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Strengthening Public Health Nursing in the United States

  • Date: Nov 05 2013
  • Policy Number: 201316

Key Words: Public Health Infrastructure, Public Health Workforce

Related APHA Policy Statements

APHA Policy Statement 2005-12 – Strengthening the Public Health Work Force to Address Current and Future Challenges, Policy

APHA Policy Statement 201119 – Increasing Efforts to Encourage Governmental Health Departments to Seek Accreditation

APHA Policy Statement 200911 – Public Health’s Critical Role in Health Reform in the United States

APHA Policy Statement 201117 – APHA Endorses the World Health Organizations’ Global Code of Practice on the International Recruitment of Health Personnel

APHA Policy Statement 201015 – Securing the Long-Term Sustainability of State and Local Health Departments Policy Statement

APHA Policy Statement 200915 – The Integration of Core Public Health Education into Undergraduate Curricula

APHA Policy Statement 20091 – Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities, Policy #20091

The American Public Health Association is represented by a wide variety of disciplines and professionals. A strong public health infrastructure requires adequate public health personnel. Public health nursing resources have been decreasing, and ongoing shortages threaten the ability to meet the health needs of communities. Public health nurses (PHNs) are the largest discipline within the public health workforce. Decreases in funding at all governmental levels have diminished the ability to ensure a sufficient PHN workforce that can in turn provide population-based nursing interventions and document outcomes effectively. The intent of this policy statement is to seek to establish federally funded public health workforce scholarships and loan repayment programs, enhance internships and fellowship programs in public health agencies, enhance leadership development programs for everyone in the public health workforce, and increase core financial support for the public health infrastructure. To help support these activities, we need to promote the use of PHNs within interprofessional practice environments.

Problem Statement
The Patient Protection and Affordability Care Act (PPACA), passed by the 111th Congress, elucidates the need for a stronger public health infrastructure and mandates the expansion and sustainability of prevention and public health programs aimed at improving health and restraining the rate of growth in private- and public-sector health care costs.1–4 Strategies related to prevention and wellness will require a strong public health workforce, including public health nurses (PHNs), to meet the goals of the PPACA. Title V of the PPACA is projected to improve access to health services, particularly among low-income, underserved, uninsured, minority, and rural populations and populations facing health disparities. This is dependent upon increasing the supply of a qualified health care workforce.4 However, under the current health care infrastructure and without a strong PHN workforce, the PPACA may not improve health care for many of the most vulnerable populations (e.g., immigrant workers, poor women, individuals who are homeless).5–8 Consequently, sustaining a strong PHN workforce will enhance the likelihood that the PPACA will result in better patient outcomes in a cost-effective manner.

PHNs are the largest discipline within the public health workforce.9–11 Current reforms in the health delivery system and decreases in public health funding at the federal, state, and local levels have contributed to a reduction or elimination of essential public health resources, services, and programs.11,12 Consequently, public health agencies have transitioned from providing direct individual-level services to population-focused services inclusive of those provided by PHNs.11,12

Public health agencies have experienced a reduction in their workforce capacity, including public health nurses. From 1980 to 2000,13 the ratio of PHNs to the general population decreased by more than 25%. In addition to having an impact on provision and maintenance of existing public health services,11,12 this could lead to difficulties in effectively responding to emerging public health priorities such as infectious and chronic diseases14 and improving population health outcomes.15,16

Public health nursing practice focuses on population health and has included working with vulnerable and disenfranchised individuals, families, and communities and across systems to improve health outcomes through health promotion, disease prevention, community engagement, and other activities.15–22 Educational preparation for PHN practice incorporates the core competencies for public health professionals identified by the Council on Linkages Between Academia and Practice and the Quad Council of Public Health Nursing Organizations.23

In state and local health departments (LHDs), approximately 37% and 32% (respectively) of all nurses provide clinic-based care, while only 10% of nurses in state health departments and 6% in LHDs report being engaged in population-level prevention activities.22

Recruitment and retention of public health nurses poses a significant challenge for state and local health departments. The PHN workforce is aging and does not reflect the diversity of communities in which PHNs work. Few minority PHNs hold leadership positions, and few promotional opportunities exist for public health nurses.22 Public health nurses’ salaries and benefits are not competitive with salaries for nurses in acute care settings20,22 or other employment sites (e.g., hospitals, home health care).19,24,25

Gaps exist in the education and training needs of public health nurses. This is compounded by a lack of promotional and training opportunities26 and associated challenges related to recruiting and retaining qualified public health nurses and prepared PHN faculty.19 In state and local health departments, 29% of individual nurses report not holding a bachelor’s degree in nursing, which is considered the entry-level qualification for public health nursing practice. Approximately 12% of nurses in state and local health departments report an advanced degree at the master’s level, and less than 1% hold a doctoral degree.22

Targeted recruitment of a diverse PHN workforce is necessary to address the needs of an increasingly diverse population. Recruitment strategies should include those that enable individuals from socioeconomically challenged and other diverse backgrounds to affordably access institutions of higher learning. Innovative education-practice models that support nurses currently in the workforce in matriculating and attaining a bachelor’s degree in nursing are key to developing a diverse PHN workforce.

Infrastructure gaps and variations in collection of PHN-sensitive outcome data represent a significant challenge in measuring and reporting the contributions of public health nurses to improving population health outcomes.27

Proposed Recommendations Statement

APHA recommends the following: increasing legislative funding support to strengthen the public health workforce infrastructure, including public health nurses, with a focus on prevention, health promotion, and population-focused practice; developing academic-practice partnerships to prepare public health nurses for changes in public health delivery system; developing the capacity for public health nurses to function at their highest levels of education, competence, and licensure; developing opportunities for public health nurses to build their capacity for health system and health policy leadership; developing effective strategies to recruit and retain qualified public health nurses; and increasing funding to support a research agenda that measures the effectiveness of PHN-sensitive interventions with respect to population health outcomes.

Opposing Arguments/Evidence

Budgets are constrained in health departments at all levels: A strong public health infrastructure is needed in the context of a fluctuating economy with increasing unemployment and underemployment and reduced (or a lack of) health insurance coverage. For example, an assessment of the impact of a budget cut in a Washington State LHD demonstrated the following outcomes: (1) elimination of vital public health programs and services, (2) widespread layoffs (10%–25%) of public health professionals, (3) a significant decrease in county-level funding, and (4) an increased demand for public health services for women and children.28In Georgia the population has increased by 1.5 million over the past decade, while the public health nursing workforce has been reduced by about 22% as a result of high turnover rates, lack of funding, and noncompetitive salaries.29 Such budget cuts have an adverse impact on the ability of the public health system to respond to communicable disease outbreaks and emerging diseases and threats. Consequently, the system’s capacity to meet the mandate of improving the health and well-being of all is diminished. PHNs are critical to executing these core public health activities. Budget constraints that diminish the PHN workforce are occurring at the same time that states and communities, as well as the country as a whole, are reporting a need for more public health nurses.30

The shortage of nursing faculty makes it difficult to increase graduation rates among BSN and graduate nurses prepared at the PHN and advanced PHN levels. According to earlier estimates, more than 100,000 public health workers (or 23% of the current workforce) were expected to retire by 2012, leaving a large void of expertise to be filled.31 Because PHNs represent the largest professional group in the public health workforce, there is an immediate and critical need to prepare a knowledgeable, skilled, and effective PHN workforce. However, a 2012 American Association of Colleges of Nursing (AACN) survey32 showed that there were a total of 1,181 faculty vacancies in 662 nursing schools with baccalaureate and/or graduate programs across the country. There was a national nurse faculty vacancy rate of 7.6%, most (88.3%) of which were faculty positions requiring or preferring a doctoral degree. The top reasons cited by schools having difficulty finding faculty were a limited pool of doctoral-prepared faculty (32.9%) and noncompetitive salaries relative to positions in the practice arena (27.6%). Multiple and diverse strategies have been funded nationally to address the faculty shortage. For example:

  1. The Jonas Center for Nursing Excellence announced that its Jonas Nurse Leaders Scholar Program has expanded nationally and now provides funding and support for 198 doctoral nursing students in 87 schools across the United States, making it one of the largest programs addressing the nation’s dire shortage of doctoral-prepared nursing faculty.[32] AACN has worked with the Jonas Center to facilitate this program’s expansion to all 50 states and is administering the program for a new cohort of scholars that includes both PhD and DNP students.33 
  2. In September 2010, AACN announced the expansion of NursingCAS, the nation’s centralized application service for registered nurse (RN) programs, to include graduate nursing programs. One of the primary reasons for launching NursingCAS was to ensure that all vacant seats in schools of nursing are filled to better meet the need for RNs, advanced practice RNs, and nurse faculty. In 2009, more than 10,000 vacant seats were identified in master’s and doctoral nursing programs alone. NursingCAS provides a mechanism to fill these seats and maximize the educational capacity of schools of nursing.34
  3. In July 2010, the Robert Wood Johnson Foundation released Expanding America’s Capacity to Educate Nurses: Diverse, State-Level Partnerships Are Creating Promising Models and Results, a policy brief describing the capacity innovations of 12 partnerships that are effectively addressing nursing and nurse faculty shortages. Among the report’s recommendations are requiring all new nursing graduates to complete a BSN program, requiring non-baccalaureate-prepared registered nurses to obtain a BSN, and enhancing the pipeline into baccalaureate and graduate nursing programs.35
  4. In 2009, a group of experts called for adapting federal funding mechanisms (i.e., Title VIII and Medicare) to focus on preparing more nurses at the baccalaureate and higher degree levels. This policy emphasis is needed to adequately address the growing need for faculty and nurses to serve in primary care and other advanced practice roles. There is evidence that new nurses prepared in BSN programs are significantly more likely to complete the graduate-level education needed to fill the nursing positions in which job demand is expected to be the greatest.36
  5. In February 2003, Congress appropriated $20 million in funding for new programs created under the Nurse Reinvestment Act. Designed to address the nursing shortage, this legislation includes $3 million for a nursing faculty loan program that provides loan forgiveness for students in graduate programs who agree to work as nurse faculty upon graduation. Funding through this program will be dispensed by schools of nursing to students pursuing a faculty career.37

Public health professionals other than PHNs can be hired for some functions at a lower salary: Many factors that contribute to health disparities can be decreased and/or eliminated through the work of PHNs or advanced PHNs. The Nurse Family Partnership program is an exemplar of an evidenced-based public health program that provides intensive home visitations by a public health nurse to at-risk, lower income women who are pregnant for the first time. A randomized controlled trial38 examined the effectiveness of home visiting by paraprofessionals and nurses (in comparison with control groups) in improving maternal and child health outcomes. Results showed that the nurse-visited mother-child dyads had significant improvements on a wide range of maternal and child outcomes (e.g., greater reductions in cotinine levels, lower frequency of language delays among children). In contrast, the mother-child dyads visited by paraprofessionals exhibited improvements in only a single area related to maternal social interaction.

In a secondary analysis of cross-sectional data from a 2005 national profile of local health departments, results demonstrated significant improvements with respect to a department’s performance in decreasing health disparities when its leader had a clinical background as either a registered nurse or a physician.15,16 The data also suggested that when the LHD leader was a registered nurse, there were improvements in terms of ensuring a prepared public health workforce and improved quality outcomes. These findings demonstrate that PHNs are prepared and active in addressing the social determinants of health through disease prevention and health promotion activities that improve population health outcomes.

Action Steps

  1. State legislatures and federal regulators should increase funding to support the development of the public health workforce as well as postsecondary education in nursing and public health, particularly in diverse and underrepresented communities.
  2. State legislatures and regulatory nursing organizations should codify the baccalaureate in nursing as the entry-level qualification for public health nursing practice.
  3. The Health Resources and Services Administration (HRSA) should fund entry-level and advanced nursing education with a focus on increasing the diversity of the nursing workforce.
  4. HRSA should provide funding to the American Association of Colleges of Nursing (in collaboration with the Centers for Disease Control and Prevention [CDC]) to support educational and training opportunities for entry- and advanced-level public health nurses in population-focused practice and leadership.
  5. HRSA should provide funding to the American Association of Colleges of Nursing (in collaboration with CDC) to support educational and training opportunities for preparing population-focused nursing educators.
  6. Public and private employers should develop compensation and benefit programs for PHNs that are equitable and comparable to those for registered nurses in other employment or practice settings and sectors (e.g., hospitals, home health care).
  7. Governmental and nongovernmental organizations should develop educational and training opportunities for public health nurses in population health systems and areas of health policy leadership.
  8. The National Institutes of Health, CDC, and other governmental and nongovernmental organizations should fund a PHN research agenda that measures the effectiveness of PHN-sensitive interventions with respect to population health outcomes.
  9. The US Bureau of Labor Statistics should establish a public health nurse code in its Standard Occupational Classification System to monitor and evaluate the PHN workforce.


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