Chapter 2. History of Public Health and Public and Community Health Nursing CHAPTER SUMMARY

Transcription

1 2-1 Chapter 2 History of Public Health and Public and Community Health Nursing CHAPTER SUMMARY The roles of public and community health nurses are varied and challenging. Throughout history, the roles of the public and community health nurse have changed to respond effectively to the prevailing public health problems of the times. The roles have been dynamic and multifaceted and have relied heavily on the science of public health. Part of the appeal of public and community health nursing is due to the autonomy of the practice and the use of problemsolving and decision-making skills in the role. Many of the current roles can be traced to the early nineteenth century, when public health efforts focused on environmental conditions such as sanitation, control of communicable diseases, education in personal hygiene, disease prevention, and care of the sick in their homes. Although health threats from communicable diseases, the environment, chronic illnesses, and the aging process have changed over time, the foundation principles and goals of public and community health nursing have not changed. Finally, as the population of the United States ages and desires to remain at home in spite of decreased family and community resources, different community health care needs emerge. ANNOTATED OUTLINE I. Change and continuity: The history of community and public health nursing reflects changes in the specific focus of the profession while emphasizing continuity in approach and style. A. Although threats to health from communicable disease, the environment, chronic illness, and the aging process have changed over time, the foundation principles and goals of public and community health nursing have not changed. The roles of community and public health nurses in the United States developed from several sources and are an ongoing product of various social, economic, and political forces. B. Historical measures to provide for the public s health: The ability to preserve health and treat illness has depended on the contemporary level of science, the use and availability of technologies, and the degree of social organization. II. America s colonial period and the New Republic. A. During the colonial period, women were responsible for caring for all household members. Based on the English Poor Law of 1601, American social welfare agencies provided limited aid for those without sufficient support from family or private benefactors. Few hospitals existed, and these were only in the larger cities. Early colonial public health efforts focused on Copyright 2004, 2000, Mosby, Inc. All Rights Reserved

2 2-2 control of communicable diseases, as urbanization and trade contributed to increased incidence of disease, including periodic epidemics. B. The Public Health Service was established in 1798 as the Marine Hospital Service. Environmental conditions, including inadequate housing and poor sanitation, were additional risks to health. Early experiments in providing nursing care at home tended to focus more on moral elevation and less on illness intervention. By the middle of the nineteenth century, interest in developing boards of health grew, although these were slow to recommend and implement comprehensive approaches to preventing disease. III. Nightingale and the origins of trained nursing: Family-based caregiving structures became inadequate in Europe in the early nineteenth century. Many women who performed nursing functions were untrained and unreliable; improved hospitals would depend on an improved workforce. A. The origins of professional nursing are found in the work of Florence Nightingale, who developed education and practice models that strongly influenced the U.S. nursing profession and public health nursing. Nightingale greatly improved the health of British soldiers during the Crimean War. After the war in 1856, she organized hospital nursing practice and education. Believing that proper nutrition, rest, sanitation, and hygiene were necessary for health, she differentiated sick nursing from health nursing. Her colleague, William Rathbone, founded the first district nursing association in IV. America needs trained nurses: public health nursing, : During America s Industrial Revolution, women s employment and volunteer work in the public sphere gradually expanded. During the 1870s, the first nursing schools based on the Nightingale model opened in the United States. Beginning in the mid-1880s, early visiting and public health nurses cared for the poor at home and had a positive impact on the health of mothers and young children and on the reduction of communicable diseases. Middle and upper-class ladies assisted these nurses financially and administratively. A. Lillian Wald emerged as an established leader of public health nursing during its early decades. She founded Henry Street Settlement in 1893, which later became the Visiting Nurse Service of New York City. In 1909, visiting nursing remained concentrated in the northeastern quadrant of the United States. Agencies depended financially on local philanthropic sources. Sponsored by the American Red Cross, the Town and Country Nursing Services spread visiting nursing outside urban centers and into rural areas, with 100 agencies established before World War I. B. Occupational health nursing began in 1895 as an outgrowth of early home visiting efforts, when Ada Mayo Stewart was hired by the Vermont Marble Company. Between 1914 and 1943, the number of these industrial nurses grew from 69 to 11,110. C. School nursing in America: Concerned about children excluded from school due to resolvable infectious and communicable diseases, Lillian Wald arranged the development of school nursing in New York City in Lina Rogers was the first school nurse, who worked in the schools and made home visits to families. D. The profession comes of age: The National Organization for Public Health Nursing (NOPHN), the dominant force of professional nursing in public health, was founded in 1912 with

3 2-3 a membership of nurses and their lay supporters. It continued the publication of the Visiting Nurse Quarterly, begun in The NOPHN sought to improve education for visiting and public health nursing by raising standards and by encouraging new educational programs. Nurses were also active in the American Public Health Association through the Public Health Nursing Section, formed in E. Public health nursing in official health agencies: Public health nursing in official health agencies at local, state, and federal levels grew more slowly than in voluntary agencies before World War I. Where agencies were developed, public health nurses were critical staff members. The nursing care they provided was diverse, complex, and multifocused. F. World War I and the importance of public health nursing: With the onset of World War I, adequate staffing of public health nurses was more difficult. The influenza pandemic was met by a coalition of the NOPHN, the Red Cross, the U.S. Public Health Service, and local organizations. G. Paying the bill for community and public health nurses: The major obstacle to extending nursing services in the community was limitations on adequate funding. Early nursing agencies received charitable contributions. Lillian Wald, with Lee Frankel, shaped the nursing service of the Metropolitan Life Insurance Company in This service provided funding for nursing agencies and significantly reduced mortality rates for policyholders and for their children under age 3. V. Public health nursing, A. Efforts to shape public policy: Nurses influenced public policy and advocated establishment of the federal Children s Bureau in 1912 and implementation the Sheppard- Towner Program of the 1920s. Credited with saving many lives, the latter provided federal matching funds to establish maternal and child health divisions in state health departments. B. In 1925, Mary Breckinridge established the Frontier Nursing Services in southeastern Kentucky. She geared the program toward improving the health care of this rural population and succeeded in reducing pregnancy complication, maternal mortality, stillbirths, and infant mortality. C. African-American nurses in public health nursing: African-American nurses seeking to work in public health nursing faced challenges from segregation in the South and the North, difficult access to education and supervisory positions, and lower pay compared to white nurses. Yet African-American public health nurses, in collaboration with national organizations, had a significant positive impact on the communities they served. D. Between the two world wars: economic depression and the rise of hospitals: The economic crisis during the 1920s Depression deeply challenged nursing with decreased funding to address quickly increasing health needs for a growing population of the poor and jobless. The Federal Emergency Relief Administration supported nurse employment and built new services to meet the health needs of the depression period. Many nurses newly entered public health service, but they were often inadequately prepared for this practice. Visiting and public health nurses continued to evaluate the value of preventive care compared to bedside care of the sick, as well as whether interventions should be directed toward groups and communities or toward individuals and their families. E. Increasing federal action for the public s health: The Social Security Act of 1935 provided funding for expanded education and employment of public health nurses, especially in

4 2-4 official health agencies. Federal funding for public health services used a categorical framework to focus on specific priorities, for example, heart disease or mental health, rather than using a comprehensive approach. VI. World War II: Extension and retrenchment in community and public health nursing. A. The U.S. involvement in World War II in 1941 accelerated the need for nurses, and federal funding for nursing education was expanded in response to advocacy by the nursing profession and its friends, such as U. S. Representative Frances Payne Bolton. While reduced staff and funding sometimes led to retrenchment in visiting and public health nursing agencies, new innovations broadened the scope of public health nursing practice. B. The federal Emergency Maternity and Infant Care Act of 1943 (EMIC) provided funding for medical, hospital, and nursing care for the wives and babies of servicemen. VII. Public health nursing at mid-twentieth century. A. The Rise of chronic illnesses: With extended life span and increased duration of life after diagnosis with chronic illness, visiting and public health nurses faced new challenges related to chronic illness care, long-term illness and disability, and chronic disease prevention. In official health agencies, categorical programs focused on a single chronic disease and funded narrowly defined services. Some visiting nurse associations and some health departments adopted coordinated home care programs to provide complex, long-term care to the chronically ill, often after hospitalization. These innovative programs provided a model for later reimbursement through Medicare and Medicaid. The increased prevalence of chronic illness encouraged growth in combination agencies, although they proved difficult to administer. Many of the combination services implemented between 1930 and 1965 later retrenched into their former structures as government agencies or voluntary agencies. B. During the 1950s, public health nursing practice increased its focus on the psychological elements of patient, family, and community care. C. Failure of financing for community-oriented nursing: Hospitals gradually became the preferred place for illness care and childbirth during the 1930s and 1940s. Financing for voluntary nursing agencies was greatly reduced in the early 1950s when the nursing services sponsored by life insurance companies and by the American Red Cross were all discontinued. Blue Cross and other hospital insurance programs considered payment for visiting nurses. Implementation of Medicare and Medicaid programs in 1966 provided many options for payment of home nursing care. D. Consolidation of national nursing organizations: The National Organization for Public Health Nursing merged into the National League for Nursing in The subsequent loss of public health nursing leadership and focus resulted in a weakened specialty. E. Professional nursing education for public health nursing: Brown s 1948 report, Nursing for the Future, recommended basic nursing preparation at the university level to include public health nursing concepts. Education for public health nurses was actually divided between schools of nursing and schools of public health, although collegiate education for public health nurses gradually centered in schools of nursing.

5 2-5 F. New forms of payment for community-oriented nursing: Medicare and Medicaid payment for visiting nurses prompted the rapid proliferation of home health care agencies of all types, especially official agencies and for-profit agencies. G. Community organization and professional change: Social changes of the 1960s and 1970s impacted public health nursing, and nurses work reflected a commitment to action with the community. New programs addressed economic and racial differences in access to health care services. The Economic Opportunity Act provided funds for neighborhood health centers, Head Start, and other community action programs. Beginning in 1965, the nurse practitioner movement opened a new era for nursing s involvement in primary care. VIII. Community and public health nursing from the 1970s to the present: During the 1970s, nursing was reviewed as a powerful force for improving the health care of communities. By the 1980s, concern grew about the high costs of health care in the United States. Health promotion and disease prevention programs received less priority as funding was shifted toward acute care and out of health services altogether. Home health care weathered several threats to adequate reimbursement of services. Nurses in official health agencies diminished in numbers. A. The Future of Public Health: This landmark report (1988) vividly documented the impact of reduced political support and financing on public health organizations in the United States. B. The Healthy People Initiative: This initiative has influenced goals and priorities for public health and public health nursing and called attention to the need for effective implementation strategies. C. The 1990s debate about health care focused on issues of cost, quality, and access to direct care services. Despite considerable interest in health care reform and universal health insurance coverage, the national debate emphasized reform of medical care rather than comprehensive change. In 1991 nursing organizations joined to support health care reform. D. New and continued challenges have triggered growth and change in community/public health nursing, including nurse-managed centers, new populations in new communities, transfer of official health services to private control, nursing shortage, leadership and education, and natural and human-made disasters. E. Today, community and public health nurses look to their history for inspiration, explanation, and prediction. It is the vision of what community-oriented nursing can accomplish that sustains these nurses. ADDITIONAL CLINICAL DECISION-MAKING ACTIVITIES 1. Which of Lillian Wald s important innovations do you see as most important? Why? 2. If you were Lillian Wald and chose to devote your energy to critical forces affecting the health of Americans today, what issues or points would receive your highest priority? 3. Explore the history of public health nursing in your city, county, or state. 4. Interview your faculty about community health/public health nursing in the recent past. 5. What obstacles did African-American nurses face in the first half of the twentieth century in their efforts toward becoming and working as visiting or public health nurses? What is the current situation?

6 Select a book about nursing written for children or youth, such as the Cherry Ames series. What period in the development of nursing does this represent? How accurate is the portrayal of that time period? What is left out? Why might issues be left out? 7. Florence Nightingale had impact on nursing in the United States. Given what is said in this chapter, why do you think she would have had credibility to accomplish this influence? 8. Trace the types of funding for visiting and public health nursing, as detailed in this chapter. Which type of funding do you prefer for visiting and public health nursing? 9. Trace the development of education for visiting and public health nursing. Should education for visiting and public health nursing be conducted in schools of nursing or in schools of public health? 10. Several famous nurses are profiled in the chapter. Which nurse do you find most interesting? Why? 11. Compare the development of visiting and public health nurses in the United States to its development in Canada. CRITICAL ANALYSIS QUESTIONS 1. What was Florence Nightingale s role in the development of nursing? 2. Which accomplishments of Lillian Wald supported improved health for children? 3. Payment for nursing services by live insurance companies: Who were the key figures in its inception? What factors influenced this development? What factors led to its end? 4. Compare the factors that triggered the growth of community/public health nursing in voluntary agencies and in official agencies. 5. How has the federal government influenced the practice of community/public health nursing? 6. Identify the roles and functions of the National Organization for Public Health Nursing. 7. Why did Mary Breckinridge go to Kentucky? What were the results of her work, both for the local area and nationally? 8. Which factors influenced the role of public health nurses in local health departments? (a) What factors tended to enhance their influence, roles, and functions? (b) What factors tended to diminish their influence, roles, and functions? 9. What was the impact of the 1980s report The Future of Public Health on community/public health nursing? ANSWERS 1. Florence Nightingale s influence on the development of nursing included: a. The belief that nurses should receive specific training in nursing and established schools and hospitals to accomplish this. b. The belief that nurses should demonstrate moral and respectful behavior. c. Differentiation between health nursing and sick nursing. d. The use of basic health measures to identify outcomes of nursing care. e. Serving as a colleague of William Rathbone and influencing development of visiting nursing. 2. Lillian Wald supported improved health for children through measures including:

7 2-7 a. Participation in the playground movement, which encouraged healthy play areas to improve child health. b. Started Henry Street Settlement to provide social services in Lower East Side of New York City. c. Began public health nursing to provide home visits to promote infant and child health. d. Initiated school nursing to promote health of children, keep them in school, and enhance their learning. e. Codeveloped nursing services through the Metropolitan Life Insurance Company to improve the health of workers and their families. f. Advocated for establishment of the federal Children s Bureau to improve the health of children. 3. Payment for nursing services by live insurance companies: a. Who were the key figures in its inception? i. Lillian Wald ii. Dr. Lee Frankel b. What factors influenced this development? i. Life insurance company wished to decrease payments to beneficiaries for illness. ii. Nursing agencies sought an additional source of income for nursing services. iii. Nursing agencies wished to reach and provide services to working populations. iv. Improve health and reduce mortality of insured working people and their families. c. What factors led to its end? i. Greatly reduced mortality and morbidity for infectious diseases for insured groups. ii. An increase in long-term illness nationally due to increased chronic illness prevalence and increased proportion of aged in society. iii. Improved maternal-child morbidity and mortality, leading life insurance companies to doubt further improvement. iv. Reduced life insurance company profits attributable to outcomes of nursing services. 4. a. Voluntary agencies providing nursing services developed due to: i. Infectious disease concerns and morbidity/mortality in urban areas, due to immigration and migration. ii. Desire to provide care for the poor. iii. Trained nurses were now available; became a critical part of the intervention. iv. To a certain extent, a fear of immigrants, as well as a desire to socialize new immigrants. v. The progressive reform movement encouraged social interventions that benefited people previously ignored. vi. Change in the women s role; women now freed from restrictions of being at home. Wealthy women sponsored voluntary agencies, and working women were educated as nurses with the freedom to work in community agencies. b. Official agencies providing nursing services developed due to: i. Desire to reduce infectious and communicable diseases due to mortality, morbidity, and epidemics. ii. Success of public health nursing in cities suggested it might be successful in rural areas as well. iii. Demonstration projects through the Red Cross Town and Country Program, foundation-supported programs.

8 2-8 iv. Willingness of county-level leadership to accept demonstration programs and to develop funding for county-level public health nurses. 5. The federal government influenced the practice of community/public health nursing through: a. Providing funding to states for nursing practice through Sheppard-Towner, the TERA and FERA and other Depression-era programs, EMIC, Social Security Act programs for maternal-child health, Medicaid, and Medicare. b. Funding for basic nursing education and for graduate education in nursing. c. Funding for nursing research. d. Community development programs of the 1960s to the present. e. Development and funding for nurse practitioners and other advanced practice nurses. 6. The roles and functions of the National Organization for Public Health Nursing include: a. Established a national organization to promote public health nursing visibility. b. Provides forums for professional interchange, including conferences and journals. c. Sets educational and professional standards. d. Collaborated with other nursing organizations and other professions. 7. a. Mary Breckinridge went to Kentucky to establish a project that would demonstrate means to reduce mortality for pregnant women, new mothers, infants, and children. She really wanted to make a difference. Breckinridge chose eastern Kentucky because she identified risk factors there and found a lack of physicians and poor access to health care. b. The results of her work for the local area included: i. Provided basic health services ii. Established and developed a health care infrastructure iii. Reduced maternal-child mortality and morbidity c. The results of her work for the nationally included: i. Demonstrated the outcomes of nursing interventions. ii. Introduced nurse-midwives into the United States. iii. Initiated the Frontier School of Midwifery. iv. Demonstrated the capacity of nursing care to make a wide difference in health status in a particular community. 8. a. The influence, roles, and functions of public health nurses in local health departments was enhanced by: i. Projects that demonstrated outcomes of nursing services. ii. Addressed communicable diseases and epidemics through prevention and intervention. iii. Disaster events demonstrated the flexibility and impact of public health nurses. iv. Increases in maternal-child mortality and morbidity. v. Funding for screening for tuberculosis, lead poisoning, and so forth. vi. Funding for immunization outreach and campaigns. b. The influence, roles, and functions of public health nurses in local health departments was diminished by: i. Lack of funding for nursing salaries. ii. Lack of funding for nursing programs. iii. Local physicians perceived competition. iv. Existing problems appeared to be resolved.

9 The impact of the 1980s report The Future of Public Health on community/public health nursing was that it: a. Reinforced nurse perceptions that the public health infrastructure had eroded. b. Documented trend toward decreased funding of public health services at all levels. c. Enhanced visibility of long-term trends. d. Issued a call for change and a warning about increased risks for which the United States was unprepared.