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Everyday PeopleBy Rebecca Ray and NurseWeek.comCindy, a mother of three on Alaska's Kenai Peninsula, had an abscessed molar and recurring tooth pain. But she wasn't able to see a dentist. Those in her area either didn't take Medicaid patients or took only patients who could pay a certain amount up front. The nearest dentist who took Medicaid patients was 150 miles away, and Cindy (not her real name) didn't have a car reliable enough to make the trip. This year, however, she finally was able to receive treatment when a new dental clinic opened in Kenai. Various community members launched the Aspen Dental Center for residents who have no access to dental care. The clinic is the brainchild of JoAnn Hagen, MS, RN, PHN, public health nurse manager for the Kenai Peninsula, and her fellow Healthy Communities/Healthy People task force members. Although the clinic didn't make headlines, it was "one of the most exciting things I've done in a long time," Hagen said. As a public health nurse, Hagen often participates in projects that reach far and wide. She focuses on populations, rather than individuals, and aims to prevent diseases rather than to treat them. Strength in numbersPublic health nurses' influence is only continuing to grow as more and more nurses are choosing the specialty. Registered nurses employed in public and community health settings increased by 155 percent between 1980 and 2000, while the overall RN population increased by 62.2 percent in the same time period, according to the Health Resources and Service Administration's 2000 National Sample Survey of Registered Nurses. Also, public health nurses make up the second-largest group of working registered nurses at 18.1 percent, or 402,000 individuals, the report said. Hospital nurses make up the largest group of working RNs at 59.1 percent. Public health nurses don't usually focus on performing or assisting with medical procedures. Instead, they focus on educating clients and examining community trends to prevent diseases. However, they can give immunizations, provide medications for communicable diseases, run health screening clinics and refer clients for medical follow-up. Jennifer Schmidt, RN, PHN, had worked in hospitals and taught nursing throughout Alaska for about a decade before she moved to Fairbanks, where the public health nurse manager at the state-run Fairbanks Regional Public Health Center asked her to apply for a public health nursing position. "I had always enjoyed looking at the big picture and looking at ways that problems could be avoided, so it fit," Schmidt said. She has covered the Fairbanks North Star Borough since 1982. She visits clients in their homes in order to provide information and help families stay healthy. Schmidt spends a lot of time directly serving clients, such as administering pregnancy tests and running new-parent clinics. Clients can be referred by hospitals, doctors or agencies. Sometimes, they even refer themselves. Public health nurses prefer home visits because they can get a better picture of individuals' or families' resources and health needs, Schmidt said. "I love the variety in public health nursing," Schmidt said. "I like working with clients and families, and going beyond the individual problem and seeing what else is going on." Family-centered careCandace House, PHN, a public health nurse with the Kitsap County Health District in Washington state, used to work in med/surg and rehabilitation until she began to work in home health. She enjoyed working with families so much that she switched to public health nursing. As team leader of the county's Child Health Advocate program, House works mainly with children referred by agencies such as the state Department of Social & Health Services. Her clients range from young, new parents to children from dysfunctional families to children in the court system. She educates parents on how their children's brains develop so they can be more effective parents, and this can reduce child abuse and neglect. House said she prefers teaching families in this setting over interacting with them in a hospital or clinic setting. Schmidt agrees. "You learn so much about people and how to best work with a family when you do home visits, as opposed to in a clinic room," she said. House's public health nurse co-workers, Marty Gordon, PHN, and Nancy Acosta, PHN, also work in the Parent Child Health Program. However, they see a wider age range of clients than House, and primarily see pregnant women and young parents. Gordon said she enjoyed giving clients the support and confidence to achieve their goals, such as becoming educated about breast-feeding. Besides parent and child health, public health nurses also focus on specialties such as controlling the spread of communicable and sexually transmitted diseases, nonemergent and preventive care for inmates, injury and violence prevention, bioterrorism and surveillance and emergency preparedness and disaster planning. House, Gordon and Acosta usually make about three or four scheduled home visits each day, and carry a 50- to 60-client caseload at a time. Self-managementSharon Trucker, MS, RN, assistant nursing director and nurse recruiter at the Los Angeles County Department of Health Services, said that public health nursing is fairly independent in that nurses have a lot of say in planning their schedules. This is especially true in Alaska. Doctors don't run the Fairbanks public health center; the nurses work under nursing guidelines, said Schmidt, who sometimes must drive long distances to see clients in remote villages. The Alaska State Department of Health & Social Services covers most parts of the state because many boroughs don't have health departments. Most public health nurses in Alaska are state employees. The Los Angeles County Department of Health Services-which, according to 2000 U.S. Census data, services more than 15 times as many people as the state of Alaska-is structured differently. Two kinds of public health nurses work in Los Angeles County: district nurses and program nurses. While each district nurse services a specific geographic area of the county, program nurses focus on specific subpopulations. As a district public health nurse, Norman Gray, MS, RN, PHN, focuses on a group of census tracts that encompass 50,000 residents. Most of his work, which is state-mandated, involves reporting people with tuberculosis, sexually transmitted diseases or acute communicable diseases, tracking people at risk of acquiring the diseases and arranging treatment and screening. He also focuses on community-based education, such as speaking to groups about healthy eating. On rare occasions, he tries to solve problems by bringing them to the attention of elected officials. Program public health nurses work with subpopulations such as children in foster care. Nurses in Los Angeles County's foster care program educate the social workers about their clients' potential or existing medical problems. Like district nurses, program nurses work on connecting clients with the right resources. Practice distinctionsMedical professionals nationwide have diverse beliefs about the difference between community health and public health nursing. For the Kitsap County department, the two are one and the same. However, for the Los Angeles County department, community health nurses are more focused on treating a client instead of a population, and on treating-rather than preventing-diseases. Community and public health nursing involve three levels of prevention: primary, secondary and tertiary, according to Kathleen Smith, MPH, APRN, RN, clinical nurse specialist in community health for the Los Angeles County department. Primary prevention involves preventing a problem, secondary prevention involves solving a problem in its early stages and tertiary prevention involves tackling a full-blown problem. Ideally, public health nurses focus mainly on primary prevention, while community health nurses focus on secondary and tertiary prevention, said Margaret Avila, MSN, MS, NP, RN, nursing director of public health administration for the county department. Public health nurses also operate at three levels of practice: the individual, the community and the system as a whole, Smith said. They don't see themselves as being the sole remedy, but as being part of a multifactored approach that involves other community disciplines. When asked what was most challenging about public health nursing, "It's all a challenge," House said. She said it was sometimes a challenge to develop relationships with families and have them be receptive to visitors and information. Also, the issues clients deal with can be overwhelming, Acosta said, and sometimes it's hard to know where to start. The need to improve public health in most jurisdictions is enormous, and the resources are limited, Smith said. Because of limited resources, public health nurses must prioritize and focus on providing services that no one else addresses. Also, the potential workforce is limited because of the nationwide nursing shortage. Most jurisdictions in California prefer to hire nurses with both a BSN and a public health nursing certificate from the California Board of Registered Nursing, Avila said. However, because of the nursing shortage, jurisdictions have hired nurses without a BSN who appear to have comparable training, such as nurses who have received the public health nursing certificate from California State University, Dominguez Hills. To compensate for the nursing shortage, some jurisdictions have contracted out their disease control activity, while others have developed a team approach that involves public health nurses, social workers and paraprofessionals. California's requirements for PHNs, however, are stiffer than most states', Avila said. To work for Maine's statewide system, for example, a public health nurse needs only an associate degree, according to Beth Patterson, MN, RN, Maine state director of public health. In the past, Schmidt said, the epidemics that public health nurses dealt with were communicable diseases. Today's epidemics, such as violence, substance abuse and mental illness, are more insidious, she said, and it's harder for nurses to demonstrate theyhad an effect. Public health nursing is a constant educational process, Schmidt said, in that public health nurses are always having to learn about new nationwide and worldwide concerns such as smallpox, SARS and the West Nile virus. Not surprisingly, federal and state budget crunches have resulted in less money for public health. Most public health resources have gone toward bioterrorism and emergency and disaster planning. With more emphasis on bioterrorism during the past couple of years, public health organizations have encountered more demands. Nurses also have to be in a constant state of readiness, Avila said. The Los Angeles County department's bioterrorism program has grown tremendously since Sept. 11, according to Los Angeles County public health nurse Jennifer Rivera, MSN/MPH, CNS, RN. Nurses in this program often train hospital staff in how to prepare for bioterror attacks. Despite the challenges of public health nursing-as well as the reality that the everyday life of a public health nurse may not be as dramatic as an "ER" episode, Schmidt doesn't regret her career choice. She said she often enters a situation with an idea of what the major problem is, only to have her preconceptions shattered. But even in these situations, she has succeeded in helping families and communities solve their problems. "There's strength in every situation," she said. "In every family or community, you can usually find some strength to build on." |
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