A Public Health Nurse to Population Ratio Linda Olson Keller, DNP, RN, FAAN American Public Health Association San Diego, California October 26, 2008
Objectives • Overview of PHN Ratio History • Overview of Public Health Nurse Task Analysis • Recommendations & Next Steps
“One good community nurse will save a dozen policeman.” Herbert Hoover 1929
Earliest known census of PHNs in US reported in 1901 by Harriet Fulmer at the International Congress of Nurses in Buffalo, New York 58 public health nursing organizations (largely Visiting Nurse Agencies) employing about 130 nurses (Division of Nursing, 1968, p.1) PHN Census History
PHN Census History1916 to 1931 Statistical Department of the National Organization for Public Health Nursing Periodic enumerations of public health nursing agencies and PHNs 1926 3,269 agencies in the US employing 11,171 PHNs (AJPH, 1926).
1927 Ratio of one PHN for every 2000 person in the population "on the basis of evidence already available as to the essentials for adequate community service." Hiscock, Ira V. "Community Health Problems" published by the Commonwealth Fund, New York, 1927
Planning Administration Popular Health instruction Vital statistics Communicable Disease control Venereal disease control Tuberculosis control Maternity and child hygiene School hygiene Public health nursing Milk and food control Sanitation Laboratory services 1932 Commonwealth Fund Committee on Administrative Practice of APHA
1932 Commonwealth Fund Committee on Administrative Practice of APHA An analysis of time spent by PHNs on • communicable disease control • venereal disease control, • tuberculosis control, • maternity and child hygiene • school hygiene • bedside care (for chronic diseases such as cancer and heart disease)
1932 Commonwealth Fund Committee on Administrative Practice of APHA Hiscock recommended “one nurse to 2,000 population, or 50 nurses in a city of 100,000 population”
1936 Milbank Memorial Fund PHN task analysis: • number of home visits made • number of clinic visits by patients • number of examinations given to school children
1936 Milbank Memorial Fund “It has been recommended that there should be one public health nurse to every 2,000 population. Thus the number of people in the district served by a public health nurse may be used as a unit for measuring the adequacy of public health services.” Marian G. Randall. How Much Work Can a Rural Public Health Nurse Do? The Milbank Memorial Fund Quarterly, Vol. 14, No. 2. (April 1936), pp. 163-172.
1943 Subcommittee on Local Health Units, Committee on Administrative Practice of the American Public Health Association Emerson, Haven, and Luginbuhl, Martha. (1945). Local Health Units for the Nation, Commonwealth Fund. Cambridge, Massachusetts: Harvard University Press
Functions of a local health department 1943 • Vital statistics • Control of communicable diseases, including tuberculosis, the venereal diseases, malaria and hookworm disease • Environmental sanitation, including supervision of milk and milk products, food processing, public eating places, and maintenance of sanitary conditions of employment • Public health laboratory services • Hygiene of maternity, infancy, and childhood, including supervision of the health of the school age child • Health education of the general public
In order to fulfill these functions in a community of 50,000 persons “one full-time professionally trained and experienced medical officer of health, a full-time public health or sanitary engineer and a sanitarian of non-professional grade, ten public health nurses, one of whom would be of supervisory grade, and three persons for clerical work” (Emerson,1945, p. 2)
1937-1972 “Census of Public Health Nurses” State Directors of Public Health Nursing & Public Health Nursing Branch of the Division of Nursing, U.S. Public Health Service Census annually 1937-1953, 1955, 1957 biennially 1960-1964 *1968 *1970 *1972
1937-1972 “Census of Public Health Nurses” Quality of public health nursing: • Ratio of nurse-to-population coverage • Amount of guidance available to staff through supervision and consultation • Educational preparation of the nursing personnel
1951 For a number of years the National Organization for Public Health Nursing and the American Public Health Association have advocated one public health nurse to each 5,000 of the population for the usual preventive services rendered by a health department
1951 “When bedside nursing care of the sick is provided, the commonly accepted ratio is one nurse to each 2,000 of the population. Two and one-half times as many nurses are needed on a health department staff if a bedside nursing service is added to the usual health department services.” McIver, P. (1951) A discussion of the study of combination services in public health nursing. AJPH, 42: 63-68.)
1954 “In programs for the prevention and control of disease, one public health nurse to 5000 population is considered to be a reasonable and practical ratio.” McIver P& W. B. Farris 1954 “Trends in public health”. Nursing Outlook, 2:352-358, July 1954.
1965 "In the best judgment of the Consultant Group, the Nation should have some 850,000 professional nurses by 1970. . . At this level [one public health nurse to 5,000 population] 43,000 qualified public health nurses would be needed in state and local agencies.” U.S. Public Health Service, “Towards Quality: Needs and Goals. Report of the Surgeon’s General’s Consultant Group on Nursing 1963
1968 • National existing ratio of 21.3 nurses per 100,000 population or one nurse per 4,703 population (highest ratio ever reported) • National goal of 40 per 100,000, or one nurse per 2,500 population – (District of Columbia & Delaware had achieved this goal) Roberts, D., Saba, V., & Allen, H. (1970). American Journal of Nursing, 70:11, 2394-2399.
Ratio of Local Agency Nurses to Population
"Public health nurses do what nobody else is doing. And what every community deserves." Georges Benjamin, MD, FACP Executive Director, American Public Health Association (APHA)
Alaska Arizona Arkansas California Colorado Connecticut Georgia Illinois Kentucky Missouri Louisiana Maine Massachusetts Minnesota Mississippi Montana New Jersey New Mexico New York North Carolina PHN Task Analysis60 Staff Level PHNs (29 states) North Dakota Ohio South Carolina Tennessee Texas Utah Virginia Washington Wisconsin
Job Responsibilities n=60 (*Participants selected all categories that applied)
PHN Task Analysis • By population • By practice/program area
88% PHNs work in health promotion/ prevention programs in the community • Lead • Tobacco use • Teen pregnancy prevention • Perinatal hepatitis B • Infant car seat safety • Dental health • Worksite wellness
PHN Role in the Community • 87% (52/60) of PHNs serve on or work with groups related to public health issues • 60% (36/60) PHNs participate in community organizing activities • 47% (28/60) of PHNs chair or lead groups related to public health issues
“How much time do I have to answer this? The biggest impact on the health of the community would be a much less healthy society. Primary prevention would be gone! I don't see anyone else focusing on primary prevention like we are.” What would be the impact on the health of the community if no PHN services? PHN Task Analysis Participant
PHN Role in Emergency Preparedness • 100% participant in EP activities. • 97% participate in their local/state health department response trainings • 90% participate in local or state health department response drills.
PHN Role in Emergency Preparedness • 67% work in mass dispensing clinics • 53% work in in shelters • 28% work in in screening sites 48% triage individuals in mass dispensing clinics and screening sites
"From the perspective of local public health, you can have the greatest written plans in the world, but if you don't have enough staff, including public health nurses, to carry out those plans, the plans are worthless." Rex Archer, MD, MPHNACCHO President Director of Health,Kansas City Missouri Health Department
93% PHNs work in immunization clinics 63% PHNs plan immunization clinics • Flu (95%) • General (88%) • Public Health [well-baby, WIC](61%) • Hep A/B for individuals exposed to disease (61%) • Schools (55%) • Hep A/B for employees at work sites (41) • Travel (20%)
Percentage of PHNs who work in clinics
Immunization (93%) STDs & HIV (61%) DOT (57%) Prenatal (56%) Family Planning (48%) WIC (46%) Well baby/child (44%) Lead (44%) Senior Health (35%) School-based clinics (33%) EPSDT (28%) Primary care (20%) Chronic Care Management (19%) Types of Public Health Clinics
Percentage of PHNs who perform case management 11.7% 88.3%
Individuals TB (52%) Pregnant women (47%) Families with newborns/ young children (45%) Breastfeeding women (37%) Children with lead (33%) Children with disabilities (33%) Individuals chronic disease (25%) Individuals with mental illness (18%) Children with IEP plan (18%) Frail older adults (17%) Individuals HIV (13%) Adults with disabilities (10%) Types of PHN Case Managementn=60
PHN Role with Vulnerable Populations 87% facilitate and assist vulnerable individuals’ access to services and basic life needs 81% perform activities related to vulnerable children and/or adults 70% advocate for improved increased health care availability and access
What would be the impact on the health of the community if no PHN services? The most vulnerable among us would suffer immeasurably… PHN Task Analysis Participant