involved in criminal activity, less dependent on social welfare, and less likely to have had teenage pregnancies themselves (
      • Eckenrode J.
      • Campa M.
      • Luckey D.W.
      • Henderson C.R.
      • Cole R.
      • Kitzman H.
      • Olds D.
      Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-Year follow-up of a randomized trial.
      ). This is only one program but demonstrates the lasting impact of strategic and appropriate use and training of the PHN workforce and the critical need and potential of public health nurses to assist with the health of those who most need it. The loss of PHN for such communities could be devastating, especially in rural areas and with at-risk populations who most depend on the work of public health nurses for the health and well-being of themselves and their families.
      In addition to traditional roles of public health nurses in home visiting, with the advent of the Affordable Care Act, there has been a national health care shift toward primary care. Public health nurses are making substantial contributions to the implementation of the Affordable Care Act and the expansion of primary care. Their efforts include the integration of primary care and public health, providing clinical preventive services, care coordination, patient navigation, establishment of private and public partnerships, and focusing on population health assessment, analysis, and health planning strategies (
      • Edmonds J.K.
      • Campbell L.A.
      • Gilder R.E.
      Public health nursing practice in the Affordable Care Act era: A national survey.
      ).

      Enlisting PHN to Strengthen the Public Health Infrastructure and Improve Health

      Although the focus on health care reform and primary care has been positive, there have been unintended consequences of these efforts. The continuing decline in the number of public health nurses, as a result of budget cuts, the use of less expensive providers for services, and changing PHN roles (
      Association of State and Territorial Health Departments (ASTHO)
      Budget cuts continue to affect the health of Americans.
      ), has resulted in a public health nurse-to-population ratio that would concern early leaders of the field. Although provider-to-population ratios were once critical in the planning of workforce adequacy in PHN, these ratios have received little attention for some time. In 2008, the Association for State and Territorial Directors of Nursing (ASTDN) (now the Association of Public Health Nurses) prepared a detailed report on the history of public health nurse-to-population ratio expectations. Their recommendation was to establish a minimum “standard national ratio of 1 public health nurse to 5,000 population” (
      Association of State and Territorial Directors of Nursing (ASTDN)
      Report on a Public Health Nurse to Population Ratio.
      , p. 1). The report also pointed out that this ratio would need to be lower for communities with more vulnerable or impoverished populations.
      Public health nurses remain the largest group of health professionals of the public health workforce (
      • Beck A.G.
      • Boulton M.L.
      • Coronado F.
      Enumeration of the Governmental Public Health Workforce, 2014.
      ). However, with an estimated 47, 270, public health nurses in local, state, and federal agencies and a population of 316.4 million in 2013, the ratio of public health nurses to population is 1 to 6,693. This ratio is well above the recommended minimum of 1:5,000 and does not account for communities with at-risk populations. To meet this minimum recommendation, the United States would need more than 63,000 public health nurses. Additional significant recommendations that would further increase the number of public health nurses needed to promote population health is a ratio of “1 supervisor to no more than 8 public health nurses” and the requirement for the baccalaureate degree for PHN practice (
      Association of State and Territorial Directors of Nursing (ASTDN)
      Report on a Public Health Nurse to Population Ratio.
      , p. 52).
      More broadly, unintended consequences of the emphasis on primary care has been decreasing attention to the role of the public health nurse in the community, a loss of Title VIII funding for public health nurses, and a loss of traineeships for advanced education of public health nurses. With the dynamic changes in health care reform and attention to the triple aim of improving population health, lowering per capita costs, and improving the patient experience of care, it is time to refocus care once again on the community and to renew the role of PHN.
      Strengthening the public health workforce, however, requires renewed efforts to increase funding opportunities to provide education for public health nurses and create career pathways for advanced public health nurses. Funding is critically important, especially considering the 2012 eligibility changes made to Title VIII, outlining traineeship preferences for nurse practitioners and nurse midwives (). Renewed support and economic investment in PHN will strengthen the public health workforce to promote a culture of health as the U.S. health care system strives to meet the triple aim and assure the effective implementation of health care reform. Public health nurses will have the capacity to care for individuals in the community, as well as vulnerable communities and populations. Well-prepared advanced public health nurses will be able to address care management needs of individuals, a renewed priority of health care reform, as well as population and system level factors including social determinants and health disparities through PHN practice and research.

      Responses and Policy Options

      PHN's proven potential to contribute to population health outcomes is crucial to the ability of the public health infrastructure to support a renewed focus on health promotion and disease prevention within health care (
      • Hassmiller S.
      Leveraging public health nursing to build a culture of health.
      ). The NACNEP, which is authorized by Section 851 of the Public Health Service Act and amended by Public Health Law 105 to 392, is charged with providing recommendations to Congress and the Secretary of the USDHHS concerning policy matters relating to the nurse workforce, education, and practice improvement. The 12th Annual Report to Congress (

      National Advisory Council on Nurse Education and Practice (NACNEP). (n.d.). Public health nursing: Key to our nation's health. Retrieved from http://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Meetings/12thannualreportpublichealthnursing.pdf

      ) outlined this strategy clearly and succinctly. This report calls on Congress and the Secretary of the USDHHS to strengthen PHN education and practice and identifies PHN as key to a healthier future and better health outcomes. The NACNEP report asserts that the health of a nation is strongly dependent on the strength of its public health workforce—a workforce with PHN as its largest profession. Moreover, the 14th Annual Report to Congress (
      National Advisory Council on Nurse Education and Practice (NACNEP)
      Preparing nurses for new roles in population health management.
      ) highlights the need to prepare nurses for roles in population health management, which are historically within the purview of PHN.
      These two reports are complementary and provide strong arguments for investment in public health and population health science infrastructure, training, and research. Such action would acknowledge and leverage the capacity of the nursing profession to lead population health and quality improvement in diverse and changing communities in the United States and around the world. PHN led the nursing profession with its focus on social determinants of health in the early 20th century. With enactment of the NACNEP recommendations, PHN will assume a transformative role in achieving healthy populations through primary prevention and population-based efforts.

      The Academy's Position

      The American Academy of Nursing (the Academy) fully supports efforts to increase PHN capacity, to strengthen the public health infrastructure, and to promote and protect the health of communities and populations. The Academy endorses the 12th Annual NACNEP report, Public health nursing: Key to our nation's health, and the 14th annual NACNEP report, Preparing nurses for new roles in population health management. One of the most essential aspects of these NACNEP reports is the recommendation for increased training and education for nurses in the area of public health and population health management, under Title VIII of the Public Health Services Act.

      Recommendations

      • Encourage key stakeholders including the American Nurses Association, American Association of Colleges of Nursing, National League for Nursing, Quad Council Coalition, American Public Health Association, Association of State and Territorial Health Officials, Center for Disease Control and Prevention, National Association of County Health Officials, Public Health Foundation, and the Robert Wood Johnson Foundation to review and respond to the 12th and 14th Annual NACNEP reports.
      • Urge Congress to enact legislation and appropriate funding for the development of advanced PHN traineeships, repayment programs, and stipend support through Title VIII.

      References

        • Abbott L.S.
        • Elliott L.T.
        Eliminating health disparities through action on the social determinants of health: A systematic review of home visiting in the United States, 2005-2015.
        Public Health Nursing. 2017; 34: 2-30
        • American Public Health Association, Public Health Nursing Section
        The definition and practice of public health nursing: A statement of the public health nursing section.
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        • Association of State and Territorial Directors of Nursing (ASTDN)
        Report on a Public Health Nurse to Population Ratio.
        Author, 2008 (Retrieved from http://www.quadcouncilphn.org/documents-3/2008-astdn-report-on-a-public-health-nurse-to-population-ratio/)
        • Association of State and Territorial Health Departments (ASTHO)
        Budget cuts continue to affect the health of Americans.
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        • Beck A.G.
        • Boulton M.L.
        • Coronado F.
        Enumeration of the Governmental Public Health Workforce, 2014.
        American Journal of Preventive Medicine. 2014; 47: S306-S313
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        • Luckey D.W.
        • Henderson C.R.
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        Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-Year follow-up of a randomized trial.
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        • Campbell L.A.
        • Gilder R.E.
        Public health nursing practice in the Affordable Care Act era: A national survey.
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        Leveraging public health nursing to build a culture of health.
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        For the public's health: Investing in a healthier future.
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        What is population health?.
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        • Kairalla J.A.
        • Lutz B.J.
        • Pereira D.
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        Public health nursing case management for women receiving temporary assistance for needy families: A randomized controlled trial using community-based participatory research.
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        • National Advisory Council on Nurse Education and Practice (NACNEP)
        Preparing nurses for new roles in population health management.
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      2. Nurse–Family Partnership (n.d.). Positively transforming the lives of babies, mothers and families. Retrieved from http://www.nursefamilypartnership.org/

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        • U.S. Department of Health and Human Services (USDHHS)
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