What Is a Public Health Nurse?
Historical Visions of Public Health Nursing
Karen Buhler-Wilkerson, PhD, RN, FAAN
Lillian Wald, founder of the Henry Street Settlement (1893) in New York City, invented the term public health nursing to put emphasis on the community value of the nurse whose work was built upon an understanding of all the problems that invariably accompanied the ills of the poor. Wald’s practice among the sick poor quickly convinced her that their diseases most often resulted from causes beyond an individual’s control and that treatments needed to be prescribed in an all-round way with consideration for the social, economic, and medical aspects of each case. By looking at nursing practice from the patient’s point of view, encouraging personal and public responsibility, and providing a unifying structure for the delivery of comprehensive, equally available health care, Wald conceptualized a new paradigm for nursing practice.
Whether a patient’s problems were isolated and unusual or common to many was, according to Wald, important to know because the process of finding out the answer to this question often led logically to identification of an appropriate remedy. Wald’s vision resulted in nursing practice that went beyond simply caring for patients and their families during illness to encompass an agenda of reform in health care, industry, education, recreation, and housing.
What Wald called "our enterprise of public health nursing" was not an isolated undertaking, nor was she a lone American heroine. Her paradigm for nursing practice was based on knowledge gained during two decades of experience in visiting nursing and owed much to Progressive reform and the public health movement of the turn of the century. Although Wald embodied the professionalization of visiting nursing, due credit must also be accorded the thousands of nurses across the country who legitimated the practice of nursing in the community.
To Teach Healthful Living and Disease Prevention
While Wald was developing her new agenda for the reform of society and delivery of health care, the changing emphasis of the “public health campaign” simultaneously created yet another aspect of the bond between nursing and public health. As the focus of the public health movement shifted from what eminent public health leader C-E.A. Winslow described as environmental sanitation and bacteriology to the personal conduct and health practices of the individual, it required a new worker, a teacher of healthful living and disease prevention. By 1910, most of the large visiting nurse associations and numerous boards of health and education had initiated disease-prevention programs for school children, infants, mothers, and patients with tuberculosis.
Health visiting offered nurses a new opportunity for professional independence, status, and economic security. As one medical authority suggested, they were the relay station to carry the power from the control stations of science, the hospital, and the university to the individual homes of the community. This was a time of unprecedented possibilities for nursing. Not, surprisingly, the number of agencies seeking their services had increased from only 58 in 1901 to nearly 2,000 by 1914. Nurses entering this new field had also begun to specialize, limiting their work to one age group or disease. Specialization, these nurses argued, allowed them to become experts, to lead others, and to contribute to the much needed literature in public health. They saw themselves as participating in the growing specialization of the medical profession. Because it was difficult to combine a focus on prevention with meeting the bodily needs of patients, the roles associated with care of the sick and health teaching increasingly diverged.
Wald argued that the public health nurse was the link between families’ social, economic, and health needs and the services they required to become and stay healthy. She was therefore opposed to specialization and to the distinctions between health teaching and direct patient care. If the message of health was to be carried to troubled families, something also needed to be done for these families. Thus, the increasingly isolated and narrowly focused mission of health education challenged Wald’s vision of a broadly focused agenda for nursing in the struggle for social betterment. Specialization was antithetical to her concept of public health nurses’ organic relationship to their neighborhoods.
Prevention vs. Cure?
By the late, 1920s, public health nurses had indeed demonstrated their ability to advance the public health mission, but the field had reached a turning point. Despite the intent of reformers for a conceptually coherent and centrally structured set of public health services, there were nevertheless 4,262 separate, small and independent local government and voluntary agencies sponsoring public health nurses. This growth was characterized by an idiosyncratic mix of initiatives providing an unpredictable assortment of both preventive and curative nursing services. Gaps and duplication of services were an inevitable outcome. Isolated and uncoordinated, these agencies were increasingly vulnerable to shifts in community support and perceptions of need. As the confusion grew, the rationale for public health nursing became increasingly obscure to both its practitioners and the public.
In response, many nursing leaders began to campaign for the creation of comprehensive, coordinated community-based nursing services. Leaders now considered separating the curative and preventive functions of the public health nurse to be a mistake, and they argued for a combined model that would unite both voluntary and publicly funded agencies. Nurses within this more rational system would be general practitioners who would care for all people in the neighborhood, in sickness and in health, regardless of income or type of illness. Numerous studies and demonstration projects from the 1920s through the 1940s confirmed that such a system would eliminate duplication in administration, transportation, and health services. Despite their ability to demonstrate that this unification model met the needs of most of the patients it served, however, organized nursing was never able to create the institutional framework necessary to implement their vision.
The reality was that public health nursing was no longer able to engage the support of the larger infrastructures of medical and wider social institutions in their quest to create and finance comprehensive community-based care. The social, medical, and demographic circumstances that had created support for their work in the community were now much less urgent. With fewer immigrants, declining death rates from often dramatic and frightening infectious diseases, the growing dominance of chronic illness, and the centrality of the hospital, the work of the public health nurse seemed increasing inconsequential to the public.
Nurses as Guardians of the Public’s Health
Over the years, public health nurses have assumed a variety of roles and titles, but in the absence of an influential or cohesive constituency, Wald’s vision of nurses as guardians of the public’s health could only be partially realized. Today, once again, frightening diseases, alienation among the disenfranchised, a vexing economic climate, and unmet health needs of populations at greatest risk constitute a crisis in caring. As we anticipate the implementation of health care reform, one cannot help but wonder if public health nursing might have the opportunity to be reinvigorated and returned to the role Wald prescribed. As historian Susan Reverby suggested during a previous campaign for health reform, such a paradigm shift could go a long way toward making an inadequate medical care system into a health care system that provides for all the public.
C.-E.A. Winslow. “The Untilled Fields of Public Health.” Science, 51 (9 January, 1920): 23-33. Karen Buhler-Wilkerson, “Bringing Care to the People: Lillian Wald’s Legacy to Public Health Nursing,” American Journal of Public Health, 83 (December 1993): 1778–86.
Karen Buhler-Wilkerson, “Public Health Nursing: In Sickness or in Health?” American Journal of Public Health, 75 (October 1985): 1155–61.
Karen Buhler-Wilkerson. False Dawn: The Rise and Decline of Public Health Nursing, 1900-1930. New York: Garland Publishing Co., 1990.
Susan Reverby, “From Lillian Wald to Hillary Rodham Clinton: What Will Happen to Public Health Nursing?" American Journal of Public Health, 83 (December 1993):1662–63.
Marla Salmon, “Editorial: Public Health Nursing—The Opportunity of a Century,” American Journal of Public Health, 83 (December 1993): 1674–75.
Karen Buhler-Wilkerson (1944-2010) was Professor Emerita, University of Pennsylvania School of Nursing and Director Emerita of the Barbara Bates Center for the Study of the History of Nursing.