Advanced Practice Nursing and Public Health
November 2013
David Vlahov

As we pause this month to reflect on the assassination of President Kennedy half a century ago, many of us with a stake in public health nursing are quite familiar with his leadership role in the fights over Medicare. We think in particular of one address to Congress where Kennedy paraphrased the historian and philosopher Arnold Toynbee. Toynbee had concluded from his research that you could predict the greatness and the durability of any society by the manner in which it cared for its vulnerable populations: the aged, the children and those suffering with illness and disability. What was at stake, therefore, said Kennedy, was nothing less than our survival as a nation and our place in history.

His comments and the battles over Medicare have echoes today, of course – perhaps especially for nurses. With the Affordable Care Act’s refreshing emphasis on prevention, health promotion and wellness, nurses are poised to play an ever more prominent role in the health care system. This makes perfect sense, since we have been the backbone of public health since the beginnings of modern nursing. One need look no further than the model of Lillian Wald, who understood before most others that improving the health of entire populations went far beyond a simple clinical visit – and that nurses are critical to expanding the reach of health-related services.

Wald founded Henry Street Settlement in 1893, part of which spun off to become the Visiting Nurse Service of New York. In addition to individual health care services, she set up education programs, social clubs, language classes for immigrants and more. In doing so, she established herself as a powerful advocate for social reform, public health and human rights.

Wald is the model nursing must look to as we plunge deeper into the era of health care reform. Already, people are looking to advanced practice nurses – practicing to the level of their education – to provide primary care in a wide range of settings, such as local health department clinics, accountable care organizations and public schools. But like Wald, nurses and nurse educators must step outside the clinic to appreciate and act at the community, city, state and national levels for the creation of both programs and policies.

Among other things, this means bringing an environmental health perspective to physical and social environments such as schools and workplaces, as well as to municipal, national and global policy actions. It means closer and more consistent interaction with sectors of government that oversee urban planning, transportation and criminal justice – in short, any arenas that affect or promote health. Likewise, public health nursing must continue to increase its engagement with corporations to promote access to healthy products.

We must also bring our proud tradition of interdisciplinary work – collaborating with nurses, physicians, dentists, veterinarians, behavioral scientists, laboratory scientists, epidemiologists, health economists, health services researchers and policymakers – to interprofessional education. As health professions increasingly explore ways to learn together, nurses bring an important perspective and need to be seated prominently at the table. We can help frame and teach the vocabulary, tools and leadership skills that will, ultimately, strengthen the public health infrastructure at the local and national level.

Finally, to put muscle into achieving an increasingly effective public health workforce, nursing needs more formal faculty development and, as a stretch goal, to incorporate competencies within the NCLEX. Such competencies are important across specialties, including acute care, because practicing nurses in all settings can credibly testify that patient outcomes are shaped by upstream factors – from neighborhood milieus to government policies – that influence individual behavior.

We can thank Lillian Wald for leading the charge to incorporate that essential perspective in our health care system.

Comments

I read this comment (thanks David) after attending the IOM committee meeting this morning at Laurel Heights about incorporating social and behavioral data into "meaningful use" criteria for electronic health records. This is another area where nursing is critical! Barbara Koenig

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