During senior-year public health rotation, 50 years ago, I shared the caseload of a district public health nurse in Philadelphia. Under her tutelage, I saw how families’ lives affected health. With my navy blue uniform and black bag, I rode public transportation to home visits and offered health teaching to some of the passengers. I visited chronically ill elderly patients and conducted follow-up visits for children who had not been immunized or who had experienced accidental poisonings, teaching their mothers how to safely store dangerous substances.
Over time, the role of the public health nurse as I'd experienced it disappeared. Health districts were downsized to clinics caring for the sick instead of focusing on health. It was a cost-cutting strategy that bit back. For example, with relaxed vigilance on immunizations, by 1991 less than half of Philadelphia preschoolers had been immunized and the city experienced a measles outbreak with 938 cases and nine deaths.
I found myself thinking of my experience as a public health nurse as I moderated a panel of nurses and physicians at a January 2017 meeting of health care experts in Philadelphia at Independence Blue Cross Foundation headquarters, convened to discuss the role of RNs in transforming primary care.
The panelists framed their viewpoints around the 2016 Macy Foundation report, Registered Nurses: Partners in Transforming Primary Care (http://links.lww.com/AJN/A93), as well as Berwick and colleagues’ “triple aim” for the health care system: improving care experiences, improving population health, and reducing the cost of care (Health Affairs, 2008).
Panelists reasserted the Macy report's recommendation for a greater focus on primary care and interprofessional teamwork in undergraduate nursing education. With the absence of sufficient primary care and community-based clinical sites, could we design imaginative clinical experiences to lay the groundwork for reconfigured RN roles in primary care? Were there enough faculty prepared to teach students in environments less structured than the hospital?
In addition, would RN positions in primary care have competitive salaries and healthy work environments? After all, Bodenheimer and Sinsky (Annals of Family Medicine, 2014) had proposed adding a fourth aim to the “triple aim”: improving the work life of health care providers. Like other professionals, nurses gravitate to well-defined work with just compensation that fulfills societal needs and yields personal fulfillment. Will the leaders of primary care practices restructure care to facilitate RN practice at full scope—managing groups of patients; creatively using technology; collaborating with hospitals, schools, and key agencies to improve the lives and health of patients and families?
In fact, the work of RNs in primary care and public health has always been crucial. As I listened to the panelists, I thought about Florence Nightingale's belief that the art of “health nursing” was as important as the art of “sick nursing.” Her emphasis on prevention rather than cure and a proactive role for the nursing profession rings true today. I thought about Lillian Wald, who founded the Henry Street Settlement in the early 1900s, about Margaret Sanger, who designed services focused on women's reproductive health, and about the leaders of today's nurse-managed health centers movement.
The panel's insights prompted me to offer a few strategies.
- Require every nursing student to study the outcomes of 40 years of community-based work by nurse-led health centers.
- Require courses that illuminate the work of nurse reformers who challenged the status quo.
- Create incentives for primary care practices and faculty to craft inspiring student experiences that examine the relationship between life circumstances and health.
- Dress nursing students in updated blue uniforms as well as in scrubs as a symbol of commitment to “health nursing.”
We have the goals, the commitment, and the support: it is time for a new direction.