By 1950, more than 17 years would have been added to the average span of American life…. It could not have been accomplished without skilled nursing for the sick; the participation of nurses in immunization and case-finding programs; persuasive teaching of health principles by nurses in homes, schools, hospitals, industries, clinics, and health centers; and the public information for groups of community leaders (Roberts, 1954, p. 4).
Nursing is in an ideal position to respond to numerous challenges facing the healthcare system today. The list of challenges related to the health needs of our nation and our global neighbors is nearly endless: skyrocketing costs of health care and the resultant need for a renewed emphasis on prevention and health promotion measures, healthcare inequalities and disparities, the epidemic of childhood obesity, immigration, the increasing complexity of care for those with chronic illness, anticipated pandemics, emerging and reemerging infectious diseases, threats of bioterrorism, the burden of disease, the enormous expansion of technology, the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) epidemic, unemployment, homelessness, violence, increasing globalization, and increasing evidence of the major impact that the economic and social environments have on health, to name some of these challenges. As the nation responds to the healthcare system crises, public health has regained attention as a viable response to meet many of these challenges. Nurses are a large workforce with a lengthy history of practicing in public health settings. Many nurses practice in positions that place them in people’s homes, schools, workplaces, houses of worship, public clinics, and other settings where public health expertise is needed.
Although barriers exist to specializing in public health nursing, it is imperative that nursing education programs prepare graduates who are skilled in use of public health practices, able to work as a member of multidisciplinary public health teams, are knowledgeable of the determinants of health affecting populations, and know how to integrate this knowledge into interventions that positively impact the health of individuals, families, and communities. This chapter explores the educational mandates for nursing students as related to public health, educational challenges, and practical learning exemplars that integrate these into learning experiences that can develop public health skills, knowledge, and aptitudes in nursing students— in other words, “applying and doing” in nursing education. Graduates must be prepared as professionals ready to meet rapidly changing healthcare system demands.
Challenges to Nurse Educators
Nursing and nursing education have come full circle. History seems to repeat itself, but the context changes. From the early days of the colonies to the present, the United States has struggled with its nursing numbers, the preparation of its nursing workforce, and containment and conquering of its infectious diseases and other major causes of maiming and death. Our state and federal governments coasted through the last five decades and reduced resources that were needed to build a strong public health workforce and infrastructure, which are now costly to reconstruct and repair. There is a pressing need to graduate nurses capable of understanding and meaningfully contributing to the public’s health. As mentioned elsewhere in this text, leaders such as Florence Nightingale, Lillian Wald, and Clara Barton pressed to create, implement, and sustain public health initiatives that changed health and disease practices for decades after their deaths. They modeled perseverance and courage and met the challenges of their times. They were among the first nurse systems thinkers.
Historically, public health nurses were valued by society and functioned autonomously. They practiced in settings and with populations that were of minimal interest to other healthcare disciplines. Traditionally, public health nursing care encompassed the unempowered and the invisible—women, children, the poor, immigrants, and other disenfranchised groups. Gradually, practice shifted from personal
healthcare services, such as home care, to public health issues and activities. It is beyond the scope of this chapter to comprehensively explore major discoveries and movements that altered public health needs and practices. Dramatically, the cataclysmic events that redirected the nation’s public health policies, urgencies, and attention were the terrorist attacks on the World Trade Center and the Pentagon and the brave passengers of a hijacked airliner that crashed near Shanksville, Pennsylvania, on September 11, 2001. Thousands were killed and even more were injured or sustained chronic conditions because of their part in that day’s activities. Shortly thereafter, the anthrax exposures of thousands in New York, Florida, and Washington, DC, forced a reexamination of the weakened public health infrastructure and ultimately the preparation of nurses for a timely response to population needs.
The Institute of Medicine (IOM, 2003
) developed seven public health priorities, which are summarized in Box 17-1
. Nursing education programs are addressing these priority needs as well as other initiatives such as disaster preparedness. Public health issues are competing with bioterrorism activities for resources. The worldwide economic depression remains unresolved, and its full effects are yet to be seen. Regardless of the pressures felt by nurse educators and nursing students, preparation for effective public health needs is central to developing and sustaining a prepared nursing workforce and a healthy population.
Following a tornado, these lone steps mark a reminder of the homes that were present hours before. Inhabitants are at a local shelter receiving health care and aid from nursing students and relief organizations.
Responding to the Public Health Needs
Teaching IOM: Implications of the Institute of Medicine Reports for Nursing Education
, based on the series of IOM reports for nursing education
aimed at improving the safety and overall quality of health care in the United States, addresses areas of interest to nurse educators in preparing students in public health (Finkelman & Kenner, 2007
). The IOM (2003)
report views education of health professionals as a “bridge to quality care” (p. 9
) and states that education must change to meet the needs of current and future healthcare systems.
The authors provide understanding that adding content is nearly impossible in already overfilled curriculums but offer that threads such as cultural competence and informatics (Shultz, 2009b
) can be woven into other public health learning activities, allowing the student to gain the knowledge and experience its application. Suggestions also involve students from different health-related professions located in the academic institution to have joint educational opportunities.
In addition to legislative expectations such as a state’s nurse practice acts, nursing program approval standards and health laws, and other requirements such as clinical agency expectations, numerous organizations, such as accrediting bodies, affect nursing education in the United States. National initiatives that push for increased competence in gerontology, women’s health, safety, healthy work environments, and end-of-life practices add to the challenges facing nursing students and educators. Currently, programs’ lengths and types are defined by law and graduates enter practice after passing the National Council Licensure Examination, which tests practice expectations, within 6 months of graduation. Faculty must create learning activities that quickly involve students in increasingly complex case situations to graduate competent, dedicated, lifelong learners.
Table 17-1 Relevant Nursing Public Health Definitions
The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (American Nurses Association, 2003 , p. 6 ; 2004, p. 7 )
Science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort (Winslow, 1920 , p. 30 )
Public health practice
What we as a society do collectively to ensure the conditions in which people can be healthy (IOM, 1988 , p. 1 ; 2003, p. 28 )
Public health nursing
A practice that is affected by “… biological, cultural, environmental, economic, social, and political factors. As part of the healthcare system public health nursing practice is responsive to these factors through working with the community to promote health and prevent disease, injury, and disability” (American Public Health Association, 2011, para. 2)
A specialty practice of nursing defined by scope of practice and not by practice setting (Council on Linkages Between Academia and Public Health Practice, 2001 ; Quad Council of Public Health Nursing Organizations, 1999 )
Public health nursing specialty
Contains 8 core foundation principles of public health nursing identified and discussed in the Public Health Nursing; Scope and Standards of Practice (American Nurses Association, 2007 ; Association of Community Health Nursing Educators, 2003 )
Students at all educational levels need exposure to relevant definitions of nursing, public health, and public health nursing and an understanding of public health nursing as a specialty (Table 17-1
). Beyond basic understandings, faculty program decisions involve collectively selecting methods to incorporate learning public health concepts and nursing roles (Table 17-2
). Faculty may choose a public health total curriculum, a multicourse focus, or a single-course
focus. Complex learning, such as public health nursing, most often takes time. An early curriculum introduction to the concepts and roles fosters deeper understanding before graduation. The greater the lack of experienced public health nursing clinicians, the more faculty will need to creatively develop relationship-based clinical experiences.
Table 17-2 Select Examples of Public Health Concepts and Public Health Nursing Roles
Public Health Concepts
Public Health Nursing Roles and Duties
Disaster planning and response
Collect, monitor, and analyze data
Public health surveillance
Health policy and legislation involvement
Community and population assessment
Use of evidence-based interventions
Infectious disease prevention, recognition, and care
Identify community needs
Create and implement educational activities
Health agency roles (federal, state, local)
Direct primary caregiver
Epidemiology—the scientific core
Organize public health services
Integrating Learner Knowledge, Skills, and Aptitudes to Develop Public Health-Focused Nursing Care
Because of the limited time for educational experiences (both didactic and clinical), there is a need to create learning experiences that meet multiple outcome objectives. Carter, Kaiser, O’Hare, and Callister (2006)
urged teaching-learning strategies
based on public health nursing practice (Quad Council of Public Health Nursing Organizations, 1999, public health nursing competencies (Quad Council, 2004
), and Essentials of Baccalaureate Nursing Education for Entry Level Community/ Public Health Nurses
(Association of Community Health Nursing Educators, 2000
). Program, course, and class decisions affecting learning rest with faculty. Exemplar teaching and learning examples are provided in the narrative that follows. They are modifiable depending on learner expectations and placement of the learning strategies in the nursing program.
Where possible, faculty align clinical assignments directly to theory application. For situations where finding appropriate clinical experiences is difficult, either clinical experiences or simulations are created. Theory and application are at the individual, family, and community levels. Many class activities are discussed at the national and global levels, with some students participating in international experiences. Application of national and global issues to the local situation is made. Nurse educators, from novice to expert, build real-world learning activities that use cognitive, affective, and psychomotor skills. Evidence-based teaching, learning, and evaluation methods are increasing in numbers and scope as the science of nursing education is pursued (Shultz, 2009a
). Many of these are applicable to teaching public health nursing that faculty are urged to use and further research.
In the beginning of the public health-focused nursing course, students are introduced to the learning outcomes. For most students, viewing the community as the client is difficult to grasp, as is the idea of population-focused care. As the semester’s content outline, clinical rotations, and learning assignments are reviewed, the students begin the journey of combining concepts that seem to be unrelated, such as healthcare financing and epidemiology, into what they will come to know as public health nursing. As each content area is covered, the learning links between them are explained and experienced. By the end of the semester, bridges between those links are stronger and the students view the interrelated concepts of public health more clearly.
An example of an assignment that encourages these connections involves the students locating and presenting a current event article in class. They prepare the public health news item for display on the classroom’s bulletin board after the in-class verbal presentation. Connections to the various concepts in public health are made during the classroom discussion. The assignment increases student awareness of media interpretations of health-related news items and their relevance to nurses. An example is the media events announcing the severe acute respiratory syndrome, caused by a virus that led to illness and death for many in 2003. From China, the disease spread rapidly to other countries by airline passengers traveling internationally. In this situation, the media coverage lasted several months and was timely for class discussions. News items that involve health promotion and prevention studies are especially useful for class discussions because of the nature of these studies and the amount of rapidly conflicting information that often appears simultaneously.
Early in the semester, healthcare financing, healthcare systems, health policy, and political issues are taught. Emphasis is on their interconnectedness and the dramatic influences they bear on health status and needs. Extensive discussion regarding effects on vulnerable populations and concern for social justice dominate learning. At this section’s conclusion, students produce an in-class debate on the pros and cons of universal health care. It is typically a lively debate. Preparation requires knowledge of public health concepts and assigned readings. In a reflective summative evaluation of the activity, students report a broader view of the issue and additional insight into how populations and the healthcare system are affected.
Public Health Clinical Experiences
Clinical experiences involve nursing in schools, local health departments, rural health clinics, home health settings, screenings (hearing, vision, scoliosis, body mass index,
laboratory, and wellness focused), area agencies on aging, and disaster management simulation (Bambini, Washburn, & Perkins, 2009
). Students use clinical experience guidelines for each separate experience (see example in Figure 17-1
). Each requires a student self-assessment (establishes goals and monitors progress toward them), which is a technique that enhances self-directedness (Nicol & Macfarlane-Dick, 2006
). Fitzpatrick (2006)
determined that self-assessment positively influences students’ development, particularly their sense of autonomy and thinking skills (Maclellan & Soden, 2006
). When shared, faculty members gain insight into students’ thinking (Davies, 2002
), and it becomes a mechanism for personalized feedback (Cato, Lasater, & Peeples, 2009
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