1. A Public Health Nurse to Population Ratio Linda Olson Keller, DNP, RN, FAAN American Public Health Association San Diego, California October 26, 2008

2. Objectives 1.Overview of PHN Ratio History 2.Overview of Public Health Nurse Task Analysis 3.Recommendations & Next Steps

3. “One good community nurse will save a dozen policeman.” Herbert Hoover 1929

4. 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

5. PHN Census History 1916 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).

6. 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

7. 1932 Commonwealth Fund Committee on Administrative Practice of APHA 1.Planning 2.Administration 3.Popular Health instruction 4.Vital statistics 5.Communicable Disease control 6.Venereal disease control 7.Tuberculosis control 8.Maternity and child hygiene 9.School hygiene 10.Public health nursing 11.Milk and food control 12.Sanitation 13.Laboratory services

8. An analysis of time spent by PHNs on 1.communicable disease control 2.venereal disease control, 3.tuberculosis control, 4.maternity and child hygiene 5.school hygiene 6.bedside care (for chronic diseases such as cancer and heart disease) 1932 Commonwealth Fund Committee on Administrative Practice of APHA

9. Hiscock recommended “one nurse to 2,000 population, or 50 nurses in a city of 100,000 population” 1932 Commonwealth Fund Committee on Administrative Practice of APHA

10. 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

11. “ 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. 1936 Milbank Memorial Fund

12. 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

13. Functions of a local health department 1943 1.Vital statistics 2.Control of communicable diseases, including tuberculosis, the venereal diseases, malaria and hookworm disease 3.Environmental sanitation, including supervision of milk and milk products, food processing, public eating places, and maintenance of sanitary conditions of employment 4.Public health laboratory services 5.Hygiene of maternity, infancy, and childhood, including supervision of the health of the school age child 6.Health education of the general public

14. 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)

15. 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

16. 1937-1972 “Census of Public Health Nurses” Quality of public health nursing: 1. Ratio of nurse-to-population coverage 2. Amount of guidance available to staff through supervision and consultation 3. Educational preparation of the nursing personnel

18. 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

19. 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.)

20. 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.

21. 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

22. 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.

24. YearPHN per 100,000 Population per Nurse 19479.610, 329 195010.59,500 19578.911,199 19609.110,937 19649.210,818 196821.34,703 197013.77,322 Ratio of Local Agency Nurses to Population

25. " 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)

26. PHN Task Analysis 60 Staff Level PHNs (29 states) Alaska Arizona Arkansas California Colorado Connecticut Georgia Illinois Kentucky Missouri Louisiana Maine Massachusetts Minnesota Mississippi Montana New Jersey New Mexico New York North Carolina North Dakota Ohio South Carolina Tennessee Texas Utah Virginia Washington Wisconsin

27. n=60

31. Job Responsibilities n=60 Categories Number of Participants* Adolescent Health6 Adult Health6 Disease, Prevention and Control 11 Emergency Preparedness7 Family Planning6 Generalist16 Immunizations17 Maternal & Child Health19 Tuberculosis8 Women’s Health18 (*Participants selected all categories that applied)

32. PHN Task Analysis  By population  By practice/program area

35. 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

36. 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

38. “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

39. 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.

40.  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 PHN Role in Emergency Preparedness

41. " 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, MPH NACCHO President Director of Health, Kansas City Missouri Health Department

42. 93% PHNs work in immunization clinics 63% PHNs plan immunization clinics 1.Flu (95%) 2.General (88%) 3.Public Health [well-baby, WIC](61%) 4.Hep A/B for individuals exposed to disease (61%) 5.Schools (55%) 6.Hep A/B for employees at work sites (41) 7.Travel (20%)

43. Percentage of PHNs who work in clinics

44. Types of Public Health Clinics 1. Immunization (93%) 2. STDs & HIV (61%) 3. DOT (57%) 4. Prenatal (56%) 5. Family Planning (48%) 6. WIC (46%) 7. Well baby/child (44%) 8. Lead (44%) 9. Senior Health (35%) 10. School-based clinics (33%) 11. EPSDT (28%) 12. Primary care (20%) 13. Chronic Care Management (19%)

46. 88.3% 11.7% Percentage of PHNs who perform case management

47. Types of PHN Case Management n=60 1.Individuals TB (52%) 2.Pregnant women (47%) 3.Families with newborns/ young children (45%) 4.Breastfeeding women (37%) 5.Children with lead (33%) 6.Children with disabilities (33%) 7.Individuals chronic disease (25%) 8.Individuals with mental illness (18%) 9.Children with IEP plan (18%) 10.Frail older adults (17%) 11.Individuals HIV (13%) 12.Adults with disabilities (10%)

48. 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

50. The most vulnerable among us would suffer immeasurably… What would be the impact on the health of the community if no PHN services? PHN Task Analysis Participant

51. Percentage of PHNs who conduct home visits

52. Types & Frequency of Home Visits 1. Health Promotion (74%) 2. Case Management (72%) 3. DOT (68%) 4. Contact Investigation (68%) 5. Newborn (66%) 6. Abuse and Neglect (64%) 7. Parenting (62%) 8. Prenatal (58%) 9. Child G & D (58%) 10. Post partum (56%) 11. Special Needs Child (54%) 12. Lead (50%) 13. SIDS follow-up (40%) 14. Court ordered (34%) 15. PH nuisance (28%) 16. Homecare (20%)

53. The impact would be devastating. While all aspects of public health are important, it is the nurse who pulls all the little pieces together. One short visit can result in a 30-45 minute stay, with multiple referrals to community agencies being provided. It is the nurse who looks at the big picture to ensure services are being received. What would be the impact on the health of the community if no PHN services? PHN Task Analysis Participant

54. 78 % conduct health screenings n=60 1.Immunization status (94%) 2.Mantoux (68%) 3.Hypertension/Blood Pressure (68%) 4.Infant/Child Growth and Development (66%) 5.Lice (62%) 6.Nutrition (62%) 7.Anemia (57%) 8.Abuse & Neglect (49%) 9.BMI (49%) 10.Lead (45%) 11.Vision (45%) 12.Hearing (45%) 13.Dental (43%) 14.Interpersonal violence (43%)

55. PHN Role in Disease Prevention & Control 78% PHNs investigate disease and other health threats

57. PHN Role in TB Prevention & Control  75% PHNs report that they work with clients with latent or active TB  23% work with TB clients daily; 15% weekly; and 28% monthly  83% administer and read tuberculin skin tests

58. PHN Role in TB Prevention & Control  68% of PHNs conduct Directly Observed Therapy (DOT) home visits  68% of PHNs investigate TB contacts

60. Recommendation One Establish a standard national public health nurse to population ratio of 1 public health nurse to 5,000 population.

61. Nationally accepted standard: 1 PHN to 5,000 population ratio Common standard to evaluate and compare the public health nursing infrastructure within and across states North Carolina: PHN to population ratios in local health departments range from 1 PHN to 21,491 population to 1 PHN to 1,541 population (Personal communication, J. Reed)

62. Recommendation Two Establish a standard national ratio of one public health nurse supervisor to no more than 8 public health nurses.

63. Ratio of 1 supervisor to no more than 8 PHNs The Nurse Family Partnership requires a ratio of 1 full-time nursing supervisor to no more than 8 nurse home visitors The National Incident Management System “span of control” (ratio of supervisor to personnel) ranges between 1 to 3 and 1 to 7

64. Recommendation Three Require the baccalaureate degree as the educational credential for public health nursing practice.

65. Baccalaureate preparation for PHNs The baccalaureate degree in nursing is the educational credential for entry into public health nursing practice ANA Scope and Standards of Public Health Nursing 2007

66. Recommendation Four Collaborate with other public health disciplines to consider recommended population ratios for all public health professionals

67. Next Steps 1.Implement a national survey to identify existing PHN ratios, supervisor ratios, and educational preparation of PHNs in US 2.Convene a task force to recommend a set of community criteria that would require a PHN to population ratio less than 1:5,000 3.Engage stakeholders in discussion on potential strategies for utilizing the recommended PHN to population ratio.

68. Next Steps 4.Explore strategies for promoting and enforcing the baccalaureate educational requirement as the credential for PHN nursing practice. 5.Convene partners to discuss recommended population ratios for all public health professionals.

69. Thank you to Emily Litt, DNP, RN, PHN for her invaluable assistance with this project. ASTDN extends a sincere thanks to the 60 public health nurses that completed the Public Health Nursing Task Analysis and to the 29 local and state health departments for their time, expertise, and contributions to the future of public health nursing practice. Acknowledgements

70. This report is supported by funding from a cooperative agreement with the U.S. Department of Health and Human Services; Centers for Disease Control and Prevention, Cooperative Agreement award number U50/CCU31903. Opinions in this report do not necessarily represent the official policy of the CDC. Additional support for the report was received from the RWJ Executive Nurse Fellows Alumni Association Seed Grant Program, “A Public Health Nurse/Population Ratio for the 21st Century.” Acknowledgements